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 indicate that mid-esophageal tumors with celiac lymph node involvement are considered resectable if the patient is physiologically fit 1. This is particularly relevant in 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

• The American College of Surgeons supports the use of minimally invasive esophagectomy techniques for elderly patients who are otherwise fit, as these are associated with lower post-operative morbidity and quicker functional recovery 1
• McKeown esophagectomy (right thoracotomy + laparotomy + cervical anastomosis) is particularly suitable for mid-esophageal tumors, as recommended by the Society of Surgical Oncology 1
• Research shows that elderly patients (≥70 years) with locally advanced esophageal cancer can achieve comparable outcomes to younger patients when undergoing esophagectomy, with similar perioperative mortality rates and length of stay 2

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
   • Since this patient is described as "well," they would likely benefit more from surgical resection
   • Celiac node failures occur in approximately 10% of patients treated with definitive chemoradiation without celiac coverage 3

2. Stent (Option B):

   • Stenting is a palliative procedure for dysphagia relief, not a curative approach
   • No evidence supports stenting as primary management for a patient who is well enough for definitive treatment

3. Chemotherapy alone (Option D):

   • The European Society for Medical Oncology explicitly states that chemotherapy alone is not recommended as a standalone treatment for resectable esophageal cancer 1

Prognostic Considerations

• Studies show that patients with celiac lymph node involvement who undergo surgical resection can achieve long-term survival, with 5-year survival rates of approximately 11% 4
• The number of positive nodes, rather than their specific location, correlates best with survival 4
• Patients with celiac node disease who undergo resection have similar prognosis to other N1 patients without celiac node involvement 4

Important Considerations for Elderly Patients

• Preoperative assessment by an esophageal surgeon is essential to confirm physiologic ability to undergo esophagectomy 1
• Elderly patients may experience higher rates of specific complications such as atrial fibrillation and urinary retention postoperatively 2
• Treatment should be performed at specialized centers where postoperative mortality for esophagectomy should be less than 10% 1