11gional relapse [ 7 ]. MacDonald et al. reported a randomized trial
comparing postoperative adjuvant CRT with surgery alone for
adenocarcinoma of stomach or esophagogastric junction [ 8 ]. The
trial included 281 patients with 21 esophagogastric junction pri-
maries in the adjuvant CRT arm and 275 patients with 18 esopha-
gogastric junction primaries in the surgery alone arm. Adjuvant
CRT consisted of five cycles of 5FU and leucovorin in combination
with 45 Gy of RT in 25 fractions. Adjuvant CRT significantly
improved median overall survival (36 vs 27 months) and reduced
relapse (43% vs 64%) compared with surgery alone. Although only
about 20% of patients in this trial has esophagogastric junction
adenocarcinoma, postoperative CRT is still considered appropriate
for high-risk esophageal adenocarcinoma especially for those with
R1 (involved margin) or R2 (gross residual disease) after surgery
(see Note 3). At risk lymphatic regions in RT should include para-
cardial, paraesophageal, and celiac axis nodes. In case of R2 resec-
tion, surgical clips can be placed during surgery to mark the site of
residual disease to facilitate RT planning and possible boost dose to
gross disease. With the inclusion of anastomosis and lymphatic
areas, the RT volume can be quite extensive. Consideration may be
given to deliver boost to site of residual disease to total 50.4 Gy in
1.8 Gy daily fractions with simultaneous intensity modulated
radiotherapy (IMRT) boost or cone down fields with three-
dimensional conformal radiotherapy (3DCRT).In unresectable disease, RT to the esophageal primary may still be
considered for palliation of obstructive symptoms or bleeding (see
Note 4). For palliative purpose, conventional anterior-posterior
opposing fields or three-dimensional conformal radiotherapy
(3DCRT) usually suffices. The dose can be 30 Gy in ten fractions.
A higher radiation dose may be needed for better local symptom
control. Intraluminal brachytherapy can also be used for palliation
of stenosis. The radiation source can be loaded through a Ryle’s
tube and can treat cancer with 1 cm radius of the source. High
dose rate (HDR) brachytherapy 6 Gy for three fractions or 8 Gy
for two fractions at 1 cm from the center of the source axis can pal-
liate dysphagia. If used as a boost, HDR brachytherapy should be
given before external radiotherapy [ 9 , 10 ].3 Methods: Procedures of Radiotherapy
Patient will lie in supine position, usually with arms raised above
head and body. Immobilization device like BodyFIX (which is a
vacuum body cushion) should be used to improve immobilization
and accuracy in daily setup.2.4 Palliative
Radiotherapy
3.1 Position
of the Patient
Radiotherapy