TARGET DELINEATION OF CANCER ESOPHAGUS

1. TARGET DELINEATION
CANCER ESOPHAGUS
DR KANHU CHARAN PATRO
1

2. IN EVERY CASE
1. As effective as possible.
2.As less toxic as possible.
3.As simple as possible.
4.As short as possible.
5.As economic as possible
2

3. Diagnosis of Esophageal Cancer
• Esophagus-
Malignant
Esophageal Cancer
– Squamous Cell Ca
• Mid-esophagus
– Adenocarcinoma
• Distal Esophagus
3

4. ALWAYS SEARCH
• Gather any small piece of important
information:
–Clinical – P/E, EGD, EUS, CT, PET…
• Evaluate operability & resectability (anatomic &
physiologic staging).
• Consider aggressive & multi-modal approach.
• Optimize RT target volume to achieve Tx goal.
• Monitor and adapt to changes during RT course.
4

5. SYSTEMATIC ERROR
5

6. 6

7. Esophagus
Cancer
Lymph
Nodes
7

8. LYMPH NODE INVASION
• Many studies have reported that lymph
node recurrence increases dramatically with
–Deeper invasion,
–Higher number of lymph nodes with positive
metastases,
–Poorer tumor differentiation,
–Longer tumor length after esophagectomy
8

9. Incidence of Lymph Node Metastases for
Squamous Cancer
9

10. 10

11. 11

12. Radiation Target Advice on the
Lymph Nodes
Cervical Esophagus: include
supraclavicular and possible
cervical nodes
Proximal Third: supraclavicular
and para-esophageal
Middle Third: para-esophageal
Distal Third/GE Junction: para-
esophageal, lesser curvature,
celiac axis 12

13. 13

14. TARGET VOLUMES-ARE STRAIGHT FORWARD?
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15. 15

16. 16

17. 17

18. WHICH WINDOW?
18

19. LEVEL AND WIDTH FOR DELINEATION
WIDTHWIDTH
LEVELLEVEL
A. Brightness refers to the overall lightness or
darkness of the image.
B. Contrast is the difference
in brightness between objects in the image.
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20. Brightness- window level Contrast- window width
20

21. WIDTH LEVEL
21

22. 1. CT: standard imaging modality
2. Complementary information by EUS and PET scanning
3. PET scanning in suspicious conditions
WHICH image?
22

23. PET
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24. Suspicious node
24

25. WHEN IT IS UNCLEAR
THINK OF NUCLEAR
25

26. Suspicious node
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27. Suspicious prevertebral node
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28. Moureau et al. IJROBP 2005
Increased Target Volume in OesophagealIncreased Target Volume in Oesophageal
CarcinomaCarcinoma
28

29. HENCE PET
1. For tumor-node-metastasis (TNM) staging of
the mediastinum
2. Screening for metastases that might not be
detected by CT alone
3. For radiotherapy planning
29

30. WHEN THINGS ARE SUSPICIOUS
PET CT IS AUSPICIOUS
WHEN THINGS ARE SUSPICIOUS
PET CT IS AUSPICIOUS
PARAMETER VOLUME
CHANNGE
TREATMENT CHANGE
T STAGE
UPSTAGING
1. PREVENTS GEOGRAPHICAL MISSING
2. MAY CHANGES TT FROM CURATIVE TO PALLLIATIVE
DOWN STAGING 1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. MAY CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
N STAGE UPSTAGING 1. PREVENTS GEOGRAPHICAL MISSING
2. MAY CHANGES TT FROM CURATIVE TO PALLLIATIVE
DOWN STAGING 1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. MAY CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
M STAGE UPSTAGING MAY CHANGES TT. FROM PALLIATIVE TO BSC
DOWN STAGING MAY CHANGES TT. FROM PALLIATIVE TO CURATIVE
30

31. Bird’s eye view Eagle’s eye view
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32. 32

33. ITV REALLY EXISTS?
Current practice in RT uses ICRU definition
of target volume
1. Gross tumor volume (GTV)
2. Clinical target volume (CTV)
3. Planning target volume (PTV)
33

34. 34

35. Typical Radiation Field
for Cervical or Upper Esophagus
radiation
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36. Typical Radiation Field for Middle
Esophagus
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37. Typical Radiation Field for Lower
Esophagus
37

38. Typical Radiation Field for Lower
Esophagus
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39. ORGANS AT RISK
39

40. Identify the Normal Structures that Might be
Affected
Lung Lung
Heart
Kidney
Spinal Cord
Kidney
Spinal Cord
Radiation
Liver
40

41. Lung and
Trachea
Esophagus
Radiation to the lung and trachea can lead to
coughing, or shorteness of breath, if the
esophagus cancer is invading into the trachea
there is a risk of a fistula (TE fistula)
Long terms risks are related to scarring or fibrosis
in the lung which can cause breathing problems
41

