Background:
Despite maximum therapy the prognosis of esophageal carcinoma still remains extremely poor. New treatment strategies including improved radiation therapy techniques promise better outcome by improving local control through precise dose delivery due to higher conformality.
Case Report:
A 62-year-old patient with locally advanced carcinoma of the gastroesophageal junction underwent definitive radiochemotherapy with intensity-modulated radiation therapy (IMRT). On positioning control with the in-room CT, the distal esophagus, and hence the tumor, was found to be highly mobile exhibiting changes in position of up to 4 cm from fraction to fraction.
Results:
IMRT plans were created for various positions establishing a plan library to choose from as appropriate. CT scans were performed prior to each treatment fraction to clarify esophagus position in order to choose the adequate treatment plan.
Conclusion:
Image guidance was crucial in this unusual case of esophageal carcinoma. Without the information from position control CTs, the tumor would have received only about half the prescribed dose due to variations in position. For this specific case, in-room CT scans are probably superior to kilo- or megavoltage CTs due to the higher soft-tissue contrast enabling detection of positioning variation of the organ and offering the possibility to use the CT for treatment planning.
Hintergrund:
Die Prognose bei Ösophaguskarzinom ist derzeit trotz maximaler Therapie schlecht. Neue Therapieansätze einschließlich hochkonformaler Strahlentherapietechniken mit präziser Dosisapplikation versprechen bessere Ergebnisse durch erhöhte lokale Kontrollraten.
Fallbericht:
Ein 62-jähriger Patient mit lokal fortgeschrittenem Karzinom des gastroösophagealen Übergangs erhielt eine definitive Radiochemotherapie mittels intensitätsmodulierter Strahlentherapie (IMRT). Auf den Lagekontroll-CTs am „in-room“-CT zeigte sich der distale Ösophagus und damit der Tumor als äußerst lagevariabel mit Positionsveränderungen von bis zu 4 cm zwischen den einzelnen Strahlentherapiefraktionen.
Ergebnisse:
Für die verschiedenen Lagevarianten wurden IMRT-Pläne erstellt und je nach aktueller Ösophagusposition vor der jeweiligen Behandlung ausgewählt. Vor den Bestrahlungssitzungen wurde jeweils ein Kontroll-CT durchgeführt, um die aktuelle Position des Ösophagus zu bestimmen.
Schlussfolgerung:
„Image guidance“ war in diesem ungewöhlichen Fall entscheidend. Ohne die Information aus den Lagekontroll- CTs hätte der Tumor aufgrund der hohen Lagevariation nur etwa die Hälfte der verschriebenen Dosis erhalten. In diesem speziellen Fall ist das „in-room“-CT zur Lagekontrolle der Kilovolt- oder Megavolt-Bildgebung aufgrund des höheren Weichgewebskontrasts deutlich überlegen und ermöglicht erst den Nachweis der Lagevariation, aber auch eine erneute Bestrahlungsplanung auf Basis des Lagekontroll-CTs.
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Jensen, A.D., Grehn, C., Nikoghosyan, A. et al. Catch Me if You Can – the Use of Image Guidance in the Radiotherapy of an Unusual Case of Esophageal Cancer. Strahlenther Onkol 185, 469–473 (2009). https://doi.org/10.1007/s00066-009-1935-6
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DOI: https://doi.org/10.1007/s00066-009-1935-6