Chemoradiation for esophageal and gastroesophageal junction cancer, before surgery or as definitive treatment. The target is long and runs between the lungs and the heart and into the upper abdomen, so the planning work is in balancing lung and heart dose — and, near the junction, the liver, kidneys, spleen and stomach.
Preoperative chemoradiation is usually 41.4 Gy in 23 fractions with weekly carboplatin and paclitaxel, from the CROSS trial, followed by surgery. When those drugs can't be used, one protocol suggests 45–50.4 Gy in 1.8 Gy fractions with cisplatin and 5-FU.
Definitive chemoradiation, for patients not having surgery, is usually 50.4 Gy in 28 fractions (or 50 Gy in 25). The INT 0123 trial found no benefit from raising the dose to 64.8 Gy. Larger volumes are sometimes treated to a lower dose level first, in two phases or with an SIB.
Lung limits are tighter before surgery, because lung dose has been linked to complications after the operation — so the constraint table has one column for each approach.
The target is long and crosses the chest into the abdomen, and its lower end moves with breathing.
Supine with the arms above the head, in a vacuum bag or on a wingboard, with head, knee and ankle supports. For cervical and upper thoracic tumors, the arms are kept by the sides.
Arms up clears the way for beams through the chest. For high tumors the raised shoulders would crowd the beam paths to the neck and upper chest, so the arms are kept down instead.
Fasting before simulation and treatment is considered, especially for distal and junctional tumors, sometimes with a small drink of oral contrast to outline the esophagus.
Stomach filling changes the position of the junction and the shape of the stomach next to the target, so keeping it similar every day keeps the anatomy close to the plan.
A 4DCT or another motion-specific scan — breath-hold or gated — especially for distal and gastroesophageal junction tumors.
The upper esophagus barely moves, but the lower esophagus and junction move with the diaphragm. The target volume has to account for that motion. One NRG template notes that a maximum-intensity projection (MIP) shouldn't be used to build the internal target volume for esophageal tumors; it asks for the tumor to be drawn on the individual phases instead.
Image fusion aligns an outside scan with the planning CT so the target can be drawn using information the CT doesn't show. For esophageal and GE junction cancer the scan is FDG-PET/CT, ideally taken in the treatment position so its CT can serve as the planning CT. Endoscopy and endoscopic ultrasound (EUS) findings are read alongside the images rather than fused.
Nodes that are suspicious on PET or proven on EUS biopsy are treated as involved, so the PET shapes the nodal GTV. A free-breathing diagnostic PET may not line up with the esophagus even when the spine does — especially at the GE junction, which moves with breathing — so check the registration at the level of the tumor.
Cone-beam CT, recommended daily, matched to bone with the soft tissue reviewed.
The spine gives a reliable match for upper and mid-thoracic tumors, but the junction can move relative to bone with breathing and stomach filling, so the soft tissue check matters most there.
What each volume represents. Expansions and nodal regions come only from your protocol.
The primary tumor and any involved nodes, defined from PET/CT, CT, endoscopy and EUS.
The ends of the primary are the hardest part to see, and they decide where the CTV starts and stops.
The GTV across the breathing cycle, drawn on the 4DCT phases, for tumors that move. Concept page →
Distal and junctional tumors move with breathing; that motion is accounted for here rather than in the PTV.
An expansion mainly along the length of the esophagus — and into the gastric cardia for distal and junctional tumors — with a smaller radial margin, trimmed at anatomical boundaries. Elective nodal coverage varies between protocols.
Esophageal cancer spreads up and down beneath the lining, so the CTV follows the esophagus rather than being a uniform expansion. It is drawn along the anatomy, not with an automatic margin.
The CTV expanded for setup uncertainty.
The PTV sits between the heart and lungs, so its size directly drives lung V20 Gy and heart dose.
