Radiotherapy Protocol for the management of UGI Cancer 

This is radiotherapy protocol for the East Midlands RT Operational Delivery Network (ODN). Tumour sites are: 
Oesophagus 

Document revision History 

Version Number 

Date 

Document History. 

0.01 

23/09/22 

Initial Draft Collation by PM 

0.02 

14/3/23 

Edits following email feedback from CK 

0.03 

19/04/23 

Changes throughout following UGI 
protocol review meeting 

In attendance: 

E.James, C.Knox, Z.Stokes, P.Das, 
J.Davies. K.Das 

Updated draft shared to clinician group 
for any further comments 

0.04 

11/05/23 

Feedback from R.Silverman 

0.05 

12/08/23 

Changes added for palliative 
management following NICE guideline 
update 

Recommended agreed by R.Gabitass. 
Agreed by UGI clinicians via email. 

0.06 

27/02/24 

Reviewed by Radiotherapy planning 
team. 

In attendance: 

D.Holmes, V.Ohlendorf, M.Bland, 
L.Martins. 

Updated draft shared to planning team 
for any further comments 

0.07 

22/03/24 

Reviewed at ECAG and agreed for 
approval. 

1.0 

April 2024 

Final version uploaded to SharePoint 

V1.1 

January 2025 

KD/PM- References improved as per 
Dec 2024 NOG action 



 

 

 

 

 

 

 

 

 

 


 

 

Table of Contents 

Radiotherapy Protocol for the management of UGI Cancer .................................................................................................. 1 
Table of Contents .................................................................................................................................................................... 2 
1. Indications for treatment ............................................................................................................................................ 3 
2. Investigations required ............................................................................................................................................... 3 
3. Information given to patients ..................................................................................................................................... 4 
4. Consent ....................................................................................................................................................................... 4 
5. Trials ............................................................................................................................................................................ 4 
6. Position and immobilisation ....................................................................................................................................... 4 
7. Planning ....................................................................................................................................................................... 5 
8. Dose Constraints ......................................................................................................................................................... 6 
9. Prescribed dose ........................................................................................................................................................... 8 
10. Prescription Point .................................................................................................................................................... 8 
11. Palliative Intent ....................................................................................................................................................... 9 
12. Treatment ............................................................................................................................................................. 10 
13. During treatment .................................................................................................................................................. 10 
14. Peer Review........................................................................................................................................................... 10 
15. Late Effects ............................................................................................................................................................ 10 
16. Follow Up .............................................................................................................................................................. 11 
17. Glossary ................................................................................................................................................................. 12 
18. References ............................................................................................................................................................ 13 


 

 

 

 

 

 

 


1. Indications for treatment 

 

 Histologically confirmed Squamous cell / Adeno carcinoma of the oesophagus or Other rarer types like Small 
cell / Large cell carcinoma. 
 Staging confirms no distant metastases 
 PS 0-2 for Radical treatment 
 Primary tumour and nodal disease encompassable within a radiotherapy field 
 If patient had previous radiotherapy, retreatment is at clinician’s discretion and consider Peer review. 
 No contraindications to chemotherapy if having concurrent treatment. 




 

Treatment options: 

 Definitive Chemoradiotherapy (DCRT) 
 Pre-Operative Neoadjuvant Chemo-Radiotherapy 
 Post Operative Radiotherapy +/- Chemotherapy 
 Radical radiotherapy only 
 Palliative Radiotherapy 


 



 

2. Investigations required 

 Histological confirmation of malignancy 
 Diagnostic / staging imaging to include: 
 OGD 
 EUS – If indicated for further local staging, according to the local practise. EUS should be ideally reported with 
reference to CT identifiable structures. 
 Staging laparoscopy (where indicated) 
 CT TAP with contrast 
 18-FDG PET-CT 
 Full Lung function tests: 


·Definitive ChemoRT and Definitive Radiotherapy: FEV1 ≥ 1.0l, TLCO/DCLO ≥ 40% 

· Pre-Operative Neoadjuvant ChemoRT and Post–operative Adjuvant: FEV1 ≥ 1.5l, CPEX acceptable. TLCO/DCLO ≥ 40% 
(Ideal guidelines-NeoSCOPE[10]) 

