Post-op CRT for GE Junction/Distal esophagus

[deleted4401]

60 yo man admitted for fatigue, found to have Hgb 5.8. W/u revealed large GE junction/prox tumor mass, bx - adenoCA. PET-CT showed no distant disease, no positive LNs. No EUS done. Good PS, no wt loss. Esophagectomy. 13.5cm tumor, extending into adventitia/gastric subserosal tissue. 12/18 periesophageal/perigastric nodes positive. Involved deep/distal margin but final gastric margin was negative. pT3N1. Now, we are seeing for post op CRT.

How the F are you supposed to tx post-operatively? The anastomosis goes nearly to neck, and then to tx tumor bed you have to go down into the abdomen. The field is transcontinental. How high would you treat? Where would you cheat to limit volume? We're going to kill him if we include anastomosis, gastric remnant, tumor bed, LN basins. Why do they operate on these people??

-S

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[G'ville Nole]

Had a similar case a few years ago. We ended up treating the tumor bed and locoregional lymphatics with a modification of those giant fields you see in the Smalley consensus paper, and adding a "postage stamp" field over the anastomosis (thoracic inlet on this guy), hypothesizing that the remainder of the gastric remnant/neoesophagus was at a low risk of harboring residual disease relative to the potential toxicity of including it.

Of course, as I recall, we pretty much ended up killing the guy, so maybe don't do what I did.

 

[SchwettieBalls]

Per one of the GI attendings at my institution re: post-op GE junction, "if don't kill someone every now and then, your volumes are too small."

Preop chemorads is definitely the way to go with these folks...

 

[radonc]

60 yo man admitted for fatigue, found to have Hgb 5.8. W/u revealed large GE junction/prox tumor mass, bx - adenoCA. PET-CT showed no distant disease, no positive LNs. No EUS done. Good PS, no wt loss. Esophagectomy. 13.5cm tumor, extending into adventitia/gastric subserosal tissue. 12/18 periesophageal/perigastric nodes positive. Involved deep/distal margin but final gastric margin was negative. pT3N1. Now, we are seeing for post op CRT.

How the F are you supposed to tx post-operatively? The anastomosis goes nearly to neck, and then to tx tumor bed you have to go down into the abdomen. The field is transcontinental. How high would you treat? Where would you cheat to limit volume? We're going to kill him if we include anastomosis, gastric remnant, tumor bed, LN basins. Why do they operate on these people??

-S

here are some suggestions, none based on data
1. dont cheat on volumes unless you absolutely have to.
2. try imrt with dose painting if you need to reduce normal tissue constraints
3. offer pt amifostine
4. make sure pt has j-tube, nutrition, and gi on board before starting therapy
5. read and re-read smalleys article and gunderson book chapter before drawing volumes

 

[Palex80]

I would deliver a maximum of 45 Gy with 1,8 Gy/d.
It could be wise to shrink down the fields after 39,6 Gy or so if you have to.
I am aware that some people here would like to treat to a higher dose, but I wouldn't do it.

Try to limit the fields. According to where those positive lymph nodes were, try to exclude areas that are not considered high risk areas. For example, try to limit fields towards portal vein lymph node areas, if lymph node involvement was not heavy along the left gastric artery.
We really do not know how big those fields are supposed to be and we do have favorable evidence from Japan, showing that extending lymph node dissection does not necessarily lead to a survival benefit. Therefore why extend radiation fields? Similar developments have place in the treatment of pacreatic cancer, with the fields becoming smaller and smaller over the past decade.


As for chemo, I would not try doing any multiple-substances-combinations.
5FU alone should be enough and I would rather give it in week 1+5 as bolus rather than over the entire treatment time. It may be inferior in its efficacy that way, but the toxicity should be more manageable, bearing in mind how huge the fields are going to be. I would only give him the week 5 chemo, if he's still fit.
The medical oncologists may give their combination CT after RCT is finished.

 

[medgator]

Guess I had to get this type of referral sooner or later..... sigh.

Any thoughts on the techniques used in this SWOG paper from NEJM 2001?

http://www.nejm.org/doi/full/10.1056/nejmoa010187#t=articleTop

The 4500 cGy of radiation was delivered in 25 fractions, five days per week, to the tumor bed, to the regional nodes, and 2 cm beyond the proximal and distal margins of resection. The tumor bed was defined by preoperative computed tomographic (CT) imaging, barium roentgenography, and in some instances, surgical clips. The presence of proximal T3 lesions necessitated treatment of the medial left hemidiaphragm. We used the definitions of the Japanese Research Society for Gastric Cancer for the delineation of the regional-lymph-node areas.17,18 Perigastric, celiac, local para-aortic, splenic, hepatoduodenal or hepatic-portal, and pancreaticoduodenal lymph nodes were included in the radiation fields. In patients with tumors of the gastroesophageal junction, paracardial and paraesophageal lymph nodes were included in the radiation fields, but pancreaticoduodenal radiation was not required. Exclusion of the splenic nodes was allowed in patients with antral lesions if it was necessary to spare the left kidney. Radiation was delivered with at least 4-MV photons. Doses were limited so that less than 60 percent of the hepatic volume was exposed to more than 3000 cGy of radiation. The equivalent of at least two thirds of one kidney was spared from the field of radiation, and no portion of the heart representing 30 percent of the cardiac volume received more than 4000 cGy of radiation. Fluorouracil (400 mg per square meter) and leucovorin (20 mg per square meter) were administered as an intravenous bolus on each of the first four days and the last three days of irradiation. This regimen was shown to be tolerable in a previous trial.