Case: Esophageal Cancer with weird nodes

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Palex80

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Hello! I have a case for you and looking forward to hearing your input.

Male patient in his sixties, known history of tobacco use. Now presents with swallowing difficulties and is diagnosed with a cT3 G3 SCC of the thoracic esophagus.
No immediate regional nodes affected, but two findings on PET-CT: one node in the uppermost mediastinum (almost SCV) and a few other nodes grouped together in the coeliac region. The first biopsy of the tumor was negative and compliance was an issue, so it took some time to complete workup. A new CT done 6 weeks after the PET-CT shows the nodes growing in size, but no apparent new nodes. Swallowing has also worsened.

According to the new staging system, these nodes are still regional, so it's a cT3 cN2 cM0.
However, back in the old days this node metastatic pattern would have classified as cM1a, if I am not mistaken.

Anyways, the nodes lie more than 30cm apart. So with a traditional volume including ENI one would irradiate the full length of the esophagus to include all the nodes between the primary and those two metastatic nodes sites. On the other hand, one does not have to do ENI and could simply leave a gap in between.

I am not sure if definite radiochemotherapy is the right answer here, chances of cure are small due to the node pattern and toxicity is going to be an issue, especially with ENI.

Your thoughts? The surgeons do not want to operate. The patient seems cisplatin-eligible.

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Back in the day full length esophagus radiation was standard of care ( herskovic nejm 1990s randomized trial). The chemo rt arm got 30 gy whole esophagus and 20 gy boost. The rt arm got 50 gy then 14 gy boost.

I would treat, especially with squamous histology. I’ve typically done 39.6-41.4 to large field including the entire esophagus (if both distal and proximal nodes involved) followed by boost to 50.4. If concerned about dvh I think dropping to 36gy for initial phase is option. If still can’t meet goals, having gap in fields and not covering the entire elective area is my last resort. I’ve seen patient fail in “the gap”
 
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If they are asymptomatic (swallowing ok) then starting with chemo and making sure they don’t met out, prior to chemorads is reasonable approach also.
 
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Back in the day full length esophagus radiation was standard of care ( herskovic nejm 1990s randomized trial). The chemo rt arm got 30 gy whole esophagus and 20 gy boost. The rt arm got 50 gy then 14 gy boost.

I would treat, especially with squamous histology. I’ve typically done 39.6-41.4 to large field including the entire esophagus (if both distal and proximal nodes involved) followed by boost to 50.4. If concerned about dvh I think dropping to 36gy for initial phase is option. If still can’t meet goals, having gap in fields and not covering the entire elective area is my last resort. I’ve seen patient fail in “the gap”
Agree with thiss. I'll just do chemo RT. Usually try to get 41.4 to 45 Gy to whole field and then boost primary to 50.4 Gy

Lung dose are definitely the pain but we usually get it within constraints.

Just an extra piece of advice, I do recommend getting a J tube upfront for these large field treatment. I have 1 patient who did fine but he was a super star. A lot of them need nutritional support.
 
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Completely agree with the above. If surgery seems unlikely, I think you have to take gross disease to 5040. I usually favor to RTOG 1010 4500/5040 sequential approach, but that would probably be too much here.

An alternative I've considered but hadn't had the chance to use yet (thankfully): 5040 with isotropic 1cm expansion, 4500 with classic 1cm/4cm expansions around gross disease, and then 4140 (or lower) "connecting" volume between the two. Maybe it still ends up blasting constraints and it has to be 5040 gross/4140 everything else...but maybe this patient is short?
 
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Completely agree with the above. If surgery seems unlikely, I think you have to take gross disease to 5040. I usually favor to RTOG 1010 4500/5040 sequential approach, but that would probably be too much here.

An alternative I've considered but hadn't had the chance to use yet (thankfully): 5040 with isotropic 1cm expansion, 4500 with classic 1cm/4cm expansions around gross disease, and then 4140 (or lower) "connecting" volume between the two. Maybe it still ends up blasting constraints and it has to be 5040 gross/4140 everything else...but maybe this patient is short?
I dose paint the gtv at 2 a day in the same plans to try and dose escalate a bit
 
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Thank you for your responses. I also agree that it's doable DVH-wise and the patient is getting tube placed to secure feeding.

Good to see that you would all still approach this as locoregionally advanced and not metastatic
 
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Back in the day when I had to treat nearly the whole esophagus, that was a patient that got subQ amifostine. And they always seemed to do much better than expected.
 
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Back in the day when I had to treat nearly the whole esophagus, that was a patient that got subQ amifostine. And they always seemed to do much better than expected.
I looked into this recently - amifostine appears to be in short supply, I was told it had been on backorder at my hospital for almost a year. Might just be a regional thing, or a local thing, but it wasn't even a possibility.
 
I looked into this recently - amifostine appears to be in short supply, I was told it had been on backorder at my hospital for almost a year. Might just be a regional thing, or a local thing, but it wasn't even a possibility.
Amifostine suddenly unavailable? Putin rattling nuclear sabres?

Yup, we're all ****ed.
 
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It’s practically an orphan drug at this point.
It really is. I think the story my pharmacists told me was that it was bought by a different drug company and there was a production issue or something?

I would love to hear if anyone else has looked into this recently. For my head and neck patients already with ports in place I was toying around with keeping it in my back pocket if I could, but it was nothing more than a daydream I guess.
 
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People still use amifostine?
375 Americans received the drug in 2019, and 205 in 2020.

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Thank you for your responses. I also agree that it's doable DVH-wise and the patient is getting tube placed to secure feeding.

Good to see that you would all still approach this as locoregionally advanced and not metastatic

Only chance for definitive control. God speed. I like the 45/25 to gross + 3cm sup/inf, 41.4 to any in-between areas, with boost to 50.4 to gross disease.
 
I've done a similar approach recently to what's been described here. Had a lower esophageal tumor with mediastinal and SCV nodes. Technically metastatic as per AJCC 8th edition but spiritually locoregional. Started with induction chemo and had a decent response. Continued with chemoRT, SIB 50 to gross + 1 cm margin, 45 to remaining esophagus and elective nodes in 25 fx. Feeding tube placed upfront. With a VMAT plan I was able to meet all constraints except low dose lung (V5), though if you've perused twitter recently, you'll notice many do not prioritize this constraint. I do personally think it's associated with lower grade pneumonitis, compared to V20 and mean lung dose, which correlate with higher grade pneumonitis, but that's a story for another day.
 
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