RADIATION THERAPY RADIATION THERAPY IN IN

CA ESOPHAGUSCA ESOPHAGUSDr. T. SujitDr. T. SujitA M O ( Radiation Oncology )Valavadi Narayanaswami Cancer Centre,G.Kuppuswamy Naidu Memorial Hospital,Coimbatore - 641037, Tamilnadu, India

April 2007

ROLE OF RT IN CA ESOPHAGUSROLE OF RT IN CA ESOPHAGUS

CURATIVECURATIVE RADICAL RTRADICAL RT PRE-OP RTPRE-OP RT POST OP RTPOST OP RT CONCURRENT CHEMORADIATIONCONCURRENT CHEMORADIATION

PALLIATIVEPALLIATIVE

EBRTEBRT

BRACHYTHERAPYBRACHYTHERAPY

TRIALS – RADICAL RTTRIALS – RADICAL RT

NO randomised trials of RT Vs SxNO randomised trials of RT Vs Sx

5 yr survival with conventional RT : < 10%5 yr survival with conventional RT : < 10%

Tumors < 5 cm , 5 yr survival : 20%Tumors < 5 cm , 5 yr survival : 20%

Stage wise 5 yr survival:Stage wise 5 yr survival: Stage I – 20%Stage I – 20% Stage II – 10%Stage II – 10% Stage III – 3 %Stage III – 3 % Stage IV – 0%Stage IV – 0%

TRIALS – RADICAL RTTRIALS – RADICAL RT

For cervical esophagus, cure rates were For cervical esophagus, cure rates were similar with Radical RT or Sx alone.similar with Radical RT or Sx alone.RT or Sx alone DOES NOT alter the RT or Sx alone DOES NOT alter the natural history of the disease.natural history of the disease.RTOG 8501: RT Vs Chemo RTRTOG 8501: RT Vs Chemo RT Better LRC and improved OS with ChemoRTBetter LRC and improved OS with ChemoRT

RT alone should be used for palliation or RT alone should be used for palliation or in medically unfit patients.in medically unfit patients.

TRIALS – PRE OP RTTRIALS – PRE OP RT

PRINCIPLE :PRINCIPLE : resectability, resectability, likelihood of tumor dissemination likelihood of tumor dissemination

during Sx , during Sx , radioresponsiveness due to unaltered radioresponsiveness due to unaltered blood supplyblood supply

5 randomised trials 5 randomised trials Only one trial ( Huang et al ) showed survival Only one trial ( Huang et al ) showed survival

advantage of 46% Vs 25% with 40 Gy RTadvantage of 46% Vs 25% with 40 Gy RT Oesophageal Cancer Collaborative Group study Oesophageal Cancer Collaborative Group study

showed no clear survival advantage.showed no clear survival advantage.

No difference in resectability rates, LRC or No difference in resectability rates, LRC or survival with pre-op RTsurvival with pre-op RT

TRIALS – POST OP RTTRIALS – POST OP RT

ADVANTAGES:ADVANTAGES: Treat areas at risk while minimising dose to Treat areas at risk while minimising dose to

OAR.OAR. Patients with node negative , completely Patients with node negative , completely

resected T1 / T2 tumors can be excluded.resected T1 / T2 tumors can be excluded.

DISADVANTAGE:DISADVANTAGE: Tolerance of stomach or bowel used for Tolerance of stomach or bowel used for

interpositioninginterpositioning

TRIALS – POST OP RTTRIALS – POST OP RT

2 randomised trials:2 randomised trials: Peniere et al :- Peniere et al :-

221 pts, mid / low 1/3221 pts, mid / low 1/3rdrd growth growth RT : 45- 55 Gy @ 1.8 Gy per #RT : 45- 55 Gy @ 1.8 Gy per # 3 yrs - 3 yrs - local failure rate ( from 35% to 10%) local failure rate ( from 35% to 10%)

- no significant disease free survival.- no significant disease free survival. Fok et al :-Fok et al :-

130 pts , RT – 49 Gy @ 3.5 Gy per #130 pts , RT – 49 Gy @ 3.5 Gy per # Local failure rate Local failure rate in patients who had palliative resection in patients who had palliative resection ( from 46% to 20% )( from 46% to 20% ) No difference for completely resected patientsNo difference for completely resected patients

Post op RT improves local control, but does not Post op RT improves local control, but does not confer any survival advantage.confer any survival advantage.

