Esophagus

Question 1

patient positioning and immobilization devices

Answer 1

SPIC and upper T spine will get a mask

Arms above head for lower T spine with trianglle under knees

Question 2

preparation for CT sim

Answer 2

2 hour fast before sim

IV and barium contrast and a 4DCT scan is required

Question 3

MARGINS

Answer 3

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

Question 4

What LN should be included in CTV

Answer 4

SHOULD include periesophageal LN

Question 5

lung dose constraints

Answer 5

> 20 gy <30%

Question 6

heart dose constraints

Answer 6

<30 Gy

Question 7

spinal cord constraints

Answer 7

<45Gy

Question 8

dose as a sole treatment or with chemo

Answer 8

Alone: 60-70Gy
chemorads: 50/25

Question 9

why is AP/PA not appropriate for GE junction tumours

Answer 9

because it would directly irradiate the heart

Question 10

most common presentation

Answer 10

dysphagia and weight loss in 90 % of patients

Question 11

what stage is esophageal cancer usually Dx at?

Answer 11

unresectab;e or metastatic stage

Question 12

how long do symptoms usually start before diagnosis

Answer 12

3-4 months

Question 13

what countries is it most common in

Answer 13

+ common in developing countries most common in Asia

Question 14

where is SCC more common, adenocarcinoma??

Answer 14

SCC is most common overall

SCC in developing countries, adenocarcinoma in developed cancers

Question 15

typically diagnosed _____.

Answer 15

late

Question 16

age in esophageal ca

Answer 16

55-85

Question 17

aden arises where, SCC arises where

Answer 17

SCC- in the upper 2/3 of the esophagus

adenocarcinoma arise in the GE junction

Question 18

ETIogy for SCC

Answer 18

SMOKING AND DRINKING

TYLOSIS AND ACHALASIA

Question 19

Ethology for adenocarcinoma

what is the #1 cause?

Answer 19

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

Question 20

length of esophaguas

Answer 20

25 cm

Question 21

t level of the esophagus

Answer 21

C7-T11

Question 22

lyre of the esophagus

Answer 22

mucosa, submucosa, nuscularis proper, amentia

but there is no serosa which allows for seeding

Question 23

LN upper 1/3 esophagus

Answer 23

deep cervical, int jugular, cervical, s’clad -> thoracic and RT lymph duct

Question 24

LN drainage of the mid 1/3

Answer 24

sup medi and post meds-> hoiracic and RT lynph duct

Question 25

LN drainage of low 1/3

Answer 25

celiac LN -> cisternal chill -> thoracic duct

Question 26

tumours of the GEJ most likely are at what stage at dx

Answer 26

70 % have LN mets at dx

Question 27

most common place for LN mets

Answer 27

abdominal LN the most common organ is the liver

Question 28

what is different about spread in an esophagus

Answer 28

skip mets can occur that means lN mets can occur anywhere along the esophagus

Question 29

what chemo agents are used

Answer 29

cisplatinum + 5 FU
OR
carboplatinum + paclitaxel

Question 30

when can bratty be used

Answer 30

concurrently with chemorads for small early stage tumours

or as a PALLIATIVE TREATMENT

Question 31

BRACHY dose for curative intent

Answer 31

done after 50-60 Gy EBRT is done and is treated with 40Gy/2 then 20Gy/2

Question 32

what agent is used in bratty

Answer 32

IR-192

Question 33

What portion of the esophagus is surgically unresectable

Answer 33

the cervical portion (upper part)

Question 34

surgery for esophagus

Answer 34

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

Question 35

treatment for stage 1-2

Answer 35

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

Question 36

treatment stage 3

Answer 36

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

Question 37

palliative brachy dose

Answer 37

15/1,16/2,18/3v

Question 38

esophageal obstruction treatment

Answer 38

stent placement or palliative bratty

Question 39

stage 4 treatment (non obstruction )

Answer 39

palliative chemo or XRT (30/10)

Question 40

her 2 neu my be expressed in what subtype? what does this indicate treatment wise?

Answer 40

may be expressed in adenocarcinoma means these ptr will also be treated with HERCEPTIN

Question 41

where is SCC located? adenocarcinoma?

Answer 41

SCC- in the upper and mid 1/3 of the esophagus

Adenocarcinoma in the distal 1/3 and GEJ

Question 42

Staging adenocarcinoma vs SCC

Answer 42

SCC- staged by location to the pulmonary vein and histologic grade
adenocarcinoma is staged by grade and NOT location

Question 43

aure se of XRT

Answer 43

ESOPHAGITIS, SKIN ERYTHEMA, FATIGUE, WT LOSS AND N & V

Question 44

What meds can be given for acute SE of XRT

Answer 44

antiemetics as N &V is a side effect
OTC- GRAVOL 
RX- kytril (granisteron)
zofran (odansetron) 
stemitil (prochlopazerine)

Question 45

is bratty typically HDR or LDR

Answer 45

HDR