What is the prognosis for metastatic esophageal cancer with lymph node involvement?

From the Guidelines

The prognosis for metastatic esophageal cancer with lymph node involvement is generally poor, with a 5-year survival rate typically below 5%. Patients with regional lymph node involvement (stage III) have a somewhat better outlook than those with distant metastases (stage IV), but both represent advanced disease. Treatment usually involves a multimodal approach combining chemotherapy (such as cisplatin/5-fluorouracil or FOLFOX regimen), radiation therapy, and possibly surgery in selected cases. Immunotherapy with pembrolizumab or nivolumab may be added for certain patients, particularly those with PD-L1 positive tumors. The extent of lymph node involvement significantly impacts prognosis, with more involved nodes indicating worse outcomes. Factors that influence survival include the patient's overall health status, age, tumor location, histological type (adenocarcinoma versus squamous cell carcinoma), and response to initial therapy. While cure is unlikely at this stage, treatment can provide meaningful palliation, control symptoms, and potentially extend survival by months to a few years in responsive cases. Early palliative care involvement is recommended to manage symptoms like dysphagia, pain, and nutritional challenges that commonly affect quality of life 1.

Key Considerations

• The number of lymph nodes removed has been shown to be an independent predictor of survival after esophagectomy, with at least 15 lymph nodes recommended for adequate nodal staging 1.
• Patients with potentially resectable esophageal cancer should undergo multidisciplinary evaluation, including clinical staging using endoscopic ultrasound (EUS) with fine-needle aspiration (FNA), if indicated, with chest and abdomen CT scan, and PET scan (PET/CT preferred over PET alone) 1.
• Palliative care should be considered early in the treatment process to manage symptoms and improve quality of life 1.
• The choice of treatment approach depends on various factors, including the patient's overall health status, age, tumor location, histological type, and response to initial therapy 1.

Treatment Options

• Chemotherapy: cisplatin/5-fluorouracil or FOLFOX regimen 1
• Radiation therapy: may be used in combination with chemotherapy or as a single modality 1
• Surgery: may be considered in selected cases, including those with regional lymph node involvement or potentially resectable tumors 1
• Immunotherapy: pembrolizumab or nivolumab may be added for certain patients, particularly those with PD-L1 positive tumors 1

From the Research

Prognosis of Metastatic Esophageal Cancer with Lymph Node Involvement

• The prognosis of patients with esophageal squamous-cell cancer (ESCC) and multiple lymph-node metastases is quite poor 2.
• Lymph node involvement is the single most important prognostic factor in oesophageal cancer, and the number of affected lymph nodes influences long-term outcomes 3, 4.
• The 5-year overall survival rate for patients with solitary lymph node metastasis after curative resection of esophageal cancer treated with radiochemotherapy is around 39.2% 5.
• Neoadjuvant chemoradiation therapy (CRT) has been shown to be beneficial for locally advanced ESCC with four or more lymph-node metastases, with a 3-year survival rate of 76% 2.
• Radiotherapy plays a major role in the management of localized or locally-advanced esophageal cancer with regional or distant lymph node involvement, and can sterilize micrometastatic nodes and cancer cells in transit in the peri-esophageal fat 6.

Treatment Options

• Neoadjuvant CRT consisting of 5-fluorouracil plus cisplatin and 40 Gy of radiation has been shown to be effective in treating locally advanced ESCC with multiple lymph-node metastases 2.
• Radiochemotherapy is a viable treatment option for solitary lymph node metastasis after curative resection of esophageal cancer, with a complete response rate of 22.9% and a partial response rate of 57.1% 5.
• Intensity-modulated radiotherapy or volumetric modulated arctherapy can be used to increase mediastinal irradiated volumes while protecting healthy tissues 6.

Factors Affecting Prognosis

• The number of affected lymph nodes is a significant prognostic factor, with more lymph nodes involved resulting in a poorer prognosis 3, 4.
• The size of the metastatic lymph node and performance status before radiochemotherapy are also significant prognostic factors 5.
• Metastatic lesion is also a significant prognostic factor, with patients having a solitary lymph node metastasis having a better prognosis than those with multiple lymph node metastases 5.