TRIALS – CHEMORADIATIONTRIALS – CHEMORADIATIONCHEMO RT Vs RT ALONECHEMO RT Vs RT ALONE

RTOG 8501 INTERGROUP TRIAL:RTOG 8501 INTERGROUP TRIAL: 121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per #121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per #

61 pts chemoRT – 50 Gy RT61 pts chemoRT – 50 Gy RT

5 FU + CDDP – on 1 , 5 , 8 & 11 weeks5 FU + CDDP – on 1 , 5 , 8 & 11 weeks Median survival : 8.9 Vs 12.5 monthsMedian survival : 8.9 Vs 12.5 months 5 yr survival : 0% Vs 30 %5 yr survival : 0% Vs 30 % Distant mets @ 5 yrs: 40% Vs 12 %Distant mets @ 5 yrs: 40% Vs 12 % Acute toxicity : 25% Vs 44 %Acute toxicity : 25% Vs 44 %

MEDIAN & OVERALL SURVIVAL, MEDIAN & OVERALL SURVIVAL, LRR LRR

AND AND ACUTE TOXICITY IN CHEMO RT ARM. ACUTE TOXICITY IN CHEMO RT ARM.

CHEMORADIATION IS A STANDARD NON-SURGICAL Tx.CHEMORADIATION IS A STANDARD NON-SURGICAL Tx.

TRIALS – CHEMORADIATIONTRIALS – CHEMORADIATIONRT DOSE ESCALATION IN CHEMO RTRT DOSE ESCALATION IN CHEMO RT

INTERGROUP 0123 TRIAL – 218 ptsINTERGROUP 0123 TRIAL – 218 pts Chemoradiation - either 50.4 Gy or 64.8 GyChemoradiation - either 50.4 Gy or 64.8 Gy

No significant difference in median survival, 2 yr survival or No significant difference in median survival, 2 yr survival or

loco-regional failure.loco-regional failure.

Intensification of RT dose beyond 50.4 Gy Intensification of RT dose beyond 50.4 Gy

(in combination with chemotherapy ) does not (in combination with chemotherapy ) does not

improve results.improve results.

TRIALS – CHEMORADIATIONTRIALS – CHEMORADIATIONPRE OP CHEMO RT Vs Sx ALONEPRE OP CHEMO RT Vs Sx ALONE

4 Randomised trials4 Randomised trials 2 studies showed 2 studies showed in local recurrence in local recurrence Urba et al – 19 % Vs 42 %Urba et al – 19 % Vs 42 % Bosset et al ( EORTC ) – 28% Vs 40%Bosset et al ( EORTC ) – 28% Vs 40%

One study showed significant survival benefit at 3 One study showed significant survival benefit at 3 yrs ( in pts who had a pathologic CR )yrs ( in pts who had a pathologic CR ) Urba et al – 64% Vs 19%Urba et al – 64% Vs 19%

One study (Walsh et al) showed benefit in median One study (Walsh et al) showed benefit in median (16 Vs 11 months ) and overall survival at 3 yrs (16 Vs 11 months ) and overall survival at 3 yrs ( 32 Vs 6%) ( 32 Vs 6%)

Results support TRIMODALITY approach.Results support TRIMODALITY approach.

EBRT TECHNIQUESEBRT TECHNIQUES

PATIENT POSITIONING:PATIENT POSITIONING: CERVICAL ESOPHAGUS: Supine with arms by the sideCERVICAL ESOPHAGUS: Supine with arms by the side

MID AND LOWER THIRD:MID AND LOWER THIRD:

SUPINE if AP – PA portals are being plannedSUPINE if AP – PA portals are being planned

PRONE if posterior obliques are being included.PRONE if posterior obliques are being included. Esophagus is pulled anteriorly and spinal cord can be spared.Esophagus is pulled anteriorly and spinal cord can be spared.

IMMOBILISATION : IMMOBILISATION : Perspex castPerspex cast

Vertebral column should be as parallel to couch as possible.Vertebral column should be as parallel to couch as possible.

Barium swallow contrast to delineate the esophageal Barium swallow contrast to delineate the esophageal

lumen and stomach.lumen and stomach.

EBRT – CERVICAL ESOPHAGUSEBRT – CERVICAL ESOPHAGUS

AP – PA foll. by opposed oblique pair.AP – PA foll. by opposed oblique pair. 2 anterior obliques and 1 posterior field.2 anterior obliques and 1 posterior field. 2 anterior obliques and 1 anterior field2 anterior obliques and 1 anterior field 4 field box with soft tissue compensators foll by obliques 4 field box with soft tissue compensators foll by obliques

( Univ of Florida tech )( Univ of Florida tech )

SUPERIOR BORDER: At C 7 SUPERIOR BORDER: At C 7 INFERIOR BORDER : At T 4 ( carina )INFERIOR BORDER : At T 4 ( carina ) 2 cm lateral margins.2 cm lateral margins.SC nodes irradiated electively.SC nodes irradiated electively.SC nodes will be underdosed if oblique portals are used SC nodes will be underdosed if oblique portals are used to treat primary; can be boosted by a separate photon to treat primary; can be boosted by a separate photon field if required.field if required.

