Guidelines for Radiotherapy of Esophageal Carcinoma (2020 Edition)

Abstract

Esophageal carcinoma is a high-incidence malignant tumor in China, ranking sixth and fourth highest in morbidity and mortality, respectively. Radiotherapy plays an important role in the comprehensive treatment of esophageal carcinoma. Standardized diagnosis and treatment based on the suggestions of a multidisciplinary team (MDT) form its foundation. For operable esophageal carcinoma, surgery after neoadjuvant chemoradiotherapy is the standard treatment; contrarily, for inoperable esophageal carcinoma, radical chemoradiotherapy is the only treatment option, and postoperative adjuvant radiotherapy can improve local control and survival rates in selected cases. Owing to the rapid technological development in radiotherapy, three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and image guidance technology are widely used in the treatment of esophageal carcinoma. Though drugs for treating cancer have been developed rapidly, we need to explore their optimal combination with radiotherapy, including chemotherapy, targeted or immune, and radiosensitizers. Esophageal carcinoma in China differs greatly from that in European and American countries in terms of etiology, pathological type, high-incidence site, etc. Therefore, the European and American guidelines on radiotherapy for esophageal carcinoma cannot be applied in clinical practice in China. This gap was addressed when the 2019 edition of the Chinese Guidelines for Radiotherapy of Esophageal Carcinoma was formulated. In combination with suggestions for the clinical application and the latest research, the 2020 edition was launched with the hope of benefiting most patients with esophageal carcinoma. Early symptoms of esophageal carcinoma are indiscernible. There is often a sense of a foreign body in the esophagus. When swallowing hard food, there is a sense of stagnation, choking, posterior sternal burning, pinprick, or traction rubbing pain. These symptoms can be mild or severe. Typical symptoms include progressive dysphagia and the production of mucoid sputum. Persistent chest pain or back pain often suggests that the tumor has invaded the extraesophageal tissue. Invasion of the tumor into the recurrent laryngeal nerve may cause hoarseness and choking on drinking water. The compression of the cervical sympathetic ganglion may lead to Horner syndrome. Similarly, its invasion into the trachea and bronchus may cause the formation of esophagotracheal or esophagobronchial fistula, respectively; this may result in severe choking during swallowing, respiratory infection, formation of esophagomediastinal fistula, or fever. If distant metastasis occurs, then the affected organs may exhibit symptoms. Most patients with esophageal carcinoma display no obvious positive signs on physical examination. Special attention should be paid to the signs of distant metastasis, such as enlarged lymph nodes in the neck or supraclavicular region, liver masses, pleural effusion, and peritoneal effusion. including blood routine, liver function and kidney function, viral serology, electrolyte, blood glucose, coagulation function, urine routine, fecal routine, etc. including cytokeratin 21-1 (CYFRA21-1), carcinoembryonic antigen (CEA), and squamous cell carcinoma antigen (SCC), etc. High expression of EGFR is an independent risk factor for the poor prognosis of esophageal carcinoma; thus, the detection of tissue EGFR expression is recommended. Immunotherapy is used as the second-line and above treatment for advanced esophageal carcinoma and first-line combined chemotherapy or postoperative adjuvant therapy; eligible patients should be tested for programmed death protein ligand 1 (PD-L1) and its combined positive score (CPS), tumor mutation coincidence (TMB), microsatellite instability (MSI), and mismatch repair protein loss (dMMR). An important method for the diagnosis and evaluation of the curative effect on esophageal carcinoma, and low-tension double-contrast radiography is recommended. Patients who are scheduled to undergo radiotherapy should be checked for contraindications to radiotherapy, such as presence of deep ulcers. Chest and upper abdomen CT examination is needed before radiotherapy and during follow-up. A contrast-enhanced CT is also recommended. The scanning range can be increased according to the location (e.g., the supraclavicular area and neck) and range of lesions. Can effectively complement CT in the diagnosis and evaluation of the curative effect on esophageal carcinoma. The diagnostic value of lymph node metastasis is similar or superior to that of contrast-enhanced CT. Functional MRI techniques such as diffusion-weighted imaging are helpful in the evaluation of the curative effect and prognosis. Mainly used for diagnosing pleural effusion, metastasis to abdominal organs, and metastasis to abdominal and cervical lymph nodes. Not recommended as a routine primary screening method for the diagnosis of bone metastasis; a positive bone scan should be confirmed by X-ray, CT, MRI, or PET/CT. Recommended only if necessary or conditional but not as a routine screening method. Upper gastrointestinal endoscopy is an important method for the qualitative and localized diagnosis and treatment of esophageal carcinoma. Endoscopic biopsy is the gold standard for the diagnosis of esophageal carcinoma. Pigmented endoscopy and endoscopic ultrasonography can confirm the morphology and extent of lesions and assist in determining the clinical T and N stages. Endoscopic metal clips mark the upper and lower edges of early lesions, which can accurately assist in target localization for radiotherapy. Helps screen for arrhythmias and history of myocardial infarction. Helps screen for lung volume, lung ventilation, and diffusion function. When the aforementioned tests cannot determine the patient's cardiopulmonary capacity to tolerate radiotherapy, an