State of Art of the Radiotherapy of Esophageal Cancer
Prof dr Chiricuta I Christian
AMETHYST - Otopeni
Tumor Board RADIOTHERAPY CENTER BUCHAREST - AMETHYST
TUMOR BOARD
Divisions, terminology, and relationships of the esophagus. UES, upper esophageal sphincter; LES, lower esophageal sphincter. (Courtesy Dr. Dorothea Liebermann-Meffert; modified.)
ESOPHAGEAL CANCER TNM
Plan de radioterapie la un pacient cu o tumora atreimii craniale a esofagului iradiata pe un voluminsufficient si cu o doza insuficienta realizat intr-uncentru cu aparatura de ultima generatie si conformrecomandarile societatii americane de oncologie.
Exemplul cel mai elocvent cum intr-un centru de radioterapie cuaparatura de virf se foloseste o tehnica de iradiere din epocacobaltului si anume tehnica box (4 cimpuri). Aceasta tehnica faceimposibila aplicarea dozei necesare pentru a obtine un controltumoral. Din cei 66 Gy necesari au fost aplicati numai 50 Gy in 25fractiuni. Maduva spinarii a obtinut deja 37 Gy din 40 posibili. Oreiradiere cu doza necesare unui control tumoral adica cel putin 66Gy la 2 luni de la finalizarea primei radioterapii este imposibila.
Acesti medici activi azi in multe centre “au cazut nepregatiti intr-oepoca “moderna” si nu pot face fata cerintelor. Cine raspunde desoarta pacientului mai sus prezentat: un protocol nefericit al uneisocietati recunoscute (NCCN), un medic ce vine din era cobalt-uluisi acum are pe mina un accelerator de ultima generatie. Underamine constiinta medicului ? De ce nu trimite acest pacient la uncentru ce ofera tratamentul necesar?
Exodul de medici cu specialitatea radioterapie si oncologie este orealitate cu consecinte dramatice asupra asigurarii unui supportadecvat pacientului oncologic. In anul 2007 a fost raportat unnumar de 100 de medici de radioterapie in reteaua de stat, azisunt numai 50-60 in toata tara la stat si privat. Necesitatileradioterapiei la o populatie de 18 -20 de milioane ar fi 80 deacceleratoare liniare ce trebuie sa fie inzestrate cu cite 3 medicide specialitate per fiecare accelerator. Deci 240 pina la 300 demedici de specialitate sunt necesari considerind si pe cei ce ies lapensie in urmatorii ani.
This analysis demonstrates a marked downstaging and a significant survival benefit with combined neoadjuvant radiochemotherapy as compared to primary resection.
Die Rolle der PET-Untersuchung
beim Esophagus Karzinom
ISRO
Target Volume DefinitionBased on Involvement of Regional Lymphatics in Dependence of the Localisation of
the Primary Tumor
Kiricuta 1992 based on data from Akiyama 1988
Incidence of involvement of the lower neck nodes of the mediastinal and upper abdominal lymphatics for the extrathoracal and the intrathorcal esophageal cancer
Esophageal Carcinoma
TNM Regional Nodes
Cervical esophagus:
- scalene, internal jugular, upper cervical
- periesophageal
- supraclavicular
- cervical
Intrathoracic esophagus (upper, middle, lower):
- tracheobronchial
- superior mediastinal
- peritracheal
- carinal
- hilar (pulmonary
- periesophageal
- perigastric
- paracardial
- mediastinal
Recommendation for Lymphadenectomy
6 or more LN
ISRO
Lymph Node Staging MapEsophageal Cancer - Standardized Node Locations
Niegweg et al. Annals of Surgery 1999
ESOPHAGEAL CANCER TNM
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
55
65
75
85
Jun 9
7
Mrz
98
Apr
98
Mai
98
Sep
98
Okt 98
Dez
98
Dez
98
Dez
98
Dez
98
Jan 9
9
Jan 9
9
Jan 9
9
Feb
99
Gewichtsentwicklung bei Pat. mit Oropharynx Ca u. Zweittumor
des Ösophagus
Gew
icht
ges
und
Tumorresektion I.
Strahlentherapie mit
66,6Gy
Tumorresektion II
KG
Ösophagus-Ca
PEG-Anlage
Strahlentherapie mit
70Gy
Orale
Trinknahrung
Sondennahrung mit
3320-3528 kcal.
Ösophaguskarzinom im mittleren Drittel, mit ausgeprägtem extraluminären Wachstum ins Mediastinum (T4 NX M0) ED 11/98
Gleiches Karzinom nach Radiotherapie mit 70 Gy von 12/98 - 1/99
(distaler Anteil des Ösophagus)
nach 70 Gy RT
nach 60 Gy RT
vor RTvor RT
nach 60 Gy RT
vor RTEsophagus
Karzinom
82 Jahre alte
Patientin
Vor RT
Nach 60 Gy RT
Vor RT
Nach 70 Gy RT
Esophagus Karzinom
82 Jahre alte Patientin
vor CHT
vor CHT
vor CHTTumorbettnach
CHT + RT
Tumor
LK Meta Supraclav.
Tumor
Esophagus Tumordes oberen intrathorakalem Drittel
Esophagus Tumormit
Dosisverteilung
Vor CHT
PETvorCHT
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
ISRO
Anatomy of the Esophagus:The lymphatic drainage Zones of Resano
Haagensen 1972
PREOP RT + CHT, RTOG 94 – 05Minski et al. JCO 2002
Therefore, 50.4 Gy at 1.8 Gy per fraction 5 days per week is currently considered standardfor patients with esophageal cancer treated with concurrent chemoradiation therapy.56–58,66
Preop RT + CHT
ESOPHAGEAL CANCER VMAT RADIOTHERAPY
dupa iradiereFistula?
dupa iradiereFistula?