Click an organ for its anatomy, why it matters and contouring resources. Superscripts link to the study behind each value.
| Organ | 41.4 Gy / 23 fxPreoperative | 50.4 Gy / 28 fxDefinitive; also 50 Gy / 25 fx |
|---|---|---|
| LungsBoth lungs combined. Lower limits before surgery reduce post-operative lung complications. | ||
| Heart / PericardiumV30 Gy <46%: under 15% risk of pericarditis. | ||
| LiverAssumes normal liver function. | ||
| KidneysIf one kidney's mean exceeds 18 Gy, keep the other kidney's V6 Gy under 30%. | ||
| Spinal CordConsider a PRV where the dose gradient next to the cord is steep. |
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| SpleenIf clinically appropriate. Above 10 Gy, hyposplenism risk rises. |
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| Small Bowel |
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Values quoted from eviQ 1861 (last reviewed 17 October 2025; review due 31 December 2027) and eviQ 1865 (last reviewed 14 June 2024; review due 30 June 2028), checked by DoseLab on 2026-09-29. Verify against your protocol, institutional policy and physician directive before clinical use.
Phase 3 CROSS trial: weekly carboplatin and paclitaxel with 41.4 Gy in 23 fractions before surgery improved survival over surgery alone for esophageal and junctional cancer. Citation checked against Europe PMC.
Intergroup phase 3 trial comparing 64.8 Gy with 50.4 Gy, both with cisplatin and 5-FU, for definitive treatment of esophageal cancer. The higher dose did not improve survival or local control, so 50.4 Gy became the standard. Citation checked against Europe PMC.
Expert-panel contouring guidelines and a CTV atlas for esophageal and gastroesophageal junction IMRT, built from three cases (GEJ, distal and mid-upper esophagus) that the panel contoured on simulation CT with the diagnostic PET/CT alongside. Citation checked against Europe PMC.
The template NRG Oncology gives investigators for the radiation therapy section of an esophageal trial, using a 50.4 Gy in 28 fraction photon-versus-proton example. It requires motion assessment at simulation, encourages a treatment-position FDG-PET/CT, prefers whole-body PET/CT to help define the volumes, and explains why a maximum-intensity projection should not be used to build the IGTV. Values in it are examples to be edited for each trial.
A thoracic organ-at-risk contouring atlas with discussion of dose limits, covering the lung, proximal bronchial tree, esophagus, spinal cord, ribs and brachial plexus. A published letter in response discusses esophageal delineation.
RTOG consensus guidelines and atlas for delineating upper abdominal normal organs. Citation checked against Europe PMC.
Atlas for contouring the heart and its substructures, including the coronary arteries, developed and validated for studying cardiac dose in breast radiotherapy.
UK guidance recommending that the spleen be contoured whenever it may be irradiated, that the mean splenic dose be reported, and that it be kept below 10 Gy when clinically appropriate. Patients above 10 Gy should be considered at higher risk of late functional hyposplenism, with vaccination and antibiotic prophylaxis discussed.
AAPM Task Group 132 report on image registration and fusion in radiotherapy. It reviews rigid and deformable registration, points out that every registration carries an uncertainty that should be understood and communicated, and gives recommendations for commissioning and quality assurance of registration software and for checking individual registrations. Citation checked against Europe PMC.
Endorsed eviQ protocol for preoperative chemoradiation of esophageal and gastroesophageal junction cancer: 41.4 Gy in 23 fractions with weekly carboplatin and paclitaxel, the CROSS regimen. It recommends PET/CT to aid tumor delineation and 4DCT especially for gastroesophageal junction tumors, and its lung limits are deliberately more conservative than in the definitive protocol to lower the risk of pulmonary complications after surgery.
Endorsed eviQ protocol for definitive chemoradiation of esophageal cancer: 50.4 Gy in 28 fractions or 50 Gy in 25 fractions, based on the INT 0123 trial. Simulation, target volumes and the organ table mirror the preoperative protocol, except that the lung limits follow QUANTEC rather than the tighter preoperative values.