Tricky esophagus case

[deleted1180461]

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75 yo with adeno, underwent neoadj chemoRT elsewhere only received 39.6 Gy then had esophagectomy and pull-through 2 years ago. Now has a small, 1cm biopsy-proven recurrence in a paratracheal (2R) node abutting the neoesophagus. Hard to know what exactly that part of the luminal structure received in terms of radiation dose given surgery. Patient refusing all forms of systemic therapy. No disease elsewhere.

Was thinking hyperfractionate to something in the 35-40 range for local control but suspect he will refuse BID and am guessing will only agree to something hypofractionated, which is lovely in the setting of surgery and ?prior RT in the area. Thoughts?

 

[Gfunk6]

SBRT to 30 Gy in 5 fractions or so. Neoesophagus has not seen radiation and per TG-101 has a dose tolerance of 35 Gy in 5 fractions. Paratracheal lymph nodes tend to not move with respiration and can be reliably tracked.

EDIT: I did some BED calcs. If you assume and alpha/beta of 3 (late reaction) 1.8 Gy x 22 fx = 39.6 Gy has a BED of 63.6. Assuming annual repair of 40%, it goes down to BED 22.8.

30 Gy in 5 fractions to paratracheal LN yields a BED of 90.

90 + 22.8 = 112.8 which is still less than 35 Gy/5 fractions dose tolerance of esophagus.

 

[deleted1180461]

SBRT to 30 Gy in 5 fractions or so. Neoesophagus has not seen radiation and per TG-101 has a dose tolerance of 35 Gy in 5 fractions. Paratracheal lymph nodes tend to not move with respiration and can be reliably tracked.

Thanks. I would feel more comfortable knowing how much of the stomach got radiated and will try and get this information (RT done out of state). Initial primary was GE junction and the field often covers a lot of the stomach.

 

[NotMattSpraker]

75 yo with adeno, underwent neoadj chemoRT elsewhere only received 39.6 Gy then had esophagectomy and pull-through 2 years ago. Now has a small, 1cm biopsy-proven recurrence in a paratracheal (2R) node abutting the neoesophagus. Hard to know what exactly that part of the luminal structure received in terms of radiation dose given surgery. Patient refusing all forms of systemic therapy. No disease elsewhere.

Was thinking hyperfractionate to something in the 35-40 range for local control but suspect he will refuse BID and am guessing will only agree to something hypofractionated, which is lovely in the setting of surgery and ?prior RT in the area. Thoughts?

Is it high up, seems like it could be far away from the initial field in level 2.

I think the 5 fraction recommendation is very reasonable, but I've leaned toward fractionating more recently on these types of cases if the patient lets you do it.

Im guessing it cant be resected...

 

[deleted1180461]

Is it high up, seems like it could be far away from the initial field in level 2.

I think the 5 fraction recommendation is very reasonable, but I've leaned toward fractionating more recently on these types of cases if the patient lets you do it.

Im guessing it cant be resected...

Yeah it likely wouldn't have been in the initial nodal field since it's above carina (and hence probably why it failed there), I was just worried about pulling up partially irradiated stomach and increasing the risk of fistula with SBRT.

 

[medgator]

Is it high up, seems like it could be far away from the initial field in level 2.

I think the 5 fraction recommendation is very reasonable, but I've leaned toward fractionating more recently on these types of cases if the patient lets you do it.

Im guessing it cant be resected...

With chemo? I feel like recurrent isolated nodal disease needs CRT and maybe some io on the back end if it can be covered

 

[deleted1180461]

With chemo? I feel like recurrent isolated nodal disease needs CRT and maybe some io on the back end if it can be covered

Patient refusing any drug therapy including chemo and IO. I will see if I can talk him into xeloda, but I doubt it based on the referral. 5 fraction SBRT would be ideal if I can convince myself fistula risk is acceptable. Of course, I've seen a boomer give 54 in 3 to a lung tumor abutting esophagus, so maybe I am overthinking this.

 

[drowsy12]

It’s Esophageal cancer, he needs systemic therapy more than RT. Hopefully will agree to it after you’re done.

If you’re going to do 5 fx in this setting when you’re concerned that the neoesopjagus may have gotten prior RT, would treat every other day or even twice a week

 

[ramsesthenice]

It’s Esophageal cancer, he needs systemic therapy more than RT.

I've salvaged a couple of these without systemic therapy. It could be recall bias, but it seems like mediastinal/supraclavicular recurrences tend to behave a little better than abdominal recurrences. Don't get me wrong, I would tell anyone looking to do everything they can to consider systemic therapy. But if they had a 2 year disease free interval, I don't think its crazy at all try try focal therapy and then re-image at the 3 month mark if they are leery of drug.

 

[NotMattSpraker]

It’s Esophageal cancer, he needs systemic therapy more than RT. Hopefully will agree to it after you’re done.

