Radiotherapy Contouring for Cervical Esophageal Squamous Cell Carcinoma

Target Volume Definition

The National Comprehensive Cancer Network recommends that the gross tumor volume (GTV) should include the primary tumor and all involved regional lymph nodes as identified on CT simulation, endoscopy reports, barium swallow, and PET/CT scans when available 1
Review all imaging modalities with the multidisciplinary team before simulation to inform treatment volume determination, as recommended by the National Comprehensive Cancer Network 1
The clinical target volume (CTV) should extend 5 cm cephalad and caudal from the GTV, with a 1.5-2 cm radial margin to account for microscopic disease spread, according to the National Comprehensive Cancer Network 1
Account for respiratory motion uncertainties when defining the planning target volume (PTV), as recommended by the National Comprehensive Cancer Network 1

The biologically equivalent dose of approximately 40-45 Gy should be delivered electively to clinically negative regions at risk for microscopic spread, as recommended by the National Comprehensive Cancer Network and the Journal of Clinical Oncology 1, 2
Deliver 40-45 Gy to elective nodal regions at risk for microscopic disease, according to the National Comprehensive Cancer Network 1

CT-based simulation with 3D treatment planning is mandatory, as recommended by the National Comprehensive Cancer Network 1
IMRT or VMAT is appropriate for cervical esophageal cancer to reduce dose to critical normal structures including the larynx, spinal cord, thyroid, and major vessels, according to the National Comprehensive Cancer Network 1
Use immobilization devices for reproducibility of daily setup, as recommended by the National Comprehensive Cancer Network 1
IV and/or oral contrast during CT simulation may aid in target localization when clinically appropriate, according to the National Comprehensive Cancer Network 1

Spinal cord: maximum dose <45 Gy, as recommended by the National Comprehensive Cancer Network 1
Heart: limit one-third of heart to <50 Gy, with particular attention to minimizing left ventricle doses, according to the National Comprehensive Cancer Network 1
Lungs: limit volume receiving ≥20 Gy to ≤20% of total lung volume, and volume receiving ≥10 Gy to ≤40% of total lung volume, as recommended by the National Comprehensive Cancer Network 1
Liver: limit 60% of liver to <30 Gy, according to the National Comprehensive Cancer Network 1
Kidneys: at least two-thirds of one kidney should receive <20 Gy, as recommended by the National Comprehensive Cancer Network 1

Complete the entire radiotherapy course within 8 weeks to avoid compromising locoregional control and survival, as recommended by the National Comprehensive Cancer Network 3
Avoid treatment interruptions or dose reductions for manageable acute toxicities through aggressive supportive care rather than treatment breaks, according to the National Comprehensive Cancer Network 1

Monitor patients weekly during treatment with vital signs, weight, and blood counts, as recommended by the National Comprehensive Cancer Network 1
Consider feeding jejunostomy or nasogastric tubes when estimated caloric intake falls below 1500 kcal/day, according to the National Comprehensive Cancer Network 1
Correlate all available imaging (CT, PET/CT, endoscopy, barium swallow) with clinical findings before finalizing treatment volumes, as recommended by the National Comprehensive Cancer Network 1