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PurposeVariation exists in cooperative group recommendations for the dorsal border for the chest wall clinical target volume (CTV). We aimed to quantify the impact of this variation on doses to critical organs and examine patterns of chest wall recurrence relative to the pectoralis muscle.Methods and MaterialsWe retrospectively assessed patterns of chest wall recurrence quantified to the recommended CTV borders for women treated between 2005 and 2017. We compared treatment plans for 5 women who were treated with left postmastectomy radiation therapy, with the chest wall contoured using varying dorsal borders for CTV: (1) Anterior pleural surface (Radiation Therapy Oncology Group), (2) anterior surface of pectoralis major (European Society for Radiotherapy and Oncology), and (3) anterior rib surface (institutional practice). Treatment plans were generated for 50 Gy in 25 fractions. Doses to organs-at-risk were compared using paired-sample t tests.ResultsInstitutional patterns of chest wall recurrence were 64.7% skin and subcutaneous tissue, 23.5% both anterior to and between the pectoralis muscles, and 11.8% isolated to the tissue between the pectoralis major and minor. No chest wall recurrences were noted deep to pectoralis minor. When comparing the plans generated per the Radiation Therapy Oncology Group versus European Society for Radiotherapy and Oncology contouring guidelines, the mean lung V20Gy, heart mean dose, and left anterior descending artery mean dose were 33.5% versus 29.4% (P < .01), 5.2 Gy versus 3.2Gy (P = .02), and 27.3Gy versus 17.8Gy (P = .04), respectively.ConclusionsThe recommended variations in the dorsal chest wall CTV border have significant impact on doses to the heart and lungs. Although our study was limited by small numbers, our institutional patterns of recurrence would support a more anterior dorsal border for the chest wall CTV consistent with older literature.

patterns of care and factors associated with outcomes among elderly patients with esophageal cancer treated with chemoradiation (CRT) with or without surgery to help guide their management. Materials/Methods: Patients 70 years of age and older with non-metastatic esophageal cancer (excluding T1-2N0) diagnosed from 2004-2013 were identified in the National Cancer Database. We included patients who were treated with CRT with or without surgery. Comparisons of categorical and continuous variables were performed using chi-squared and t-tests, respectively. Survival was compared using the Kaplan-Meier method and the log rank test. Results: In total, 4,658 patients were included (66% adenocarcinoma, 34% squamous cell carcinoma). 75% were treated with CRT and 25% were treated with CRT followed by surgery. RT dose received and course duration was similar between those who received CRT alone (median 50.4 Gy, interquartile range [IQR] 50-54; median 28 fractions, IQR 25-30; median 42 days, IQR 38-47) and those who received CRT followed by surgery (median 50.4 Gy, IQR 45-50.4; median 28 fractions, IQR 25-28; median 39 days, IQR 37-42). 76% of patients were between the ages of 70-80 and 24% were 80 years of age or older. Patients 80 years or older underwent surgery less frequently than patients aged 70-80 (6.8% versus 31%, pZ<0.001). Patients who were male, white, treated in more recent years, and treated at academic centers were more likely to undergo surgery. Charlson comorbidity was similar between patients treated with CRT alone and patients treated with CRT followed by surgery. Median survival for the entire cohort from treatment start was 15.4 months (95% CI 14.7-16.1). Of those aged 70-80, median survival following CRT alone vs CRT followed by surgery was 13.8 (95% CI 13.1-14.5) and 29.2 months (95% CI 26.3-32.7), respectively. Of those aged 80 or older, median survival following CRT alone vs CRT followed by surgery was 11.7 (95% CI 10.7-12.9) and 19.3 months (95% CI 12.9-30.7), respectively. Of those who underwent surgery, 30-day mortality was higher among those aged 80 or older as compared to those aged 70-80 (10.3% versus 5.4%, pZ0.07). 90-day mortality following surgery was significantly higher among those aged 80 or older as compared to those aged 70-80 (23% vs 13%, pZ0.01). Conclusion: Older patients with locally advanced esophageal cancer are less likely to undergo trimodality therapy with surgery and have higher mortality with trimodality therapy compared to younger patients. Further work is needed to optimize locoregional treatment for elderly patients.

however the results did not reach significance (pZ.18). Local and regional first recurrent rates were 0% and 3.7% with comprehensive RT, compared to 10.6% and 12.8% with ALND and nodal RT. 2 patients who recurred in the ALND group showed simultaneous local and regional failure, making a locoregional failure rate of 23.4%. Distant failure rates were similar at 14.8% with RT and 14.9% with ALND. Lymphedema rates of 17.4% were seen with RT compared to 26.5% with ALND (pZ.39). Conclusion: Based on our findings, in patients who do not undergo ALND, a subset of women may benefit from comprehensive RT as it appears to be an effective means of local and regional disease control in patients with ypN+ disease. We encourage participation in Alliance A011202 to obtain randomized data in this cohort. We have an ongoing analysis to determine if the ALND group had higher risk features than the comprehensive RT group, which may have predisposed them to higher rates of failure.