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?

Management of Mid-Esophageal Mass with Celiac Lymph Node Involvement in an Elderly Patient

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 Surgical Management

The National Comprehensive Cancer Network recommends that mid-esophageal tumors with celiac lymph node involvement are considered resectable if the patient is physiologically fit 1. This is supported by current TNM staging, which now classifies celiac lymph nodes as regional metastases rather than distant metastases 1.

Key considerations:

• For mid-esophageal tumors specifically, radical transthoracic esophagectomy with en bloc two-field lymphadenectomy is the procedure of choice in fit patients 1
• McKeown esophagectomy (right thoracotomy + laparotomy + cervical anastomosis) is particularly suitable for mid-esophageal tumors, as recommended by the Society of Surgical Oncology 1
• For elderly patients who are otherwise fit, minimally invasive esophagectomy (MIE) techniques are supported by the American College of Surgeons as they are associated with lower post-operative morbidity and quicker functional recovery 1

Evidence Supporting Surgical Approach

Research shows that patients with celiac node involvement can benefit from surgical resection:

• A Mayo Clinic study found that patients with celiac node involvement who underwent surgical resection had a median survival of 11.7 months, with 11% surviving at 5 years and 7% at 10 years 2
• The number of positive nodes, rather than their location, was the strongest predictor of survival 2

For elderly patients specifically:

• A 15-year study comparing patients ≥70 years with younger patients found that despite higher preoperative risk scores, older patients who underwent esophagectomy had similar:
  • Rates of severe complications
  • Perioperative mortality
  • Length of hospital stay
  • Long-term survival (44.8% at 5 years for patients ≥70 years) 3

Alternative Treatment Options and Their Limitations

1. Chemoradiotherapy:

   • Definitive chemoradiotherapy is recommended primarily for cervical esophageal carcinomas or patients unfit for surgery 1
   • For patients who are physiologically fit, as in this case, it is not the first-line recommendation for mid-esophageal tumors with celiac node involvement

2. Chemotherapy alone:

   • Not recommended as a standalone treatment for resectable esophageal cancer according to the European Society for Medical Oncology 1
   • Offers inferior outcomes compared to surgical approaches for fit patients

3. Stenting:

   • Not indicated as primary therapy for patients who are otherwise well and can tolerate definitive treatment
   • Reserved primarily for palliation in patients with advanced disease or who are unfit for surgery

Clinical Pearls and Pitfalls

• Important assessment: All patients should be evaluated by an esophageal surgeon for physiologic ability to undergo esophageal resection 1
• Preoperative staging: Celiac lymph node involvement should be confirmed preoperatively with endoscopic ultrasound and PET-CT 1
• Surgical expertise matters: Postoperative mortality for esophagectomy should be less than 10% in specialized centers 1
• Celiac node size consideration: Research suggests that celiac lymph node size (<2cm vs >2cm) may impact prognosis and could influence treatment decisions 4

Conclusion for This Case

Since the patient is described as "well" despite having a mid-esophageal mass with celiac lymph node involvement, esophagectomy offers the best chance for long-term survival and should be the recommended procedure. The evidence supports that elderly patients who are otherwise fit can undergo esophagectomy with outcomes comparable to younger patients.