42. Radiation Dose Guidelines
1. PreOperative: 41.1 – 50.4Gy (1.8- 2.0/day)
2. PostOperative: 45 – 50.4Gy (1.8- 2.0/day)
3. Definitive: 50 – 50.4Gy (1.8-2.0/day)
Higher dose (60-66Gy) may be considered in
cervical esophagus where surgery is not planned, but
there is little evidence of benefit > 50.4Gy
42

43. Dose Constraints (RTOG
1010)
43

44. PUSHING BACKWARD AND FORWARD AT A TIME
DIFFICULT BUT NOT IMPOSSIBLE
OAR
TARGET
44

45. PROTOCOLS
1. CALGB 80803 PROTOCOL
2. RTOG 1010
3. CROSS PROTOCOL
4. SCOPE-1 PROTOCOL
5. Abraham J. GUIDELINE
6. MD ANDRESON PROTOCOL
45

46. Advice from the RTOG
46

47. 47

48. RTOG 1010 Target
1.GTV (Gross Tumor Volume) = gross
cancer and obviously involved nodes
2.CTV (Clinical Tumor Volume) = GTV + 4cm
above and below and 1.0 – 1.5cm radial
margins, plus para-esophageal or celiac
lymph node axis
3.PTV (Planning Target Volume) = GTV + 0.5
– 1cm expansion
Dose: 50.4Gy in 28 fractions (45Gy + 5.4 Gy
as boost) 48

49. Start with PET – CT images of Cancer Target
Cancer
49

50. Identify the Gross Tumor Volume (GTV)
GTV
50

51. Identify the Clinical Tumor Volume (CTV)
CTV
51

52. Identify the Planning Tumor Volume (PTV)
PTV
52

53. IMRT (Tomotherapy) Plan
PTV
radiation
53

54. 54

55. C R O S S T
rial
• Preoperative Chemoradiotherapy for
Esophageal or Junctional Cancer
• 366 patients w/ T1N1 or T2-3N0 GE junction
or esophageal cancer
• Randomized
– Preoperative CRT (41.4 Gy &
Carboplatin/Paclitaxel) followed surgery
– Surgery alone
55

56. 1. CTV = GTVp with a 4 cm expansion sup/inf along the
length of the esophagus and gastric cardia and a 1.0-
1.5 cm radial expansion plus the
2. GTVn with a 1.0-1.5 cm expansion in all dimensions
3. The celiac axis should be covered for tumors of the
distal esophagus or GE junction
4. PTV expansion should be 0.5 to 1.0 cm and does not
need to be uniform in all dimensions
5. Boost PTV (50.4Gy) = GTVp and GTVn with an
expansion of 0.5 to 1.0 cm
Target Volumes
56

57. Target
Volumes
• GTV
• CTV
• – Cropped off anatomic
structures in which
invasion is not likely
(i.e. vertebrae,
trachea/bronchi, aorta,
lung)
• PTV
57

58. Target
Volumes
• GTV
• CTV
• PTV
(45Gy)
58

59. RADICAL SETTINGS
59

60. 60

61. 61

62. Treatment
Planning
• CT Simulation
– IV and/or esophageal contrast may be
used to aid in target localization
– Arms above head to maximize number of
beam arrangements
– Immobilization
– Consider 4D-CT for GE junction tumors
5NCCN. Esophageal and Esophagogastric
Junction Cancers (Version 1.2014)
62

63. 63

64. 64

65. 65

66. HOW TO DELINEATE GTV?
• Gather any small piece of important
information:
–Clinical – P/E, EGD, EUS, CT, PET…
66

67. CTV SHOULD FOLLOW GEOMETRIC
EXPANSION?
CTV should be oriented along the
esophageal, instead of being a
simple geometric expansion
67

68. PROXIMAL CTV MARGIN
1. 3-4cm margin above the proximal edge of the GTV, or
1cm above any grossly involved periesophageal nodes
2. Pathologic analysis of microscopic extension in
resected tumor specimens indicates that proximal
and distal mucosal margins of 3cm may be sufficient
for the majority of cases to encompass submucosal
spread of disease
68

69. PROXIMAL CTV IN VERY PROXIMAL
TUMORS
For very proximal tumors, the upper border
should not extend above the level of the
cricoid cartilage unless there is gross disease
at that level
69

70. DISTAL CTV FOR NON GE JUNCTION
TUMORS
For proximal or mid-esophageal tumors, a 3-
4cm margin below the proximal edge of the
GTV, oriented along the esophagus
70

71. RADIAL MARGIN
A 1cm radial margin from the outer esophageal
wall was recommended to encompass the
peri-esophageal lymph nodes
71

