What is your first line strategy in managing acute esophagitis during thoracic RT?

Zombie Question (dead thread reanimated by theMednet)!!! The amount of esophagitis that I see in practice has really diminished over the course of my long, graying career. If you ever wanted to see a horrific esophagitis, treat a Turrisi regimen to those volumes. 60% of patients got Grade 2+ esophagitis! The benefits of involved field therapy and IMRT have really improved the rate of that toxicity quite dramatically (60 Gy arm was 31% Grade 2+). So, social...er, dose distancing for the esophagus is the first line of therapy to prevent esophagitis.

The other element I think about (and frequently see people not utilize, at least on boards) is limiting your CTV expansions on involved nodes in the mediastinum. This can really impact the dose and...

Diflucan 150 mg po weekly will make a big difference.

We typically begin with an institutional formulation (xyloxylin) that is similar to magic mouthwash. If that is not sufficient (and it frequently is not) then we begin narcotics, typically hydrocodone/APAP. If the patient is maximizing this regimen and taking it around the clock, then we treat with longer acting medication such as oxycontin or a fentanyl patch.

During this time period, we also have the patient consult with a nutritionist frequently, to ensure that they are maximizing their nutritional intake. We also have a low threshold for initiating IV fluids, and will do so 2-3 times per week if the patient appears to be orthostatic. We also consult the supportive care service for management of pain. And if these outpatient approaches ...

We routinely offer patients amifostine (500 mg sc) prior to each fraction of RT (on non-chemotherapy days) as a method of prophylaxis. Our series suggests a postponement in the development of esophagitis (measured as initiation of opiate use) in patients treated using the cytoprotectant. Once the esophagitis starts it's too late to benefit from amifostine and then you are stuck with symptom control (usually opiates) to get them through the therapy.