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Presented By:
Dr. Vandana
Dept. of Radiation Oncology
CSMMU, Lucknow
Clinical Anatomy
❚ Hollow muscular tube 25 cm in
length which spans from the
cricopharyngeus at the cricoid
cartilage to gastroesophageal
junction (Extends from C7-T10).
❚ Has 4 constrictions-
❙ At starting(cricophyrangeal
junction)
❙ crossed by aortic arch(9’inch)
❙ crossed by left bronchus(11’inch)
❙ Pierces the diaphragm(15’inch)
❚ Histologically 4 layers:
mucosa, submucosa, muscular &
fibrous layer.
FIGURE Anatomy of the esophagus
Contd…
Four regions of the esophagus:
❚ Cervical = cricoid cartilage to
thoracic inlet (15–18 cm from
the incisor).
❚ Upper thoracic = thoracic inlet
to tracheal bifurcation (18–24
cm).
❚ Midthoracic = tracheal
bifurcation to just above the GE
junction (24–32 cm).
❚ Lower thoracic = GE junction
(32–40 cm).
Figure Anatomy of the esophagus with
landmarks and recorded distance from the
incisors used to divide the esophagus into
topographic compartments. GE,
gastroesophageal.
Lymphatic Drainage
❚ Rich mucosal and submucosal
lymphatic system.
❚ Most common in China, Iran, South Africa, India and the former Soviet
Union.
❚ The incidence rises steadily with age, reaching a peak in the 6th to 7th
decade of life.
❚ SCC usually occurs in the middle 3rd of the esophagus (the ratio of
upper : middle : lower is 15 : 50 : 35).
❚ Genetic abnormalities:
❙ p53 mutation, loss of 3p and 9q alleli, amp. Cyclin D1 & amp.
EGFR
Risk Factors: Adenocarcinoma
Barrett’s esophagus is a
metaplasia of the esophageal epithelial lining. The
squamous epithelium is replaced by columnar
epithelium,with 0.5% annual rate of neoplastic
transformation.
95%
Clinical Features
❚ It is commonly associated with the
symptoms of dysphagia, wt. loss, pain,
anorexia, and vomiting
❚ a: Includes nodes
previously labeled as
“M1a”
❚ b : “M1a” designation is
no longer recognized in
the 7th edn. of the AJCC
system
Staging : Squamous cell carcinoma
Staging : Adenocarcinoma
Group T N M Grade
0 Tis (HGD) 1, X
IA T1 1-2, X
IB T1 3
N0
T2 1-2, X
IIA T2 3
IIB T3
T1-2 N1
M0
IIIA T1-2 N2
T3 N1
T4a N0
Any
IIIB T3 N2
IIIC T4a N1-2
T4b Any
Any N3
IV Any Any M1
Diagnostic Workup
❚ Detailed history & Physical examination: Dysphagia,
odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines,
history of GERD. Examine for cervical or supraclavicular adenopathy.
❚ Confirmation of diagnosis:
❙ EGD: allow direct visualization and biopsy, measure proximal & distal distance of
tumor from incisor, presence of Barrett’s esophagus.
Figure Esophageal cancer with aortic invasion. An Figure Esophageal cancer with tracheal invasion. CT
arc (bent arrow) of the contact between the scan shows circumferential wall thickening of the
esophageal cancer (arrows) and the aorta proximal esophagus (arrowheads), which shows
(arrowheads) is more than 90 degrees, indicating irregular interface with the posterior wall of the trachea
aortic invasion. (arrows), indicating direct extension into the lumen
Endoscopic Ultrasonography
❚ EUS:
❙ assess the depth of penetration and LN involvement. Limited by the degree of
obstruction.
❙ Compared with EUS, CT is not a reliable tool for evaluation of the extent of
tumor in the esophageal wall.
Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT
PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B,
Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size
criteria, these lymph nodes may be considered benign on CT scan
❚ Barium swallow:
❙ can delineate proximal and distal margins as well as TEF
❙ Helpful for correlation with simulation film.
❚ Bronchoscopy: rule-out fistula in midesophageal lesions.
❚ Routine Investigations: CBC, chemistries, LFTs.
❚ Site of disease
❚ Extent of disease involvement
❚ Co-morbid conditions
❚ Patient preference.
Surgery
❚ Prerequisite for surgery
❙ disease should be 5 cm beyond cricophyrangeus.
❚ Surgery indications
❙ Lower 1/3 rd oesophageal ds involving GE junction.
❙ Tumor size <5 cm .
❙ palliative surgery
❚ Indication
❙ Used in combination with radiation for locally advanced cancers
❙ Used as single treatment modality in stage IV disease
❙ Combination chemotherapy has been used preoperatively in a combined
modality approach to esophageal Ca in hopes of controlling occult metastatic
disease and improving the resectability rate.