72. DISTAL CTV FOR GE JUNCTION
TUMORS
1. For distal esophageal or GE junction tumors, a 4cm
geometric margin distally for all cases would extend well
below the GE junction and include unacceptably large
volumes of stomach or other abdominal viscera
2. Therefore for this situation, at least a 2cm margin along
clinically uninvolved gastric mucosa was recommended. If
treating to lower, preoperative-intent doses (≤4500cGy),
3. A 4cm or greater gastric margin may be appropriate
Particularly for tumors with significant gastric extension.
Siewert III lesions, and lesions extending more than 5cm
into the stomach
72

73. Modifications to CTV
HEART
LIVER
•HEART
•LIVER
•VERTEBRAL BODY
•DESCENDING AORTA
•LUNGS
CTV
VERTEBRAL BODY
DESCENDING
AORTA
73

74. it was recommended that the CTV expansion be
limited to 0.5cm into cardiac tissue (including
pericardium), given concern for excessive cardiac dose
and the unlikelihood of microscopic extension into the
myocardium in the absence of gross invasion.
SHAVING OFF CTV FROM HEART
74

75. It was also recommended that the
vertebral bodies be entirely excluded
from the CTV in the absence of gross
invasion
SHAVING OFF CTV FROM VERTEBRA
75

76. the CTV expansion can be limited to 0.5cm
into uninvolved liver.
Excluding the liver and heart from the CTV
entirely is reasonable if robust motion
management techniques, such as
respiratory gating or an ITV approach
SHAVING OFF CTV FROM LIVER
76

77. CELIAC NODAL VOLUME
1.For distal tumors involving or approaching the GE junction, the CTV
should be extended inferiorly to the level of the origin of the celiac
axis, in order to cover the celiac lymph nodes, which normally are
located at the level of the T12 vertebral body.
2.Typically, the celiac nodal CTV will be bounded by the lateral
aspect of the vertebral body (usually T12) on the right, 0.5-1cm
beyond the lateral aspect of the aorta on the left, the vertebral body
posteriorly, and the pancreatic body anteriorly.
3. The kidneys should be excluded from the CTV
77

78. 78

79. HANDLING SPLENIC NODES
1. The splenic hilar nodes are not considered regional nodes for
esophageal cancer and do not need to be specifically included
in the CTV
2. However, with Siewert Type II GE junction tumors, given a
higher risk of lymph node involvement, the panel agreed that
inclusion of some or all nodes in the splenic hilum and
greater curvature region can be at the discretion of the
treating physician if using lower doses, depending on the
patient’s clinical and pathologic features
79

80. NODAL VOLUME IN GE JUNCTION
In the upper abdomen, between the level of the
GE junction and the celiac nodes, it was
recommended that para-aortic and gastrohepatic
ligament (often classified as lesser curvature or
left gastric) nodes be included in the CTV
80

81. 81

82. HANDLING SUPRACLAV NODES
1. For tumors above the level of the carina, it was
recommended that the bilateral supraclavicular nodal
basins be included. The recommended borders of the
supraclavicular nodes are analogous to Level IV nodes
in head and neck cancer in which the cranial border
is the level of the cricoid
2. Cranial border is the level of the cricoid cartilage, and
the anterior, posterior, and lateral borders
correspond to the borders of the
sternocleidomastoid muscles, with the inferior
border extending into the thoracic inlet
82

83. 83

84. 84

85. HANDLING MEDIASTINAL NODES
1.Distal tumors in which the CTV extends superiorly to the
mediastinum only in order to respect the 3-4cm proximal margin on
gross tumor,
2.The panel did not consider it mandatory to deliberately include
superior mediastinal nodal stations electively, other than would be
encompassed by a 1cm radial expansion of the esophagus
3.Above the aortic arch, the anterior border of the CTV can be
extended towards the sternum and clavicular heads in order to
encompass the prevascular nodes
85

86. 86

87. Handling enlarged nodes
87
In general, the CTV should include the
GTV (including any grossly involved
nodes) with at least a 1cm margin in all
directions.

