Esophagus Thread

[clintpark]

http://forums.studentdoctor.net/showthread.php?t=611660

I'm starting a new thread to separate the esophagus from IIIA NSCLC. This thread has been one of the most interesting on this Forum in a while. It's refreshing to see all the residents coming out of the wood work to chime in.

Obviously, we don’t know the real reason that dose escalation hasn’t panned out in esophageal SCC. In my practice, I will treat patients with SCC with chemoRT to 50.4Gy +/- esophagectomy beacuse I agree that this is the standard of care approach and higher doses are not supported by the currently available evidence. I’m just trying to provide some food for thought…

So, what dose would you give in an inoperable setting (which INT 0123 was) in real practice? (50 Gy? 65 Gy? Different doses for SCC/upper-mid vs. adeno distal/GEJ?)

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[qwert]

In my place, we never give more than 50.4, either for SCC or AdenoCa. I'm yet to see a case of cervical esophageal cancer though.



QUOTE=clintpark;7903977]http://forums.studentdoctor.net/showthread.php?t=611660

I'm starting a new thread to separate the esophagus from IIIA NSCLC. This thread has been one of the most interesting on this Forum in a while. It's refreshing to see all the residents coming out of the wood work to chime in.



So, what dose would you give in an inoperable setting (which INT 0123 was) in real practice? (50 Gy? 65 Gy? Different doses for SCC/upper-mid vs. adeno distal/GEJ?)[/QUOTE]

 

[TarHeelRadOnc]

http://forums.studentdoctor.net/showthread.php?t=611660

I'm starting a new thread to separate the esophagus from IIIA NSCLC. This thread has been one of the most interesting on this Forum in a while. It's refreshing to see all the residents coming out of the wood work to chime in.



So, what dose would you give in an inoperable setting (which INT 0123 was) in real practice? (50 Gy? 65 Gy? Different doses for SCC/upper-mid vs. adeno distal/GEJ?)

I would give 50.4Gy in 28 fractions for neoadjuvant or definitive, because I think that that is the approach that is best supported by the available literature. In a patient who is medically fit for surgery, I would not favor definitive chemoRT for adeno, because I don't think that the available literature supports this approach (unless you rely on the data from the 22 patients with adenocarcinoma treated in RTOG 85-01). For SCC, I just think that it is curious that the doses are the same for both neoadjuvant and definitive treatment...

 

[medgator]

Cervical esophagus SCC is so rare. I've only seen a few cases come through so far (none of which I treated). IIRC, they went to 70 Gy with cis, as the pt. was not felt to be a surgical candidate.

Is it really that much different than a hypopharynx at that point?

 

[clintpark]

Cervical esophagus SCC is so rare. I've only seen a few cases come through so far (none of which I treated). IIRC, they went to 70 Gy with cis, as the pt. was not felt to be a surgical candidate.

Is it really that much different than a hypopharynx at that point?

Cervical esophageal cancer is rarely, if ever, considered resectable.

Dr. Willett said that he/Dr. Czito treat them as any other esophagus, taking them to 50.4 Gy with cis/5FU. The only difference was that he uses IMRT for cervical esophagus whereas he uses AP->obliques->laterals technique for most of his other esophagus. He covers supraclavicular nodes.

However, if the same patient ended up on Dr. Brizel's (H+N specialist, also from Duke) service, he would receive 70 Gy with cisplatin and get RT to neck nodes as well. (Anyone from Duke who can confirm this?)

I've treated one cervical esophagus myself. Dr. Choy (by no means a GI expert, but at UTSW esophagus cancer is treated by thorax team) and I used IMRT simultaneous integrated boost; took GTV + expansion (4 - 5 cm down, up to cricoid and 1-2cm radial) + SC to 50.4 (1.8/fx) and GTV to 56 (2/fx). Neck nodes were not covered.

 

[Palex80]

We regularly give 54 Gy with 1,8 Gy/d in the definitive setting, shrinking field after 45 Gy. PET-based planning is recommended. Chemotherapy are two cycles of 5FU and Cisplatin (500mg/m2/d and 20 mg/m2/d d1-5+29-33).
Dose escalation over 54 Gy is rarely done. I recall a few cases of cervical cancer in young fit patients, where we did a concomitant boost approach up to 60 Gy.

In T1,N0 patients we may stop at 45 Gy and deliver brachytherapy with 2x5 Gy.

 

[medgator]

Is anyone dose escalating inoperable-advanced esophageal CA in 2015?

http://m.jco.ascopubs.org/content/23/10/2310.long

http://jco.ascopubs.org/content/25/10/1160.long

 

[Neuronix]

We dose escalate with dose painted IMRT.

http://link.springer.com/article/10.1007/s13566-012-0048-5

 

[iradi8u]

I dose escalate with dose painted IMRT as well.