How do you manage unresectable esophageal cancer involving both the thoracic esophagus and GE junction?

We need to remember that RTOG-8501 treated the entire esophagus for the initial fields, so treating a large field is not unheard of. With modern day treatment planning and delivery, it would be reasonable to treat definitely to treat the entire CTV (defined as the esophagus and nodes) to 45 Gy and the primary GTV-thoracic and GTV-GEJ lesions via SIBoost to 50 Gy. We would recommend a feeding tube be placed prior to getting the treatment planning scans.

I agree with @Dr. First Last. Assuming the patient is a candidate for concurrent chemoradiation, I would attempt to treat the grossly involved tumor and nodes to 50.4Gy since there is no other potentially curative therapy. If the field is very large (encompassing all or nearly all of the esophagus) then I would take the initial field to 45Gy or 41.4Gy depending on normal tissue constraints (most likely limited by lung dose) and then cone down to 50.4Gy. I am less likely to include elective nodes...

I agree with both @Dr. First Last and @Dr. First Last. Intentionally avoiding portions of the esophagus in between areas of gross disease would undertreat any microscopic occult disease. Plus treatment of the entire esophagus to ~45 Gy is better tolerated better than you might think. Of course patients should be carefully selected to receive such treatment based based on performance status, etc. The feeding tube suggested by @Dr. First Last is a good idea.