88. HANDLING TRACHEA
1. Above the carina, the CTV will therefore typically
encompass the entire trachea and extend radially in
order to encompass the lower and upper
paratracheal nodal stations, which correspond to
levels 2 and 4
2. Above the level of the thoracic inlet, the trachea
should be excluded from the CTV except insofar as
the 1cm radial margin on the normal esophagus
requires it
88

89. 89

90. 90

91. PTV MARGIN
1. With respect to PTV delineation, the panel
recommended expanding the CTV by 0.5-1cm in all
directions, depending on institutional guidelines and
the frequency of portal imaging
2. For situations where respiratory motion is observed
to be in excess of 1cm, the panel additionally
recommends the use of techniques such as
respiratory gating or abdominal compression
91

92. HANDLING STOMACH FILLING
1. Variations in gastric filling may lead to significant
intrafraction differences in the location of perigastric nodes,
and dose to normal stomach. To mitigate this,
2. Most panelists recommended keeping patients NPO for 2-3
hours before simulation and each treatment.
3. However, treating patients at a consistent interval after
meals also appears to result in reproducible gastric
positioning, and may be more comfortable for some
patients
92

93. Variations in gastric filling may lead to significant intrafraction differences in the
location of perigastric nodes, and dose to normal stomach 93

94. Special situations
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96. 96

97. PROXIMAL ESOPHAGUS
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98. 98

99. 99

100. DISTAL ESOPHAGUS
100

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102. 102

103. GE JUNCTION TUMORS
103

104. Target Delineation
• CTV is microscopic disease: Presumed to extend 3cm superior
and inferior including into stomach, along walls and out to
fascial planes (i.e. pleura).
– 3 cm Superior (Esophagus)
– 3 cm Left from GE junction to Last Slice of GTV (Stomach
Region)
– 2.5 Inferior from last slice of GTV
– 1 cm Radially around GTV
104

105. CTV- 3 cm Superior (Esophagus)
Contour the Esophagus Superiorly 3 cm from top slice of GTV.
Use MIP and respiratory phases to modify CTV for motion (ITV).
CTVGTV
105

106. Stomach Region- 3 cm Left
Contour into the stomach 3 cm from GE Junction to the
Last Slice of GTV. Only include the Stomach.
Stomach
Stomach
RegionGTV
Stomach
Stomach
Region
GTV
106

107. CTV- 1 cm Radial Exp.
Expand the GTV and Stomach Region 1 cm Radially
to make Mid CTV
Sup. CTV
Mid CTV
GTV
107

108. CTV- 2.5 cm Inferior Exp.
Expand the Last Slice of GTV Inferiorly 2.5 cm
Inferior CTV
108

109. Total CTV
Combine ALL CTVs (Superior CTV, Mid CTV, & Inferior CTV) to make a Total CTV 109

110. PTV
PTV
110

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113. 113

114. Post op settings
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117. 117

118. 118

119. 119

120. TARGET VOLUME
• BILATERAL SUPRACLAV
• MEDIASTINAL NODE
• CELIAC TRUNK
• TUMOR BED
– R1
– R2
– CRM
120

121. HOW TO DECIDE
1. Extent of surgical lymph node clearance,
2. Site of relapse after radical esophagectomy
without preoperative chemotherapy and
radiation,
3. Stage and location of the primary lesion
121

122. EXCLUSION
• They concluded that it may be unnecessary to
irradiate the left gastric area when the
primary lesion is located in the upper and
middle portion of the esophagus.
• Likewise, the bilateral supraclavicular area
may be unnecessarily irradiated in cases when
the disease is present in the lower and middle
lower thirds
122

123. COMPLEX ANATOMY
upper and middle thoracic ESCC to the
cervical nodes and difficulty in complete
lymph node dissection due to the complex
anatomy versus the lower mediastinum
and upper abdominal sites that can be
exposed more readily.
123

124. UPPER AND MIDDLE
For upper and middle ECs, various studies have
reported that the bilateral supraclavicular and
superior mediastinum have the highest rates
of recurrence and should be included within
the PORT CTV
124

125. LOWER ESOPHAGUS
• Whether locoregional recurrence patterns of
lower esophageal tumors are centered on
downward areas, such as the para-cardiac and
left gastric nodes, or on upward areas, such as
the bilateral supraclavicular and superior
mediastinal areas remains understudied
• However, the recurrence pattern for lower third
ESCC is still obscure, and the current conflicting
evidence does not rule out any area
125

126. HANDLING THE STOMA
• If cut margins are negative no need of include
• No need to treat gastric pull up
• Only mediastinum to be treated to include
nodes
126

127. LYMPH NODE DELINEATION
127

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130. V
130

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132. 132

133. Lymph nodes
133

134. Supraclavicular & upper
paratracheal
134

135. Prevertebral & prevascular
135

136. Lower paratracheal
136

137. Subaortic & para aortic
137

138. Carinal, paraoesophageal & hilar
138

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171. IMRT /VMAT PLANNING ESOPHAGUS
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174. 174
PARAMETER FULL ARC AP-PA ARC
Total lung
Lung-ptv V5
Lung-ptv V10
Lung-ptv V15
Lung-ptv V20
Heart mean
Cord max

175. BRACHYTHERAPY
175

176. 176
ABS GUIDELINES

177. BRACHY
177

178. BRACHY
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179. 179

180. Comments
• Follow the guideline
• Practice it
• Revive your one data
• Be a part of guideline
180