What is the most appropriate management for an elderly patient with a mid-esophageal mass and celiac lymph nodes (Coeliac LNs) who is asymptomatic?

From the Guidelines

For an old patient with a mid-esophageal mass and celiac lymph node involvement who is clinically well, chemoradiotherapy (option A) would be the most appropriate management. This approach is supported by the most recent and highest quality study 1, which suggests that definitive chemoradiotherapy with surveillance and salvage esophagectomy when needed is a recommended option for locally advanced resectable oesophageal cancer. The presence of celiac lymph node involvement suggests regional spread, making it a locally advanced disease, where surgery alone would be insufficient. Chemoradiotherapy can provide good local control and potentially downstage the tumor, while preserving quality of life. It typically involves platinum-based chemotherapy (such as cisplatin or carboplatin) combined with 5-fluorouracil or paclitaxel, along with concurrent radiation therapy delivered over 5-6 weeks. This approach is particularly suitable for older patients who may not tolerate the physiological stress of major surgery. Some key points to consider in the management of this patient include:

• The importance of multidisciplinary evaluation to determine the best course of treatment 1
• The role of clinical staging using EUS, CT scan, and PET scan to assess resectability 1
• The potential benefits of preoperative chemoradiotherapy in improving survival rates 1
• The suitability of minimally invasive oesophagectomy techniques, including robotics, for patients who are fit for surgery 1 Esophagectomy carries high complication rates in elderly patients, stenting is more appropriate for palliative relief of dysphagia in symptomatic patients, and chemotherapy alone would provide insufficient local control for the primary esophageal tumor. Overall, chemoradiotherapy is the most appropriate management option for this patient, taking into account the potential benefits and risks of each treatment approach.

From the Research

Management of Mid Oesophageal Mass with Coeliac LNs

• The patient's condition involves a mid oesophageal mass with coeliac lymph nodes (LNs) and is currently well.
• Considering the location of the primary tumor and the involvement of coeliac LNs, surgical management is a viable option.
• According to 2, esophagectomy is the standard of care for more advanced early esophageal cancer and should be performed at centers of excellence with high volumes, appropriate supportive staff, and multidisciplinary expertise.

Surgical Approaches

• Research comparing various surgical approaches of esophagectomy has generally failed to identify any major differences in long-term prognosis 3.
• Minimally invasive esophagectomy (MIE) has been increasingly used in patients undergoing esophageal cancer resection, with potential advantages including decreased pulmonary complications, lower post-operative wound infection, decreased post-operative pain, and decreased length of hospitalization 4.
• The application of robotics to esophageal surgery is becoming more widespread, with potential advantages over the known limitations of laparoscopic and thoracoscopic approaches to esophagectomy 4.

Lymph Node Dissection

• The prevalence of lymph node metastasis in esophageal cancer is widely spread to all three fields, and the status of LN metastasis has been recognized as a key factor that influences the outcome after EC surgery 5.
• Controlling LN metastasis is a rational therapeutic strategy, and an extended LN dissection, such as three-field lymph node dissection, may be logical, although appropriate patient selection is necessary 6, 5.

Treatment Options

• Considering the patient's condition and the involvement of coeliac LNs, esophagectomy with lymph node dissection is a suitable treatment option.
• Among the given options, esophagectomy (option C) is the most appropriate management for the patient.