Esophageal cancer

Esophageal carcinoma remains a lethal disease due to aggressive invasion at the site of the tumor, and a high rate of distant metastasis; it therefore requires a multidisciplinary approach and timely coordinated chemotherapy, radiation therapy, and/or esophagectomy. Concurrent chemoradiotherapy is the recommended standard for locally advanced disease as a neoadjuvant for surgically eligible patients or as definitive for INOPERABLE or locally advanced patients, besides being a major palliative tool. This chapter focuses on the potential benefits and the feasibility of MR-guided radiotherapy (MRgRT) in the management of esophageal cancer, firstly based on its better soft tissue contrast imaging and ability to visualize cancer physiology at staging, during, and after radiotherapy, which assists in delineating the gross tumor volume (GTV), and secondly the need to adapt treatment with response to treatment. Integrated MRgRT sounds to support the ideal goal of overall reduction in acute or late radiotherapy-induced cardiac and pulmonary toxicity, as well as related postoperative complications, by improved sparing organ at risk sparing with superior daily GTV visualization, respiratory tracking/gating, online adaptive planning, and more precise targeting. Integrated MRgRT might also assist in individualizing recommendations based on responses to chemoradiotherapy, via diffusion-weighted imaging (DWI) or dynamic contrast enhancement, leading to organ preservation or timely resection based on degree of response.