❚ Platinum doublet is preferred over single agents
❚ Cisplatin plus 5-FU or docetaxel are commonly used combinations
Regimens:
❚ Paclitaxel and carboplatin
❚ Cisplatin and 5-FU or capecitabine
❚ Oxaliplatin and 5-FU or capecitabine
❚ Paclitaxel or docetaxel and cisplatin
❚ Carboplatin and 5-FU
❚ Irinotecan and cisplatin
❚ Oxaliplatin, docetaxel and capecitabine
❚ Epirubicin, cisplatin and 5-FU (Only for adenocarcinoma)
Radiotherapy
❚ Curative
❙ Radical RT
❙ Pre-Op RT
❙ Post Op RT
❙ Concurrent chemo-radiation
❚ Palliative
❚ EBRT
❚ Brachytherapy
EBRT Techniques
❚ Patient Positioning:
❙ CERVICAL ESOPHAGUS: Supine with arms by the side
❙ MID AND LOWER THIRD:
❘ SUPINE With arms above their head if AP – PA portals are being planned
❘ PRONE if posterior obliques are being included.
• Esophagus is pulled anteriorly and spinal cord can be spared.
❚ IMMOBILISATION :
❙ Perspex cast
❙ Vertebral column should be as parallel to couch as possible.
❚ Barium swallow contrast to delineate the esophageal lumen and
stomach.
EBRT – Cervical Esophagus
Field Portals:
❚ AP – PA foll. by opposed oblique pair.
❚ 2 anterior obliques and 1 posterior field.
❚ 2 posterior obliques and 1 anterior field
❚ 4 field box with soft tissue compensators foll by obliques ( Univ of
Florida tech )
❚ SUPERIOR BORDER: At C 7
❚ INFERIOR BORDER : At T 4 ( carina )
❚ 2 cm lateral margins.
❚ SC nodes irradiated electively.
❚ SC nodes will be underdosed if oblique portals are used to treat
primary; can be boosted by a separate field if required.
EBRT – Mid & Lower1/3rd
❚ Chemoradiation:
❙ 50.4 Gy in 28 # at 1.8 Gy per #
❙ Boost to 60 – 66 Gy for residual disease
❚ Radical RT:
❙ 45 Gy / 25 # / 1.8 Gy per #
❙ boost with 2 cm margin to total dose of 60Gy
❚ Dose limitations
❙ Spinal cord Dmax:45 Gy at 1.8 Gy/fx
❙ Lung: Limit 70% of both lungs <20 Gy
❙ Heart: Limit 50% of ventricles <25 Gy
Brachytherapy (Intraluminal)
Patient selection:
❙ Primary tumor length ≤ 10 cm length
❙ Tumor confined to esophageal wall
❙ Thoracic esophagus location
❙ No nodal / systemic metastasis.
Contraindications:
❙ T E fistula
❙ Cervical esophagous location
❙ Stenosis which cannot be bypassed
Contd…
❚ Disadvantage:
❙ Tolerance of stomach or bowel used for
interpositioning.
Contd…
❚ 2 randomised trials:
❙ Peniere et al :-
❘ 221 pts, mid / low 1/3rd growth
❘ RT : 45- 55 Gy @ 1.8 Gy per #
❘ 3 yrs - local failure rate ( from 35% to 10%)
- no significant disease free survival.
❙ Fok et al :-
❘ 130 pts , RT – 49 Gy @ 3.5 Gy per #
❘ Local failure rate in patients who had palliative resection
( from 46% to 20% )
❘ No difference for completely resected patients
Post op RT improves local control, but does not confer any survival
advantage.
Trials– Chemoradiation
ChemoRT Vs RT Alone
❚ RTOG 8501 INTERGROUP TRIAL:
❙ 121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per #
61 pts chemoRT – 50 Gy RT +
5 FU + CDDP – on 1 , 5 , 8 & 11 weeks
❙ Median survival : 8.9 Vs 12.5 months
❙ 5 yr survival : 0% Vs 30 %
❙ Distant mets @ 5 yrs: 40% Vs 12 %
❙ Acute toxicity : 25% Vs 44 %
❚ Median & overall survival, LRR and Acute toxicity in Chemo RT
arm.
❚ One study showed significant survival benefit at 3 yrs (in pts who had
a pathologic CR )
❙ Urba et al – 64% Vs 19%
❚ EBRT using 3D-CRT to a total dose of 50.4 Gy (1.8 Gy per daily fraction) is
standard.
❚ IMRT is often utilized to minimize exposure to adjacent structures.
❚ Proton beam in combination with chemotherapy is being explored.
❚ Targeted biologic agents added to standard cytotoxic chemotherapy is
being explored
Conclusion
❚ Esophageal cancer is the 7th leading cause of cancer deaths.
❚ Dysphagia and weight loss are the two most common presentations in
patients with esophageal cancer.