In all esophageal malignancies, the entire esophagus from cricoid cartilage to EGJ and bilateral lungs should be contoured for proper DVH analysis. In upper esophagus tumors, the brachial plexus, larynx, and spinal cord should be contoured. In lower esophagus tumors, the heart, liver, stomach, duodenum, bilateral kidneys, and spinal cord should be delineated.

The gross tumor volume (GTV) consists of primary esophageal tumor (the greatest extension on CT, EUS, or FDG-PET) and involved lymph nodes. Lymph nodes with biopsy proof, increased FDG uptake, or enlarged short-axis diameter are delineated as GTV. The EUS can be used to better classify small paraesophageal lymph nodes that are difficult to classify on CT or FDG-PET scan.

Standard GTV to clinical target volume (CTV) expansions for the primary tumor are 3–5 cm in the longitudinal direction and 0.5–1 cm in the circumferential direction. The larger margins are applied in the longitudinal direction to account for submucosal spread (Gao et al. 2007). For involved lymph nodes, a 0.5–1-cm margin to all directions can be utilized. The CTV can be shaved off normal structures accordingly to respect anatomical boundaries. These margins can be adjusted based on the treating physician’s confidence about the disease extension (Figs.1, 2, and 3).