 For patient receiving chemotherapy with radiotherapy, further investigations will be required according to 
chemotherapy protocols 




 

Review of clinical history to include: 

-Previous radiotherapy 

-History and examination, PS 

 

Special Circumstances to consider: 

-Chronic conditions or disease that affects radiosensitivity 

-Ongoing medication that may affect response to radiotherapy 



 

 


3. Information given to patients 

-General radiotherapy booklet 

-Site specific treatment leaflet including long term side effects 



 

4. Consent 

-By IR(ME)R Practitioner at new patient / planning clinic 

-By Entitled IR(ME)R Operator under delegated authority at new patient / planning clinic 



 

5. Trials 

-Consider current trials open in any of the radiotherapy centres in the East Midlands. 

-[EMRTN TRIALS TRACKER LINK] 

-If a patient is being treated in a clinical trial then the Trial Protocol overrides the departmental protocol. 



 

6. Position and immobilisation 

 

All patients will be CT scanned as per local protocol and should consider including the following: 

 Appropriate scan levels and suitable thorax patient immobilisation. 
 All patients will be scanned supine 
 With middle or lower third primary, the patient’s arms will be positioned with arms above the head 
 In cases with upper third involvement, before CT planning scan, is recommended to use a thermoplastic head 
and neck shell and discuss treatment position with Physics staff if required. 
 Knee support and immobilisation forming with thermoplastic device or vacuum cushion, as per local protocols. 


 

 Consider asking lower third oesophageal/GOJ patients to fast and then drink water prior to CT planning and 
treatment as per local protocol (in an attempt to reproduce the same anatomical position of the stomach due to 
filling throughout treatment). It is crucial the same stomach preparation procedure is followed before planning 
and treatment. Patients who have a nasogastric tube inserted and are unable to drink due to dysphagia should 
use their tube for this purpose. 


 

 

 3DCT CT scan with intravenous contrast (providing adequate renal function and no other contraindications). 
 Consider 4DCT for lower third oesophagus or GOJ, (immediately following the 3DCT), subject to patient’s 
suitability. 


 

 The superior extent of the scan should be least 1cm superior to the apices of the lungs and 6cm superior to the 
proximal disease (whichever is highest). The inferior extent of the scan should cover the whole stomach or all of 
the Kidneys if lower it’s a lower tumour. 


 

 

 The planning CT scan should be performed at the time of or within 2 weeks of commencing neo-adjuvant 
chemotherapy. 


Consider fiducials or radio opaque markers if tumour is difficult to visualise. 



 


7. Planning 

 

Technique 

 IMRT/VMAT is the primary choice of planning technique for radical patients. 
 Conformal Radiotherapy may be considered on a case by case basis 
 If the treatment is off protocol this should be noted and the correct local procedure for recording off protocol 
treatments followed. 


 

 

 Diagnostic information should be available and discussed at MDT. 
 The PET-CT can be fused with the planning CT where applicable. 
 The volume defined from CT and EUS should not be reduced based on the PET findings alone. 


 



 

 

Volume definition 

 Follow nationally recognised, peer reviewed or trial protocols (See references[4][5][6][10]) for volume 
contouring and margins 
 The GTV, CTV/ITV margins are to be outlined by the clinical oncologist/registrar or other appropriately trained 
and approved clinician (e.g. consultant radiographer) 
 There will be situations where individual anatomy and other special conditions require that the coverage of 
the PTV may need to be compromised. In these cases, the approved clinician is required to exercise his/her 
clinical judgement and to clearly indicate the clinical priorities to the treatment planning team 
 Consider including 4DCT outlining for definitive and pre-operative lower third tumours (subject to patient’s 
suitability for 4DCT and subject to the 4DCT quality).[4] 
 Post–operative Adjuvant Radiotherapy: CTV according to area at risk of recurrence. The pre-op GTV is used to 
outline and should be included in the CTV/ITV. 