exercise cardiopulmonary function test is recommended for further assessment. Recommended for patients with a previous history of heart disease to determine any structural changes and the functional status of the heart. Esophageal angiography reveals localized thickening of the esophageal mucosa, stiffness of the local wall, filling defect, or niche shadow. Chest CT, MRI, and PET/CT show thickening of the esophageal wall, or PET/CT displays high uptake of fluorodeoxyglucose (FDG). Upper gastrointestinal endoscopy reveals early lesions such as localized erosion of the mucosa, rough and small granular sensation, local mucosal congestion with unclear borders, small nodules, small ulcers, and small plaques. The middle- and late-stage lesions mainly exhibit nodular or cauliflower-like masses, mucosal congestion, edema, erosion or pale stiffness, easy bleeding when touched, ulcers, or varying degrees of stenosis. The clinical diagnosis of esophageal carcinoma requires further pathological examination. Esophageal carcinoma includes two main types—SCC and adenocarcinoma—along with other rare types. Early esophageal carcinoma: Protuberant, superficial, and depressed (ulcer) type. Advanced esophageal carcinoma: Medullary, umbrella, ulcerative, constrictive, and intraluminal type. The World Health Organization classification of esophageal carcinoma (2010 edition) was used (see Appendix 1). Verrucous carcinoma: Though this tumor is well differentiated and does not have the ability to metastasize, its occurrence in the esophagus is associated with a higher cell and Most of show or cell or These are of and the as that of cancer a and its of is higher that of esophageal in the lower of the esophagus and from the or the in the in the and upper esophagus. in the in the esophagus and is similar to the carcinoma of the in and and diagnostic are the as for gastrointestinal These include gastrointestinal malignant and In their edition of the of esophageal and the American on and the the tumor location as the of the primary by the and by the which the of the sternal endoscopic tumor from the is by the and by the lower of the endoscopic tumor from the is from the lower of the to the of the endoscopic tumor from the is by the lower of the and by the endoscopic tumor from the is Endoscopic is as the of a can be accurately as the of the esophageal and squamous If the of the tumor is of the the lower esophagus or the tumor is according to the classification for esophageal carcinoma. If the tumor is of the then is according to the classification for The edition of (see Appendix was including clinical postoperative pathological and treatment on of patients and the of comprehensive treatment based on the suggestions of is recommended for application of the treatment to survival and improve of For patients with endoscopic mucosal endoscopic or combined is recommended. of esophageal cancer is also Endoscopic combined with radiotherapy can in a radical is recommended for patients with a of the chemoradiotherapy is also for For patients with advanced and esophageal surgery the of For patients with or the treatment of and are For patients with neoadjuvant chemoradiotherapy is recommended neoadjuvant chemotherapy is also for patients with who surgery or have radical chemoradiotherapy is recommended. For patients with neoadjuvant chemoradiotherapy is recommended radical chemoradiotherapy is recommended for in the cervical and for patients who surgery The was after neoadjuvant chemoradiotherapy or after neoadjuvant For patients with advanced such as radical chemoradiotherapy is recommended if the status score is Radiotherapy should be selected for patients with esophageal or a for Radiotherapy is recommended for patients who cannot tolerate Patients with a score of are recommended the or treatment chemotherapy or radiotherapy of patients with neoadjuvant postoperative adjuvant for patients with is and is radiotherapy or chemoradiotherapy may be for postoperative patients who have not neoadjuvant node For patients with who have neoadjuvant postoperative or postoperative chemotherapy is recommended. For patients neoadjuvant and with lymph can be chemoradiotherapy is for cancer nerve and stages. For lymph postoperative chemotherapy or chemoradiotherapy is recommended. Patients who have but not neoadjuvant chemoradiotherapy are recommended to undergo adjuvant chemoradiotherapy chemoradiotherapy who cannot tolerate or adjuvant chemotherapy patients who neoadjuvant chemoradiotherapy are recommended to undergo chemotherapy, optimal or Patients with are recommended for or combination is recommended for small cell surgery is recommended as the primary treatment for carcinoma is for malignant and evaluation of tumor determine the treatment for primary For patients with local and metastasis after radiotherapy, surgery or chemoradiotherapy can be after comprehensive assessment. of esophageal carcinoma is for patients with and for the cervical Patients with advanced disease are recommended to undergo neoadjuvant surgery for esophageal cancer is for patients with local after radiotherapy, no distant metastasis, after and for who can tolerate surgery in for patients with or chemoradiotherapy is for patients with and esophageal Patients with or cervical esophageal or with esophageal carcinoma who Patients with Patients with esophageal carcinoma with supraclavicular or lymph node metastasis Patients who cannot tolerate surgery after chemoradiotherapy or radiotherapy Patients with contraindications or high risk of to and severe cardiopulmonary Patients who or and not Patients with who not chemoradiotherapy and or and after Patients with who not chemoradiotherapy and or after chemotherapy, the of patients with advanced disease are or and radiotherapy for primary lesions should be Patients with lymph node metastasis who cannot radical radiotherapy. 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