Esophagus Flashcards
patient positioning and immobilization devices
SPIC and upper T spine will get a mask
Arms above head for lower T spine with trianglle under knees
preparation for CT sim
2 hour fast before sim
IV and barium contrast and a 4DCT scan is required
MARGINS
GTV: primary tumour mass and enlarged lymph nodes
GTV to CTV expansion for primary tumour→ 4 cm superior and inferior; 1.0 cm radial expansion
GTV to CTV expansion for lymph nodes → 1.0-1.5 cm in all directions
Another critical consideration in determining target volume is tumour motion caused by respiration, cardiac motion and esophageal peristalsis
CTV to PTV: 0.5-1.5 cm and does not have to be uniform in all directions
What LN should be included in CTV
SHOULD include periesophageal LN
lung dose constraints
> 20 gy <30%
heart dose constraints
<30 Gy
spinal cord constraints
<45Gy
dose as a sole treatment or with chemo
Alone: 60-70Gy
chemorads: 50/25
why is AP/PA not appropriate for GE junction tumours
because it would directly irradiate the heart
most common presentation
dysphagia and weight loss in 90 % of patients
what stage is esophageal cancer usually Dx at?
unresectab;e or metastatic stage
how long do symptoms usually start before diagnosis
3-4 months
what countries is it most common in
+ common in developing countries most common in Asia
where is SCC more common, adenocarcinoma??
SCC is most common overall
SCC in developing countries, adenocarcinoma in developed cancers
typically diagnosed _____.
late
age in esophageal ca
55-85
aden arises where, SCC arises where
SCC- in the upper 2/3 of the esophagus
adenocarcinoma arise in the GE junction
ETIogy for SCC
SMOKING AND DRINKING
TYLOSIS AND ACHALASIA
Ethology for adenocarcinoma
what is the #1 cause?
1 barretts esophagus
other risk factors:
GERD, lifestyle factors: low fruit and veg, high nitrate, obesity, helicobactor pylori, plummer vision syndrome and lye corrosion burns
length of esophaguas
25 cm
t level of the esophagus
C7-T11
lyre of the esophagus
mucosa, submucosa, nuscularis proper, amentia
but there is no serosa which allows for seeding
LN upper 1/3 esophagus
deep cervical, int jugular, cervical, s’clad -> thoracic and RT lymph duct
LN drainage of the mid 1/3
sup medi and post meds-> hoiracic and RT lynph duct
LN drainage of low 1/3
celiac LN -> cisternal chill -> thoracic duct
tumours of the GEJ most likely are at what stage at dx
70 % have LN mets at dx
most common place for LN mets
abdominal LN the most common organ is the liver
what is different about spread in an esophagus
skip mets can occur that means lN mets can occur anywhere along the esophagus
what chemo agents are used
cisplatinum + 5 FU
OR
carboplatinum + paclitaxel
when can bratty be used
concurrently with chemorads for small early stage tumours
or as a PALLIATIVE TREATMENT
BRACHY dose for curative intent
done after 50-60 Gy EBRT is done and is treated with 40Gy/2 then 20Gy/2
what agent is used in bratty
IR-192
What portion of the esophagus is surgically unresectable
the cervical portion (upper part)
surgery for esophagus
usually only done for patients who have a good performance status (and tumours of the mid to distal 1/3) and treatment is typically an esophagectomy which removes the entire esophagus and uses small bowel or stomach in its place
treatment for stage 1-2
NEO: chemorads +/- brrachy
50/25 XRT with 5fu cisplatinum or carboplatinum paclitaxel +/- brachy once finished the neo treatments with 40/20 +20/2 then an esophagectomy
treatment stage 3
chemorads is typically the primary also (50/25) + cisplatinum +5fu or carboplatinum + paclitaxel
surgery will be attempted if possible, can cause holes in its esophagus- these pts will not be candidates for surgery
palliative brachy dose
15/1,16/2,18/3v
esophageal obstruction treatment
stent placement or palliative bratty
stage 4 treatment (non obstruction )
palliative chemo or XRT (30/10)
her 2 neu my be expressed in what subtype? what does this indicate treatment wise?
may be expressed in adenocarcinoma means these ptr will also be treated with HERCEPTIN
where is SCC located? adenocarcinoma?
SCC- in the upper and mid 1/3 of the esophagus
Adenocarcinoma in the distal 1/3 and GEJ
Staging adenocarcinoma vs SCC
SCC- staged by location to the pulmonary vein and histologic grade
adenocarcinoma is staged by grade and NOT location
aure se of XRT
ESOPHAGITIS, SKIN ERYTHEMA, FATIGUE, WT LOSS AND N & V
What meds can be given for acute SE of XRT
antiemetics as N &V is a side effect OTC- GRAVOL RX- kytril (granisteron) zofran (odansetron) stemitil (prochlopazerine)
is bratty typically HDR or LDR
HDR