 

Organs at risk 

 Organs at risk (OAR) to be outlined as per nationally recognised, peer reviewed protocols. In addition, if close 
to PTV, the spleen should be included as per RCR guidance.[2] 


 

OAR 

 

Spinal Cord and Spinal Cord PRV 

Stomach 

Lung – Combined 

Heart 

Liver 

Spleen if close to PTV 

Right and Left Kidneys if close to PTV 



 



 

 


8. Dose Constraints 

 

Follow nationally recognised, peer reviewed or trial protocols (See references) [4] [5][6][10] for constraints. 

 Dose escalation is acceptable within a national/trial protocol scope 
 For all radical cases, if the mean radiation dose to the spleen >10Gy, consider a vaccination programme and 
prophylactic antibiotic regimen as laid out in RCR- ‘Incidental irradiation of the spleen’ [2] 




 

Example constraints are listed below 

-Dose constraints for definitive RT and ChemoRT (taken from SCOPE2): 

Structure Name 

Constraints 

Optimal 

Mandatory 

PTV 

V95% (47.5Gy) 

D median/mean 

> 95% 100% 

≥ 90% The median/mean 
should be between 98-
102% of the prescription 
dose 

External 

D1.8cc 

 

<107% of highest prescribed 
dose 

SpinalCord_PRV 

D0.1cc 

< 40Gy 

< 42Gy 

Heart 

D mean V30Gy 

< 25Gy 

< 45% 

< 30Gy 

Lungs (combine lungs) 

D mean V20Gy 

< 17Gy 

< 20% 

< 19Gy 

≤ 25% 

Stomach_excl_PTV 
(Stomach excluding PTV) 

V50Gy 

< 16cc 

< 25cc 

Liver 

D mean V30Gy 

≤ 28Gy 

< 30% 

≤ 30Gy 

Kidney_L and 

Kidney_R (Individual 

kidneys) 

V20Gy 

< 25% 

≤ 30% 

 

 

 



 

 

 

 

 

 

 

 

 


-Dose constraints for Neoadjuvant ChemoRT and post-op adjuvant RT (from NeoAEGIS): 

Structure 

Naming convention* 

Dose Objective 

Comments / acceptable 
ranges 

PTV if ‘type B’ algorithm used 

 

PTV 

V95% ≥ 99% – (0.4*% lung/PTV 
overlap) V95%≥95% for all cases 

V95% objective is individually 
determined based on the 
percentage of PTV which overlaps 
with lung tissue according to the 
formula adopted from Wills 2009. 
Reduced coverage is only allowed 
in the areas of the PTV that 
overlap with lung. 

PTV (general) 

 

 

Dmean= 100% (41.4Gy) 

Under dosage of PTV is only 
allowed if requested due to the 
proximity of a serial OAR. In this 
situation a maximum of 5% of the 
PTV volume should receive less 
than 95% of the prescription dose. 
The mean should be between 98-
102% of the prescription dose 
(i.e., 41.4Gy). 

ICRU Maximum dose 

Label patient outline as *External* 

D1.8cc < 107% 

Defined as the maximum dose to 
1.8cc of any structure within the 
external contour of the patient 

Spinal cord 

Spinal cord 

D0.1cc < 45Gy 

 

Spinal Cord PRV 

SpinalCord_PRV 

D1cc < 40Gy 

If the PTV lies close to or overlaps 
with the Spinal Cord PRV, the 
treating clinician may 
discretionally allow a point 
maximum dose up to 44.3Gy 
(107% of 41.4Gy). 

Combined Lungs 

Lungs 

V20Gy < 25% 

V5Gy < 65% 

See notes in Neo-AEGIS protocol. 
Total lung volume and V5 lung, 
VS5 lung (the volume of normal 
lung spared of exposure to doses 
of 5Gy or higher), and mean lung 
dose are recorded. Every effort 
should be made to maintain 
V5<65% of total lung volume. 

Heart 

 

V40Gy < 30% 

V25Gy < 50 

Optimal objective – to be 
achieved where possible but at 
lower priority than other 
objectives. 

Liver 

 

V30Gy < 30% 

 

Individual Kidneys 

 

V20Gy < 25% 

The glomerular filtration rate of 
each kidney has to be taken into 
account in case of suspicion of a 
decreased renal function. 

Stomach 

Stomach 

 

See notes in NEO-AEGIS protocol. 
Currently not defined as an organ 
at risk but data will be collected to 
explore correlation with toxicity. 