CERVICAL ESOPHAGUSCERVICAL ESOPHAGUS

EBRT - MID & LOWER 1/3EBRT - MID & LOWER 1/3RDRD

AP – PA followed by 1 Ant and 2 Post oblique pair AP – PA followed by 1 Ant and 2 Post oblique pair ( coning down )( coning down )

4 FIELD : AP-PA & opposed laterals – for mid 1/34 FIELD : AP-PA & opposed laterals – for mid 1/3rdrd lesions with patient in prone position.lesions with patient in prone position.

AP-PA upto 43 Gy foll by 2 Post obliques upto 50 Gy AP-PA upto 43 Gy foll by 2 Post obliques upto 50 Gy ( gross disease boosted to 60 Gy )( gross disease boosted to 60 Gy )

SUPERIOR BORDER: 5 cm proximal to superior extent SUPERIOR BORDER: 5 cm proximal to superior extent of disease.of disease.

INFERIOR BORDER:INFERIOR BORDER: MID 1/3MID 1/3RDRD – AT GE jn. As visualised by Barium swallow – AT GE jn. As visualised by Barium swallow LOWER 1/3LOWER 1/3RDRD - Coeliac plexus ( L 1 ) to be included. - Coeliac plexus ( L 1 ) to be included.

3D CRT IMRT

EBRT - DOSESEBRT - DOSES

CHEMORADIATION :CHEMORADIATION : 50.4 Gy in 28 # at 1.8 Gy per #50.4 Gy in 28 # at 1.8 Gy per # Boost to 60 – 66 Gy for residual diseaseBoost to 60 – 66 Gy for residual disease

RADICAL RT:RADICAL RT: 45 Gy / 25 # / 1.8 Gy per #45 Gy / 25 # / 1.8 Gy per # boost with 2 cm margin to total dose of 60Gyboost with 2 cm margin to total dose of 60Gy

BRACHYTHERAPYBRACHYTHERAPY

As a boost after EBRT or as a palliative As a boost after EBRT or as a palliative measuremeasure

Local control of 25% - 35 in palliative settingLocal control of 25% - 35 in palliative setting

In curative setting, addition of brachytherapy In curative setting, addition of brachytherapy does not improve results compared to does not improve results compared to Radical RT or Chemoradiation.Radical RT or Chemoradiation.

AAMERICANMERICAN BBRACHYTHERAPYRACHYTHERAPY S SOCIETYOCIETY GUIDELINESGUIDELINES

PATIENT SELECTION:PATIENT SELECTION: Primary tumor length Primary tumor length ≤≤ 10 cm length 10 cm length Tumor confined to esophageal wallTumor confined to esophageal wall Thoracic esophagus locationThoracic esophagus location No nodal / systemic metastasis.No nodal / systemic metastasis.

CONTRAINDICATIONS:CONTRAINDICATIONS: T E fistulaT E fistula Cervical esophagous locationCervical esophagous location Stenosis which cannot be bypassedStenosis which cannot be bypassed

AAMERICANMERICAN BBRACHYTHERAPYRACHYTHERAPY S SOCIETYOCIETY GUIDELINESGUIDELINES

EBRT 45 – 50 Gy with concurrent chemo foll by brachy : EBRT 45 – 50 Gy with concurrent chemo foll by brachy :

( EBRT 60 Gy if chemo is not given )( EBRT 60 Gy if chemo is not given ) HDR – 5 Gy x two # one week apart , 2 – 3weeks after EBRT.HDR – 5 Gy x two # one week apart , 2 – 3weeks after EBRT.

LDR – single 20 Gy # @ 0.4 – 1.0 Gy per hr, 2 -3 weeks after EBRT.LDR – single 20 Gy # @ 0.4 – 1.0 Gy per hr, 2 -3 weeks after EBRT.

Never concurrently with chemotherapyNever concurrently with chemotherapy

Ext diameter of applicator must be 6 – 10 mm.Ext diameter of applicator must be 6 – 10 mm.

Active length : visible tumor by UGI scopy plus 1 – 2 cm Active length : visible tumor by UGI scopy plus 1 – 2 cm

proximal & distal margin.proximal & distal margin.

Dose is prescribed 1 cm from mid source or mid dwell Dose is prescribed 1 cm from mid source or mid dwell

position.position.

APPLICATORSAPPLICATORS

TOXICITY OF THERAPYTOXICITY OF THERAPY

SURGERYSURGERY Cardiopulmonary complications, anastomotic Cardiopulmonary complications, anastomotic

leak, RL nerve palsy, stricture.leak, RL nerve palsy, stricture.

RADIATIONRADIATION Acute – esophagitis , fatigue, weight loss, Acute – esophagitis , fatigue, weight loss,

pneomonitis, perforation.pneomonitis, perforation. Chronic – stenosis ( 60%), stricture ( 20% )Chronic – stenosis ( 60%), stricture ( 20% )

CHEMOTHERAPYCHEMOTHERAPY Bone marrow suppression , mucositis.Bone marrow suppression , mucositis.

T H A N K Y OUT H A N K Y OU