Less radiation is better, again (esophagus).

[Mandelin Rain]

I'm not sure how to rectify for my practice, as I have about a 25% confidence that my "neoadjuvant" patients will ultimately undergo esophagectomy even if that's the multidisciplinary plan upfront. But I think as far as meta-analyses go, this one is fairly well done.

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[mheat3]

I have about a 25% confidence that my "neoadjuvant" patients will ultimately undergo esophagectomy

This is my issue as well and steers me away from 41.4

 

[OTN]

Bold statement to call something standard of care before a RCT is done. I don't see any reason why one couldn't be performed.

 

[Lamount]

Bold statement to call something standard of care before a RCT is done. I don't see any reason why one couldn't be performed.

I mean, the RCT that set our SOC had 41.4 Gy as the dose for neoadjuvant CRT, so a purist may argue that it already is SOC.

 

[RADONC4285]

We always do 50.4 Gy because as you pointed out many patients don't make it to surgery. Many of those RCTs likely did not use IMRT/VMAT, so toxicity is likely much better now. Just pay close attention to the heart and lung doses and 50.4 Gy should be very safe

 

[Ray D. Ayshun]

If definitive is the intent, are you all doing 50.4 or 54?

 

[metallica81788]

This doesn't matter to me as how many neoadjuvant CRTs do most of us out in the real world really see anyway? If surgeon yes definitely surgery without a quiver in tone of voice, I'm doing 41.4 no question.

How often does that actually happen? The real debate is still how much to give for definitive chemoradiation no surgery. Still ongoing.

 

[ramsesthenice]

I typically do 50 as well but to be fair pCR and survival in the Tepper CALGB study and CROSS were essentially identical (for both SCC and AC subtypes) despite different doses. The Tepper study closed early so the power isn't great but it does suggest that perhaps the possible pathologic gains with 50 vs 41.4 for patients that don't end up having surgery might not be that big.

I have a few issues with this analysis. First, there is not a lot of detail given to help me understand the characteristics of patients in each group. Second, they are trying to pull a bit of a fast one with the survival conclusion. Look at OS closer. At all but one timepoint its not that low dose is better than high dose. Its actually that low and high dose are similar and better than medium dose. But for PFS it looks like there is more of a negative correlation with dose. How does one see a 40% (relative) decrease in 5 year PFS between 41.4 and 50.4 with no corresponding difference in OS? Without knowing more about the groups I don't really have enough context to understand what is going on. Furthermore, I am very hard pressed to come up with a biologic reason that higher dose radiation would compromise distant disease control. Across the board decrements in survival would be easier to understand but that is not what they are getting. Seems like there is a high probability of some kind (more likely multiple kinds) of bias at play.

 

[RADONC4285]

We do 50.4 for definitive because there is no convincing data that higher is better. There was a phase II MDA trial with promising results with an sib to 60 Gy to GTV. However, early results from ARTDECO show 50.4 is same as 61.6 Gy and the latter had higher tox.

 

[TheWallnerus]

When it comes to esophageal, we are the anti-Billy Pilgrim... completely, totally stuck in time.

 

[Neuronix]

If definitive is the intent, are you all doing 50.4 or 54?

28 fractions, GTV boost to 56 Gy, PTV to 50.4. Could probably do 30 fx 60 Gy / 54. Hard to get OAR constraints sometimes.

 

[Ray D. Ayshun]

This feels like a finding were arguing about in a separate thread. If there was a higher pfs AND lower os with 50.4, the things we talk about re toxicity make sense. But 41.4 is not more likely to control cancer than 50.4. makes me question the inclusion criteria of the various trials, etc. I don't know anyone in the us that does 4140.

 

[seper]

Cannot trust most esophageal surgeons in my region, re: operable vs. not vs. maybe

 

[Mandelin Rain]

Wrong thread.

 

[ROforbetterorworse]

If definitive is the intent, are you all doing 50.4 or 54?

I’ve stuck to 50.4 for neoadj and definitive

 

[evilbooyaa]

Have not met an esophageal cancer patient that was a slam dunk to undergo esophagectomy. Most of mine are in their 60s-70s usually with some other medical comorbidities.

Those folks are all getting 50 from me. I do 50 and 45Gy dose painting in 25 fractions.

 

[ramsesthenice]

Have not met an esophageal cancer patient that was a slam dunk to undergo esophagectomy. Most of mine are in their 60s-70s usually with some other medical comorbidities.

Those folks are all getting 50 from me. I do 50 and 45Gy dose painting in 25 fractions.

This is my practice too (SIB). Conceptually dose escalation makes sense but there is really no good data to support doing so. The only thing consistent is increased toxicity. That said, do I ever give into temptation and take the bigger ones to 54? Sometime yes. Some bad habits are just hard to kick even when you know better

 

[deleted941485]

Whatever...ESOPEC will make this discussion irrelevant.