 

 

 

 


9. Prescribed dose [1] 

 

Criteria 

Dose fractionation 

Definitive ChemoRT 

50Gy in 25# over 5 weeks (Grade A) 

 

50.4Gy in 28# over 5.5 weeks (Grade A) 

 

60–66 Gy in 30# over 6 weeks 

For upper third oesophageal carcinoma only. Moderate dose 
escalation with IMRT can be considered, wherever possible within 
the context of a clinical trial (Grade C) 

40Gy in 15# over 3 weeks 

(Neuroendocrine Oesophageal Tumours only) 

Neoadjuvant ChemoRT 

 

41.4Gy in 23# over 4.5 weeks (Grade A) 

 

45Gy in 25# over 5 weeks (Grade B) 

(For Adenocarcinoma) 

Definitive RT alone 

 

50Gy in 15-16# over 3 weeks (GTV ≤ 5cm) (Grade C) 

 

50-55Gy in 20# over 4 weeks (Grade C) 

 

60Gy in 30# over 6 weeks (Grade D) 

 

Post-operative ChemoRT: 

 

40-50.4Gy in 20-28# (Grade A) 

 



 

 

10. Prescription Point 

Prescribed as per ICRU 50/62 reports [11] 

 

 

 

 

 

 

 

 

 

 


11. Palliative Intent 

 

Patients with limited distant metastatic disease and good PS may be considered for definitive CRT to maximise 
locoregional disease control. There may be options small volume metastases outside of primary region e.g. resection of 
liver or lung metastases, SABR. Patients with locally advanced disease, but are unfit for CRT, or have metastatic disease, 
may be considered for palliative radiotherapy. 



 

Palliative dose fractionations:[1] 

 30Gy in 10 fractions over 2 weeks 
 20Gy in 5 fractions over 1 week 
 35Gy in 15# over 3 weeks 
 40Gy in 15# over 3 weeks 
 8-10Gy in single fraction 




 

NICE Recommendations on palliative management of luminal obstruction with no curative intent for adults with 
oesophageal or oesophago-gastric junctional cancer[7] 

 

 Do not routinely offer external beam radiotherapy after stenting for people with oesophageal and oesophago-
gastric junctional cancer. 
 Consider external beam radiotherapy after stenting of oesophageal and oesophago-gastric junctional cancer for 
people with prolonged post-interventional bleeding or a known bleeding disorder. 


 



 

 

Palliative HDR Brachytherapy: 

 Consider HDR intraluminal brachytherapy for palliation of symptomatic dysphagia in patients with carcinoma of 
upper / middle / lower oesophagus. 
 The practitioner requires an ARSAC certificate. Written authorisation can be given to a non ARSAC certificate 
holder who then acts on their behalf. 
 Currently ULHT are the only trust delivering this treatment within the network and the local protocol for 
Oesophageal Brachytherapy should be followed. 




 

 

 

 


12. Treatment 

 Final pre-treatment, Physics and 1st day checks should be carried out as per local protocol. 
 These should ideally cover or take into account the following: 
 Monitoring and managing Radiotherapy delays to ensure patients start treatment according to national 
guidelines 
 Checking plan approval status and parameters as per local protocol 
 All prior preparatory and required patient information is available 
 Imaging requirements for the planned treatment are adequate according to patient plan and local protocol 
 Any prior In vivo dosimetry has been performed as per local protocol. 




 

13. During treatment 

 

 Any other patient monitoring as specified in the local protocol should be performed e.g. dietician review, weight 
checks, monitoring of bloods. 
 On treatment imaging as per local protocols. The use of CBCT for radical oesophagus patients is mandatory for 
accurate treatment. 
 For gaps in treatment follow local policy and RCR guidelines 
 On treatment and follow up reviews as per local protocols. 




 

14. Peer Review[12] 

 

 Peer Review will enable clinicians to provide high quality treatments despite potentially limited referrals. 
Documenting peer review is essential as per RCR Recommendation 10 + 11. 


 

 In order to meet the RCR standards the review will cover patient selection, prescription and target / OAR 
delineation. For some cases it may be necessary to review the final treatment plan also. 


