From the Guidelines
For an old patient with a mid-esophageal mass and celiac lymph node involvement who is otherwise well, esophagectomy (option C) would be the recommended surgical procedure. This recommendation is based on the principles of surgery outlined in the guidelines for esophageal and esophagogastric junction cancers 1. Esophagectomy involves complete removal of the tumor along with surrounding lymph nodes, offering the best chance for curative treatment in a patient who is fit enough to tolerate major surgery. The guidelines suggest that esophageal resection should be considered for all physiologically fit patients with resectable esophageal cancer, and that the presence of regional nodal metastases, such as celiac lymph nodes, does not necessarily preclude surgical intervention 1.
The choice of surgical approach depends on various factors, including the location of the tumor, the available choices for conduit, surgeon experience, and surgeon and patient preference 1. Minimally invasive esophagectomy (MIE) strategies, such as minimally invasive Ivor Lewis esophagogastrectomy or minimally invasive McKeown esophagogastrectomy, may be associated with decreased morbidity and shorter recovery times, and may be particularly useful for older patients 1. However, open surgery remains the standard for many patients, and the decision to use MIE should be made on a case-by-case basis.
In terms of specific considerations for this patient, the guidelines suggest that patients with T1-T3 tumors are resectable even with regional nodal metastases (N+), although bulky, multistation lymphatic involvement is a relative contraindication to surgery 1. Since the patient is described as "well", it is likely that they have good functional status and can withstand the physiological stress of surgery. Therefore, esophagectomy (option C) is the most appropriate surgical procedure for this patient, as it offers the best chance for curative treatment and improves quality of life by removing the tumor and surrounding lymph nodes.
From the Research
Treatment Options for Esophageal Cancer
The patient's condition, with a mid oesophageal mass and Coeliac LNs, suggests a need for palliative treatment. The following options are available:
- Chemo-radiotherapy: This treatment has been shown to provide palliation of dysphagia in up to 90% of patients 2. A study published in 2020 found that initial palliative short-course radiotherapy followed by chemotherapy can provide long-lasting relief of dysphagia in patients with esophageal adenocarcinoma 3.
- Stent: Esophageal stents can offer a high degree of palliation, but procedure-related morbidity and mortality rates are not insignificant 2.
- Esophagectomy: While esophagectomy is a major surgery, it may be an option for some patients. However, palliative esophagectomy or bypass procedures are difficult to justify in patients with a short life expectancy 2. A study published in 2008 highlighted the importance of nutrition considerations in esophagectomy patients 4.
- Chemotherapy: Chemotherapy can be used as part of a multidisciplinary approach, but response rates are only 50% at best 2.
Considerations for Treatment
When selecting a treatment, it is essential to consider the patient's disease, coexisting medical problems, performance status, and desires 2. A multidisciplinary evaluation and treatment approach has become the standard of care for esophageal cancer 5.
Treatment Outcomes
Studies have shown that concurrent radiation and chemotherapy can provide rapid improvement in dysphagia and result in normal or near-normal swallowing function of long duration 6. Immunotherapy has also been found to have a survival benefit for patients with metastatic or persistent disease 5.