What is the recommended surgical procedure for an elderly patient with a mid-esophageal mass and celiac (Coeliac) lymph node involvement who is otherwise well?

Surgical Management for Elderly Patient with Mid-Esophageal Mass and Celiac Lymph Node Involvement

For an elderly patient with a mid-esophageal mass and celiac lymph node involvement who is otherwise well, esophagectomy is the recommended surgical procedure. 1

Rationale for Esophagectomy in This Patient

The National Comprehensive Cancer Network guidelines clearly state that mid-esophageal tumors with celiac lymph node involvement are considered resectable if the patient is physiologically fit 1. This recommendation is particularly relevant to this case as:

1. The patient is described as "well" despite advanced age, suggesting adequate physiological fitness
2. Celiac lymph nodes are now classified as regional metastases rather than distant metastases in the current TNM staging system 1
3. For mid-esophageal tumors specifically, radical transthoracic esophagectomy with en bloc two-field lymphadenectomy is the procedure of choice in fit patients 1

Evidence Supporting Surgical Approach

Research evidence supports the surgical approach for this patient:

• Long-term survival is possible even with celiac node involvement. A Mayo Clinic study showed that some patients with resected celiac node disease achieved long-term survival, with 7% alive at 10 years 2
• The number of positive nodes, rather than their specific location, correlates best with survival outcomes 2
• Elderly patients (≥70 years) who undergo esophagectomy after neoadjuvant chemoradiotherapy have comparable outcomes to younger patients, with similar:
  • Rates of severe complications
  • Perioperative mortality
  • Length of hospital stay
  • Long-term survival (44.8% at 5 years for elderly vs. 39% for younger patients) 3

Surgical Approach Considerations

For mid-esophageal tumors specifically:

• McKeown esophagectomy (right thoracotomy + laparotomy + cervical anastomosis) is particularly suitable 1
• Minimally invasive esophagectomy (MIE) techniques should be considered for elderly patients who are otherwise fit, as they are associated with lower post-operative morbidity and quicker functional recovery 1

Why Other Options Are Less Appropriate

1. Chemoradiotherapy alone (Option A):

   • Definitive chemoradiotherapy is recommended primarily for cervical esophageal carcinomas or patients unfit for surgery 1
   • This patient has a mid-esophageal tumor and is described as "well," making surgery a viable option
   • Patients without celiac coverage in radiation fields have worse overall survival (16.5 months vs. 31.5 months) 4

2. Stent placement (Option B):

   • Stenting is primarily a palliative procedure for dysphagia in advanced disease or for patients unfit for curative treatment
   • Not mentioned as a curative option in guidelines for patients who are otherwise well 1

3. Chemotherapy alone (Option D):

   • Not recommended as a standalone treatment for resectable esophageal cancer according to the European Society for Medical Oncology 1
   • Inferior survival outcomes compared to multimodality approaches

Important Considerations

• Preoperative assessment should include:

  • Endoscopic ultrasound and PET-CT to confirm celiac lymph node involvement 1
  • Careful evaluation of physiological fitness for surgery

• Potential complications to monitor in elderly patients:

  • Higher risk of postoperative atrial fibrillation 3
  • Increased risk of urinary retention 3

• Surgery should be performed at specialized centers where postoperative mortality for esophagectomy is less than 10% 1