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

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 recommendation is supported by several key points:

1. Celiac lymph nodes are now classified as regional metastases rather than distant metastases in the current TNM staging system 1
2. For mid-esophageal tumors specifically, radical transthoracic esophagectomy with en bloc two-field lymphadenectomy is the procedure of choice in fit patients 1
3. The American College of Surgeons supports minimally invasive esophagectomy techniques for elderly patients who are otherwise well, as these are associated with lower post-operative morbidity and quicker functional recovery 1

Evidence Supporting Esophagectomy in Elderly Patients

Research has demonstrated that elderly patients (≥70 years) who are otherwise well can achieve outcomes comparable to younger patients:

• A 15-year study showed that despite higher preoperative risk scores in elderly patients, the rate of severe complications, perioperative mortality, and length of stay were similar between older and younger patients 2
• Long-term age-adjusted survival rates were not inferior in the elderly group (44.8% at 5 years for patients ≥70 years vs. 39% for younger patients) 2

Surgical Approach Considerations

For mid-esophageal tumors specifically, the McKeown esophagectomy (right thoracotomy + laparotomy + cervical anastomosis) is particularly suitable, as recommended by the Society of Surgical Oncology 1. The Ivor Lewis approach with extended 2-field lymph node dissection has also shown efficacy with a 5-year survival rate of 28.8% across all stages 3.

Why Other Options Are Less Appropriate

• Chemoradiotherapy alone: While definitive chemoradiotherapy is recommended for cervical esophageal carcinomas or patients unfit for surgery 1, this patient has a mid-esophageal tumor and is described as "well," making surgery the preferred option.

• Stent: Stenting is typically reserved for palliative management in patients with advanced disease or who are not surgical candidates, not as a curative approach for patients who are otherwise well.

• Chemotherapy alone: 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 with Celiac Node Involvement

The presence of celiac lymph node involvement was previously considered a contraindication to surgery, but current evidence supports a surgical approach:

• Research has shown that patients with celiac node involvement can achieve long-term survival after resection, with some studies reporting 11% 5-year survival and 7% 10-year survival rates 4
• The number of positive nodes, rather than their specific location, appears to be the stronger prognostic factor 4

Important Caveats and Considerations

• Preoperative confirmation of celiac lymph node involvement should be obtained through endoscopic ultrasound and PET-CT 1
• The size of involved celiac nodes may have prognostic significance, with nodes <2cm associated with better outcomes (median survival 13.5 months vs. 7.0 months for nodes >2cm) 5
• Esophagectomy should be performed in specialized centers where postoperative mortality is less than 10% 1
• Elderly patients have higher rates of postoperative atrial fibrillation and urinary retention, which should be anticipated and managed appropriately 2