GI · Organ at risk

Esophagus

Educational Summary

Dose constraints

Liver SBRT

ScheduleConstraintSource
42–54 Gy / 3 fx
Liver metastases
D0.1 cc ≤25.2 GyUK SABR consensus 2022
27.5–60 Gy / 5 fx
HCC or metastases
D0.1 cc ≤35 GyUK SABR consensus 2022
D0.5 cc ≤32 GyLARK (TROG 17.03)

Quoted from eviQ 4026, checked 2026-09-29. Full table with references →

Anatomy

A muscular tube running from the pharynx (at about the level of the cricoid cartilage) to the stomach. In the chest it lies behind the trachea and then the left atrium, slightly left of midline next to the descending aorta, and passes through the diaphragm at the esophageal hiatus.

Function in the body

The esophagus is the muscular tube that carries food and liquid from the throat to the stomach.

Why it matters

The esophagus sits in the middle of the mediastinum, so it matters in two different ways:

  • Conventional / hypofractionated lung RT: mediastinal nodal targets often lie right next to it. Acute esophagitis is one of the most common side effects patients notice during treatment.
  • SBRT: it becomes a limiting structure for central tumors. High dose to a small segment carries a risk of serious late toxicity such as ulceration, stricture or fistula.

Timmerman 2022 marks the esophagus with a footnote to avoid circumferential irradiation — a reminder that how the dose wraps around a tubular organ matters, not only the maximum.

In GI treatment the esophagus is the target for esophageal cancer, but it is an organ at risk for liver SBRT of tumors near the dome of the liver and the gastroesophageal junction, where SBRT sources limit a small-volume maximum.

How to contour

Kong 2011 contours the esophagus on a mediastinal window, including the mucosa, submucosa and all muscle layers out to the fatty outer layer (adventitia):

  • Top: the level of the cricoid cartilage.
  • Bottom: every slice down through the gastroesophageal junction to the stomach.
  • Oral contrast is not routinely recommended unless tumor lies near the esophagus; if it is used, the esophagus can be set to soft-tissue density for the dose calculation.

Timmerman 2022 (Tables 8–11, written for its SBRT dose tables) uses the same wall layers but contours only at least 10 cm above and below the PTV. Jabbour 2014 adds an optional gastroesophageal junction structure — a wedge that overlaps the lowest esophagus and the top of the stomach.

Review articleSource Verified
A Story of Hypofractionation and the Table on the Wall
Timmerman R · UT Southwestern Medical Center · 2022

An editorial history of the UT Southwestern SABR constraint tables — often called the “Timmerman tables” — covering how they were developed and revised, and their relationship to AAPM TG-101 and NRG/RTOG protocols. Tables 2–11 separate serial tissues (listed with a volume, a volume max and a max point dose) from parallel tissues (listed with a critical volume and a critical-volume dose max). In Tables 2–7 a footnote defines “point” as ≤0.035 cm³; Tables 8–11 add a contouring-instructions column for each structure.

Further reading

  • QUANTEC esophagus — Radiation dose–volume effects in the esophagus (QUANTEC) Source
  • RTOG 0813 protocol — RTOG 0813 protocol — SBRT for centrally located NSCLC Source
  • RTOG 0813 — Safety and Efficacy of a Five-Fraction Stereotactic Body Radiotherapy Schedule for Centrally Located Non–Small-Cell Lung Cancer: NRG Oncology/RTOG 0813 Trial Source

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