My comments are as follows.
1. Do you think this patient has been adequately staged. T x N x M0
2. I would insist on EUS to know the extent of the lesion, the EUS (T stage), and the EUS ( N stage).This information is necessary for my RT volumes when i " GUESS " the CTV based on all the available investigations - CT scan, OGD findings, PET scan and EUS.
3. Surprising the oncosurgeon has left her, but we cant argue much without seeing the patient. She may be frail, etc
(ideally she would have benefited from 2# neoadjuvant chemo with Cis/5FU followed by surgery as per the UK MRC OE02 trial)
4. Harsha asks about the Role of chemotherapy in this patient?
Indication: Concurrent Chemoradiation [ +/- neoadjuvant or adjuvant chemo ]
Now if you stick with the original version of Herskovic Trial reported by Cooper et al (RTOG 85-01)
They gave Concurrent CTRT which was followed later by 2 further cycles of Chemo as follows:
Cisplatin 75 mg/m2 D1 on weeks 1,5,8 & 11
5FU 1000 mg/m2 D1-4 on weeks 1,5,8 & 11
RT Dose:Ph 1(30 Gy) + Ph II (20Gy) (RT starts on D1 and ends in 5th week)
Results: 5 yr OS with CTRT was 26% while in RT alone arm it was 0% despite RT dose Ph 1 (50Gy) + Ph II (14 Gy)
The same group after having closed the trial, recruited another 73 patients (non-randomised but consecutive) for CTRT and surprisingly the 5 y OS was only 14%.
http://www.ncbi.nlm.nih.gov/pubmed/10235156
Only 2/3rd of the patients could complete all 4 cycles of chemo as planned.
Hence for practical purposes, many oncologists including myself prefer to give 2# Cis/5FU as neoadjuvant followed by CTRT
(This gives adequate time for Radiation oncologists for planning and presumably is better tolerated)
There are prospective and retrospective data for this, but no Ph III data for this approach.
4. Harsha asks what is the Cost of this RADICAL CTRT treatment ?
In the RTOG 85-01 trial, only 2/3rd of the patients could complete their remaining chemo.
As Andrew mentioned, most get Gr 3 toxicity. To add to Andrews comment, 8% patients get an acute life-threatening (ie, grade 4) toxic effects on the RTOG acute morbidity scale and an additional 2% died as a direct consequence of treatment.
5. Coming to Andrew, I read with great surprise this Australian prospective non-randomized trials run by the Trans-Tasman Radiation Oncology group between 1985-1999 and reported in 2003. Equally disturbing is Andrews statement
" Since then I have used 60Gy/30Fx with 2 cycles of Pt/5FU "
Unfortunately i regret to inform about a Ph III trial called__ INT 0123__ which tried to escalate the RT doses from 50.4 Gy to 64.8 Gy in combination with chemotherapy as described earlier in comment 4 by myself.
http://www.ncbi.nlm.nih.gov/pubmed/11870157 (My strong recommendation to read this trial please)
To update your knowledge, (Andrew) the higher radiation dose did not increase survival or local/regional control and in fact there was an increase not only of toxicity but also increased mortality with the higher dose.
Internationally apart from Australia, the Gold standard remains 50.4 Gy as of now for patients undergoing Concurrent Chemoradiation.
Another of Andrews disturbing comments were
" target area is PET/anatomical extent + 5cm above and below minimum "
I personally think the 5cm margin is now obsolete, though i must admit a few oncologists around the globe may be doing this and hence i would not swear by it. But as Harsha mentions we are in a PET era , hence Current Recommendations are as follows:
CTV = 2 cm longitudinal (Sup+Inf) and 1 cm axial (Ant/Post & laterally)
PTV = 1 cm longitudinal (Sup+Inf) and 0.5 cm axial (Ant/Post & laterally)
(These volumes need to be edited along the curvature of the body of the esophagus and not simply geometrical expanded)
5. Surgery Vs ChemoRadiation
There has been a trial of Surgery Vs Radiotherapy for operable esophageal cancer which was conducted at Tata Memorial Hospital in mid 90s, reported in 1999 with just under 100 pts. I agree it had quite weird primary end points with Death only being a secondary end point. And of course, not surprisingly survival in the surgery arm was significantly better than in the radiotherapy arm.
http://www.biomedexperts.com/Abstract.bme/10091752/The_quality_of_swallowing_for_patients_with_operable_esophageal_carcinoma_a_randomized_trial_comparing_surgery_with_rad
With regards to ChemoRT Vs Surgery, there has been no such trial conducted so far and frustratingly there are a few comments from some reviewers (i think surgeons) that there will never be such a trial, despite the fact that retrospective as well as prospective studies show a 5y survival of about 25-30% with CTRT which is similar to the surgical series. You also need to take into account selection bias against Radiotherapy patients who at times are locally advanced and deemed surgically inoperable or are simply medically inoperable.
Currently as of June 2010 after checking the international trial registries there is no such trial ongoing nor in the pipeline.
6. Lastly with Regards to PET scan in this equation
All what i can say is CTPET has better sensitivity and specificity than CT alone and changes the management decision in about 20% of cases. It helps your case selection or excludes those who will not have a benefit.
But your treatment regime and doses still remain the same.
Till date, there is no such data available in literature where a PET scan determines treatment modality like for instance Patient A has Radical RT, Patient B has ChemoRT, Patient C has higher RT dose in ChemoRT etc
Over and Out
I ve bored you enough with this exhaustive review of literature, (comments & criticism welcome though)
But a simple little update is always good for your Brain.
Ta, Rohit