 

 The reviewee must provide the reviewer with all relevant clinical information to peer review, which may include 
demographics, diagnosis and details of proposed treatment. Any relevant clinical tests or images must also be 
provided (see Table 1 above). 
 Responsibility for the patient will remain with the clinician under whom the patient receives their care. If a peer 
review does not occur, whatever the reason may be, it is that clinician’s responsibility to address this. 


 



 

15. Late Effects 

 Late effects will have been discussed as part of the initial discussions and counselling by the treating clinician 
and is dependent on the radiotherapy target volumes 


 

 If available, details of the local department’s late effects clinic should be provided at the appropriate interval 
following completion of Radiotherapy. 




 


16. Follow Up 

 Patients should be followed up as per local department policy. 
 Considerations: 
- Patients seen 4-6 weeks after completion of radiotherapy 
- Restaging CT at end of treatment if patient planned for surgery after chemo-radiotherapy 
- Restaging CT 3 months after completion of radiotherapy if having definitive radiotherapy 




 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


17. Glossary 

 

Abbreviation 

Definition 

# 

Fraction (i.e. Fractions of treatment) 

3DCT 

Three dimensional computed tomography (standard CT scan) 

CBCT 

Cone Beam computed tomography 

ChemoRT 

Chemotherapy with Radiotherapy 

CT 

Computed tomography 

CTV 

Clinical target volume 

EMRTN 

East Midlands Radiotherapy Network 

GTV 

Gross tumour volume 

Gy 

Gray (unit of measure for radiation dose) 

ICRU 

International commission on radiation units and measurements 

IMRT 

Intensity modulated radiotherapy 

ITV 

Internal target volume 

IR(ME)R 

Ionising Radiation (Medical Exposure) Regulations 

MDT 

Multi-disciplinary team 

MRI 

Magnetic resonance imaging 

NOG 

Network oversight group 

LDR 

Low dose rate - (Brachytherapy) 

HDR 

High dose rate - (Brachytherapy) 

OAR 

Organs at risk 

PSA 

Prostate specific antigen 

PET (PET-CT) 

Positron emission tomography (Positron emission tomography – computed tomography) 

PRV 

Planning organ at risk volume 

PS 

Performance status 

PTV 

Planning target volume 

RCR 

Royal college of radiologists 

RT 

Radiotherapy 

SABR 

Stereotactic ablative Radiotherapy 

U+E 

Urea and electrolytes 

VMAT 

Volumetric modulated arc therapy 



 

 

 

 

 

 

 

 

 

 

 


18. References 

 

[1] 

 https://www.rcr.ac.uk/media/0dvanjpu/05-gastrooesophageal-cancer-radiotherapy-dose-fractionation-fourth-edition.pdf 


[2] 

 RCR Incidental irradiation of the spleen- BFCO(21)9 Date: 2021, 
(https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfco219-incidental-irradiation-
spleen.pdf) 


[3] 

 RCR Timely delivery of radical radiotherapy: guidelines for the management of unscheduled treatment interruptions, fourth 
edition BFCO(19)1 Date: 2019 


[4] 

SCOPE2 Radiotherapy 
Planning Guidance Document version 3.0. SCOPE2 Radiotherapy Planning Guidance Document Version: 3.0 Date: 31/01/2020 


[5] 

NeoAEGIS RPGD V2 
27-Feb-2018_clean.pdf
 NeoAEGIS Radiotherapy Planning Guidance Document Version: 2.0 Date:27/02/2018 


[6] 

 SCOPE1 Radiotherapy Planning Guidance Document Version: 


[7] 

 NICE, Oesophago-gastric cancer: assessment and management in adults 


https://www.nice.org.uk/guidance/ng83 

[8] 

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4041542/ 


 

[9] 

 https://aapm.onlinelibrary.wiley.com/doi/pdf/10.1120/jacmp.v12i2.3343 


 

[10] 

 https://pmc.ncbi.nlm.nih.gov/articles/instance/5341738/bin/mmc1.pdf (NeoSCOPE) 


 

[11] 

 https://www.icru.org/reports 


[12] 

 https://www.rcr.ac.uk/media/bpvngu2n/rcr-publications_radiotherapy-target-volume-definition-and-peer-
review-second-edition-rcr-guidance_october-2022.pdf