9esophagogastric junction adenocarcinoma. Abdominal nodal
regions that are at risk include gastrohepatic ligament and celiac
axis. The celiac axis is generally located at the level of T12 and can
be identified on contrast computed tomography (CT). Prophylactic
lymphatic irradiation to celiac region should be considered in
definitive or postoperative RT.2 Materials
Considerations for radiotherapy in combined modalities treatment:
As most cases of esophageal cancer present with advanced disease
(T3, T4 or nodes positive), many would require combined modali-
ties treatment including surgery, RT, and chemotherapy.
Radiotherapy for patients with esophageal or esophagogastric ade-
nocarcinoma should be considered in the following situations.For locally advanced tumor, neoadjuvant chemoradiotherapy
(CRT) can be employed to downstage the tumor. The
Chemoradiotherapy for Esophageal Cancer Followed by Surgery
Study (CROSS) is a randomized Phase III study (Phase III clinical
trials start with a new treatment that has already worked well in a
small number of patients. The goal is to find out if the new treat-
ment is better than standard treatment and/or with fewer side
effects). In this study, the goal is to compare neoadjuvant CRT
followed by surgery versus surgery alone in patients with resectable
(T1N1M0 or T2-3N0-1M0) esophageal or esophagogastric junc-
tion cancers [ 3 ]. Neoadjuvant CRT was 41.4 Gy in 23 fractions
with concurrent weekly paclitaxel and carboplatin. Of 180 patients
randomized to neoadjuvant CRT, 161 underwent resection com-
pared with 162 in 188 patients randomized to surgery alone.
Neoadjuvant CRT plus surgery significantly improved survival,
and the median overall survival was 48.6 months versus 24 months
in surgery alone arm. The improvement in survival was more pro-
nounced in esophageal squamous cell carcinoma compared with
adenocarcinoma. Median survival for squamous cell carcinoma was
81.6 months with neoadjuvant CRT plus surgery versus
21.1 months with surgery alone (HR 0.48, p = 0.008); for patients
with adenocarcinomas, the corresponding survival were
43.2 months versus 27.1 months, respectively (HR: 0.73, p:
0.038). The CROSS trial established neoadjuvant CRT followed
by surgical resection as standard of care for patients with locally
advanced esophageal and esophagogastric junction cancer (see
Note 1). Older studies that used cisplatin and 5-fluorouracil (5FU)
concurrent with RT also showed that neoadjuvant CRT plus sur-
gery improved survival over surgery alone although the results
were less impressive [ 4 , 5 ].2.1 Neoadjuvant
Chemoradiotherapy
Before Definitive
Surgery
Radiotherapy