Inainte de iradiereFara fistula
ESOPHAGEAL CANCER VMAT RADIOTHERAPY
dupa iradiereFistula?
Inainte de iradiereFara fistula
ESOPHAGEAL CANCER VMAT RADIOTHERAPY
Inainte de iradieredupa iradiereFistula?
dupa iradiereFistula?
ESOPHAGEAL CANCER VMAT RADIOTHERAPY
Ultima iradiere (la 50 Gy)
Prima iradiere (la 0 Gy)dupa iradiere
Fistula?
ESOPHAGEAL CANCER VMAT RADIOTHERAPY
CANCER AL ESOFAGULUI PROXIMAL EXTRATORACAL CU EXTENSIE PACIENT IN VIRSTA DE 79 ANI
54 ani
8/2014
81 ani
AMETHYST TEAM
AMETHYST RADIOTHERAPY CLINIC
24 MASTER - STUDENTS
This patient is a 72-year-oldmale who presented withanemia.Esophagogastroduodenoscopy(“EGD”) revealed esophagealtumor extending from 29.0cmto 38.0cm. Endoesophagealultrasound staged this as T3 N0M0 carcinoma. CT scanrevealed abnormality involvingthe distal esophagus. The planwas for radiation therapycombined with chemotherapyand then definitive surgery.
A radiation-planning wholebody FDG PET/CT scan wasordered prior to onset oftreatment. This revealedintense increased uptake ofFDG in the distal esophagusand also two abnormal nodesin the anterior mediastinumsuperior to the primary mass.This was a surprise finding andvaluable in changing theradiation treatment volume soas to include these nodes.Both tumor staging andradiation treatment volumewere changed as a result ofthe PET/CT.
Whole body FDG-PET/CT MIP view (A), transaxial (B1) andsagittal (B2) fused images in a 64-year-old man withoesophageal carcinoma (thin arrows) and vertebralinvolvement (thick arrows), which rendered himinoperable.
Preoperative Radiochemotherapy in Gastric Cancer: Another Ongoing Shift From Adjuvant to Neoadjuvant?
JCO 2005, 3870-3871
Abdelkarim S. AllalRadiation Oncology Service, Geneva University Hospital,
Geneva, Switzerland
Fletcher1973
Perez& Brady1996
MacDonald2001
palliation AdjuvantRT+CT
Neoadjuvant
Siewert
CHEMORADIOTHERAPY AFTER SURGERY COMPARED WITH SURGERY ALONE FOR ADENOCARCINOMA OF THE STOMACH OR GASTROESOPHAGEAL JUNCTIONJ. S. MACDONALD et al. N Engl J Med, 2001; 345 (10): 725-730
Postoperative chemoradiotherapy should be considered for all patients at high risk for recurrence of adenocarcinoma of the stomach or gastroesophageal
junction who have undergone curative resection.
Greutate la inceput RT+CHT 65 kg, la sfirsit RT+CHT 65kg
66 ani
DG
ESOPHAGEAL CANCER TNM
ESOPHAGEAL CANCER TNM
PREOP RT + CHT, RTOG 94 – 05Minski et al. JCO 2002
Therefore, 50.4 Gy at 1.8 Gy per fraction 5 days per week is currently considered standardfor patients with esophageal cancer treated with concurrent chemoradiation therapy.56–58,66
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
Computed tomography (CT) scan and positron emission tomography (PET) images of a 71-year-old man who presented with abdominal discomfort. A, Chest CT scan showing abnormalesophageal thickening extending from the midesophagus to the distal esophagus.Esophagogastroduodenoscopy showed involvement with a moderately well differentiatedesophageal adenocarcinoma extending from 25 to 35 cm of the esophagus. B and C, PET scan(B) and combined PET-CT scans (C) show abnormal uptake in that area. D, Coronal PET imagesshow extent of the cancer. (Courtesy of Dr. Bohdan Bybel, Department of Radiology, ClevelandClinic.)
ESOPHAGEAL CANCER
Endoscopic ultrasonography (EUS). A, EUS can assess enlarged lymph nodessurrounding the esophageal cancer. Using certain criteria and combining them withfine-needle aspiration of suspicious lymph nodes (B), the accuracy can reach almost95%. This is highly dependent on operator experience.
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
ESOPHAGEAL CANCER
Adenocarcinoma
Squamous cell carcinoma
50
55
60
65
70
75
80
85
90
95
100
105
110
Bevor Ther. Begin RT End RT
Ge
wic
ht
in k
g
Pat.v.S. Pat.La. Pat.Jö. Pat.Kr.
Pat.Re. Pat. Ge. Pat. Wa. Pat. Fa.
Gewichts-Follow Up von Patienten mit Hochdosisstrahlentherapie bei
HNO-Tumoren
unter Immunonutrition
ESOPHAGEAL CANCER
SCC Adeno Ca
Radiation was delivered in daily fractions of 1.8 Gy (days 1–5, 8–12, 15–19, and 22–26) to a total dose of 36 Gy using a multiple field technique. Surgical resection was carried out 4–5weeks following completion of chemoradiation
28/03/14
Results
P=0.0098
163