If you’re going to do 5 fx in this setting when you’re concerned that the neoesopjagus may have gotten prior RT, would treat every other day or even twice a week

I misread originally and agree. If this is local only with no systemic, I'd lean toward a short course and more gentle like the original recommendation, 30/5 and QOD.

Id also work really hard to have a really steep gradient across the esophagus and keep circumferential dose as low as possible.

 

[TheWallnerus]

In the community I’m very leery of >5Gy per fraction near the esophagus. Sometimes no good deed goes unpunished. Especially if re-irradiation is part of the picture. I really like hyperfract here. I think patients are more persuadable than some people let on too.

Sometimes with the patients you have to be like that waitress from 'Hell or High Water.' Give the hyperfract option, and that's it. Maybe that's paternalism!

 

[drowsy12]

I've salvaged a couple of these without systemic therapy. It could be recall bias, but it seems like mediastinal/supraclavicular recurrences tend to behave a little better than abdominal recurrences. Don't get me wrong, I would tell anyone looking to do everything they can to consider systemic therapy. But if they had a 2 year disease free interval, I don't think its crazy at all try try focal therapy and then re-image at the 3 month mark if they are leery of drug.

Oh I agree and have had the same anecdotally. But he really should get chemoIO.

 

[deleted1180461]

In the community I’m very leery of >5Gy per fraction near the esophagus. Sometimes no good deed goes unpunished. Especially if re-irradiation is part of the picture. I really like hyperfract here. I think patients are more persuadable than some people let on too.

Sometimes with the patients you have to be like that waitress from 'Hell or High Water.' Give the hyperfract option, and that's it. Maybe that's paternalism!

My initial thoughts were along the same lines.
What hyperfractionation regimen would you use? Assume no concurrent xeloda.
I'm pretty sure this is going to end up being 30/5 with no PTV margin extending into esophagus but may present the option.

 

[TheWallnerus]

My initial thoughts were along the same lines.
What hyperfractionation regimen would you use? Assume no concurrent xeloda.
I'm pretty sure this is going to end up being 30/5 with no PTV margin extending into esophagus but may present the option.

I would see what 40-50Gy at 1.2 Gy fraction sizes looks like DVH wise. In theory the 50 Gy dose would have less late effects risk than 30/5, and arguably better tumor effect. In theory!

 

[deleted1180461]

I would see what 40-50Gy at 1.2 Gy fraction sizes looks like DVH wise. In theory the 50 Gy dose would have less late effects risk than 30/5, and arguably better tumor effect. In theory!

What is the BED calc you use to take into account the BID fractionation effect?

48/40 fx = BED10 of 53.8 Gy
30/5 fx = BED10 of 48 Gy

If I can even get it approved.

 

[TheWallnerus]

What is the BED calc you use to take into account the BID fractionation effect?

48/40 fx = BED10 of 53.8 Gy
30/5 fx = BED10 of 48 Gy

If I can even get it approved.

This is a bit hand-wavy stuff, but the way to account for BID fractionation is to account for time. And to account for time, a good rule of thumb is reduce the BED by 0.5 per elapsed days (a 40-fx BID regimen will take roughly ~28 days, and a 5-fx regimen takes ~5-12 days). And this only applies for BED-Gy10 calcs, not late effects calcs. So my math would be:
~~~~~~~~~~~~
48/40 fx = BED-Gy10 of 53.8 Gy (no BID time adjustment)

48/40 fx w/ BID time adjustment:
BED-Gy10 = 48*(1+1.2/10) - (28*0.5) = 40
~~~~~~~~~~~~
30/5 fx = BED-Gy10 of 48 Gy (no time adjustment)

30/5 fx w/ time adjustment:
BED-Gy10 = 30*(1+6/10) - (5*0.5) = 45.5
BED-Gy10 = 30*(1+6/10) - (12*0.5) = 42
~~~~~~~~~~~~
So, when I said 48/40 BID has "arguably" better tumor effects than 30/5, I meant arguably better if one does not account for time. If accounting for time, the 30/5 has arguably better tumor effect. Possibly 40 to 53.8 BED-Gy10 for the BID, and 42 to 48 BED-Gy10 for the SBRT.

As we all know, BID works by keeping the total Rx dose roughly the same and 1) reducing elapsed time for better tumor effect, and 2) reducing fraction size for less late effect.

 

[deleted1180461]

Why are you reducing the BED10 by the same factor for both hyper and hypo fractionation?

 

[TheWallnerus]

Why are you reducing the BED10 by the same factor for both hyper and hypo fractionation?

I don’t see they’re the “same factor”? The BEDGy-10 is reduced by 14 “points” for the hyperfract/28 elapsed day regimen and 2.5 points for a hypofract/5-day regimen. This shows the effect of time. Even though hyperfract is delivered in less time versus standard fract, it is not delivered in as short a time as a 5-fraction regimen. And thus 5-fraction regimens take very little “time hit.” Accounting for time effects shows the extreme effect a treatment break can have. In theory, a treatment break can be so long it can make a regimen have a NEGATIVE biologically effective dose 🙂