Esophageal Cancer Staging

[Gfunk6]

In AJCC 7th edition, I'm having problems trying to determine the distinction between N+ and M+ disease when it comes to "regional nodal disease."

If you have a GE jxn esophageal cancer with a positive SCV LN, is that considered N+ or M+?

I've read through NCCN/AJCC but it is not clear to me, can anyone explain or provide a link with a good explanation?

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[BobbyHeenan]

In AJCC 7th edition, I'm having problems trying to determine the distinction between N+ and M+ disease when it comes to "regional nodal disease."

If you have a GE jxn esophageal cancer with a positive SCV LN, is that considered N+ or M+?

I've read through NCCN/AJCC but it is not clear to me, can anyone explain or provide a link with a good explanation?

A similar scenario was discussed at one of ASTRO 2012 difficult cases in GI malignancies sessions. If I'm recalling correctly it was something like GE junction tumor with an upper mediastinal (much greater than 5 cm away) node. The expert panel said there's no systematic distinction for what is regional and metastatic and said the exact thing you said about AJCC - it's not clear....so at least you're in good company with not having some great reference for figuring out local vs. distant disease.

I believe the surgeon mentioned something about they often used the idea that if it's outside of a "standard surgical field" they may consider it metastatic for staging purposes, but may still treat with curative local therapy.

I know that's not helpful, but if you could watch some of that session online maybe it will shed some light.

 

[Brim]

I thought there was a blurb in the staging manual stating that regional lymph nodes extend "from the periesophageal cervical nodes to the celiac nodes.". That implies that the N-staging is independent of primary tumor location.

 

[Palex80]

The next edition should foresee N staging according to site of tumor. This is ridiculous...

 

[user_name]

I don't think it is complicated enough. I hope they add BMI as well and use different cutoffs for each subtype and tumor grade.

The system is so complicated and is really only pathologic staging for a disease that almost never gets surgery. What a tangled web we weave.

 

[Neuronix]

If you have a GE jxn esophageal cancer with a positive SCV LN, is that considered N+ or M+?

I had this exact case today. The only way I can wrap my head around not treating based on the staging guidelines is to think I couldn't encompass the esophagus from the GE junction to the SCV lymph node level without grossly exceeding esophagus tolerance, even with the relatively low dose used in the CROSS trial. I guess I could radiate half of the esophagus to curative dose, or whatever I could get away with, and then radiate the SCV in a separate field, but that seems a little weird to me. Would anyone advocate for that?

 

[medgator]

I had this exact case today. The only way I can wrap my head around not treating based on the staging guidelines is to think I couldn't encompass the esophagus from the GE junction to the SCV lymph node level without grossly exceeding esophagus tolerance, even with the relatively low dose used in the CROSS trial. I guess I could radiate half of the esophagus to curative dose, or whatever I could get away with, and then radiate the SCV in a separate field, but that seems a little weird to me. Would anyone advocate for that?

You can't take a long field to 4140 cGy? The scv is geographically separate, I think to avoid treating the pharynx, you pretty much would have to separate them out

 

[Neuronix]

You can't take a long field to 4140 cGy?

I use mean esophageal dose restriction of 34 Gy based on Quantec. I suspect you'd end up with a mean dose of 40 Gy if you tried an esophageal field that long. The question to me then becomes whether it's worth it with regards to any improvement in cure rate (doubtful) to push to that dose with the percentage of patients who'd end up feeding tube dependent (10%? 20%?). But in the absence of data who knows. To address this question, we should run a trial that won't accrue

 

[medgator]

I use mean esophageal dose restriction of 34 Gy based on Quantec. I suspect you'd end up with a mean dose of 40 Gy if you tried an esophageal field that long. The question to me then becomes whether it's worth it with regards to any improvement in cure rate (doubtful) to push to that dose with the percentage of patients who'd end up feeding tube dependent (10%? 20%?). But in the absence of data who knows. To address this question, we should run a trial that won't accrue

That isn't a hard constraint AFAIK, and is probably more applicable to lung rather than esophageal ca where the esophagus is the target

 

[user_name]

My former partner called me with a GE jxn with SCLV node and celiac nodes. I advised that he treat the GE jxn and celiacs only to 50 Gy for preservation of swallowing. See what happens with the asymptomatic sclv node with chemo. He will come back later with separate electron or photon field if he does not met out or develops symptoms.

I have a guy myself in the workup stages still. He has a SCC of the midesophagus AND a separate tumor at the distal third that is apparently SCC too. Endoscopy and PET scans show these as 2 noncontigous lesions. He also has a left sclv node in addition to mediastinal nodes but not celiac axis adenopathy. He has some other issues being addressed now so I haven't had to draw fields yet. His PS is very poor so I may also forego the SCLV node initially if the toxicity looks too high.

 

[RadOncMegatron]

I thought there was a blurb in the staging manual stating that regional lymph nodes extend "from the periesophageal cervical nodes to the celiac nodes.". That implies that the N-staging is independent of primary tumor location.

I second that SCV for GEJ = regional , although I too would be hesitant to treat all the way up. If there ever was a time for 4140 cGy its now! Although... if they don't surgical address the SCV then well ...