Esophagus Elective Nodal Coverage

[protonbrachy]

What does your institution do for elective esophagus nodal coverage?

From what I've gathered, there's "no consensus" so I wonder what different places do (elective SCV, celiac, perigastric...) for these nodes?

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[Chartreuse Wombat]

ASTRO 2015 Plenary has a RCT of elective nodal irradiation in thoracic esophageal cancer.

 

[protonbrachy]

thank you

 

[2012MD]

Just stumbled across this thread. There was a consensus paper in the Red Journal (PMID: 26104943) that I found very helpful, particularly for mid/upper lesions which we rarely see at my program.

 

[subatomicdoc]

ASTRO 2015 Plenary has a RCT of elective nodal irradiation in thoracic esophageal cancer.

The plenary was interesting with good preliminary data. Here is the abstract.

Different group but here is a recent Green Journal publication with a nodal atlas for esophageal cancer.

A great book is available for CTV design from Springer. http://www.springer.com/gp/book/9783540770435 It's from 2008 but the anatomy doesn't change. Worth a look and covers many disease sites.

 

[Haybrant]

This doesn't totally belong in this thread but its an esophageal question. I have a guy that had a esophageal stent put in, he has a mid esophageal squam 4 cm below carina. The stent is like 10 cm sup inf, I haven't seen this before. Are there any issues to consider for CRT with a stent in; he will be definitive CRT as he is not a surgical candidate. The anatomy is distorted and I cant see the thickening but I have a recent PET that I fused

 

[evilbooyaa]

I've been told by my physicists that the increase in backscatter from a metal stent (in my case, was ureteral stents) could potentially increase the dose by about 2-3%. To some extent it depended on the width and composition of the stent. Could ask your physicists? In terms of contouring I'd use the 4cm from carina as a landmark, correlate that it's within the stent, and maybe the PET?

I was told it was less of an issue with IMRT than with 3D as well, FWIW.

 

[seper]

IMHO stents before XRT are frowned upon (there are reports of mortality), but once it's in, you can't deny this patient a curative intent treatment.

 

[Spiced Meats]

IMHO stents before XRT are frowned upon (there are reports of mortality), but once it's in, you can't deny this patient a curative intent treatment.

How would you manage a TEF?

 

[medgator]

How would you managed a TEF?

From treatment response or tumor?

 

[Spiced Meats]

From treatment response or tumor?

Sorry full thought - how would you manage a TEF from tumor without stenting?

 

[PruritisAni]

Sorry full thought - how would you manage a TEF from tumor without stenting?

Treat it. There are reports of it healing after XRt though the likelihood low. But the likelihood of it improving with tumor there is even less.

 

[seper]

With TE fistulas at diagnosis, I ask for airways AND esophagus stented. Then, we treat using low fraction size, without chemo. Most patients get out of hospital eventually, but I can't recall anyone surviving > 1 year

 

[Haybrant]

IMHO stents before XRT are frowned upon (there are reports of mortality), but once it's in, you can't deny this patient a curative intent treatment.

Going back to this; should they just take the stent out before starting RT? I don't really like this idea as I suspect there is a chance of disrupting the tumor as well. What was the mortality from, rupture?

 

[seper]

I don't see why not? Let them take it out and see if patient can swallow.
Case reports that I've seen deal with esophageal perforation and also aspiration

 

[evilbooyaa]

I don't see why not? Let them take it out and see if patient can swallow.
Case reports that I've seen deal with esophageal perforation and also aspiration

And what if they can't? If the patient was so stenosed that dilatation alone wasn't enough and the patient needed a stent placed, wouldn't you want to treat the cancer around it first, then and only then remove the stent?

We've treated with esophageal stents in place even for non-TEF cases. We're generally treating them palliatively, FWIW. Why not leave the stent in place, and talk to the physicists about incorporating that back scatter dose into the plan to avoid excessive hotspots?

 

[Haybrant]

And what if they can't? If the patient was so stenosed that dilatation alone wasn't enough and the patient needed a stent placed, wouldn't you want to treat the cancer around it first, then and only then remove the stent?

We've treated with esophageal stents in place even for non-TEF cases. We're generally treating them palliatively, FWIW. Why not leave the stent in place, and talk to the physicists about incorporating that back scatter dose into the plan to avoid excessive hotspots?

I think you could, But it's taking a risk and if something happens You'll look at it and say I should have had it taken out. Everyone's gonna be blaming RT for a perf

 

[evilbooyaa]

I think you could, But it's taking a risk and if something happens You'll look at it and say I should have had it taken out. Everyone's gonna be blaming RT for a perf

Well, you're certainly right on the bolded. Fair points. I'm not saying its without risk, but the alternative of 'have the stent removed or I'm not giving you treatment' doesn't seem reasonable. Document discussion of risks and proceed.

 

[seper]

If a stent is in place, and there was no fistula, and the patient does not have mets, I would just treat. If you worry about dosimetry, you can do 3-filed 3DCRT with >=10 MV beams.