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

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

Surgical Approach for Mid-Esophageal Tumors

For mid-esophageal tumors specifically:

• 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 for thoracic esophageal cancer 2

Evidence Supporting Surgical Intervention

Research has demonstrated that:

• Patients with celiac node involvement can achieve long-term survival with surgical resection 3
• The median survival for patients with resected celiac node disease was 11.7 months, with some patients surviving beyond 10 years 3
• The number of positive nodes, rather than their specific location, correlates best with survival 3

Alternative Options and Why They're Not First-Line

1. Chemoradiotherapy:

   • Definitive chemoradiotherapy is recommended primarily for cervical esophageal carcinomas or patients unfit for surgery 1
   • For a patient who is described as "well," surgery offers better local control

2. Stent:

   • Stenting is primarily palliative and not curative
   • Not indicated as first-line treatment for patients who are fit for surgery

3. Chemotherapy alone:

   • Not recommended as a standalone treatment for resectable esophageal cancer according to the European Society for Medical Oncology 1

Important Considerations

• All patients should be assessed by an esophageal surgeon for physiologic ability to undergo esophageal resection 1
• Postoperative mortality for esophagectomy should be less than 10% in specialized centers 1
• The presence of celiac lymph node involvement should be confirmed preoperatively with endoscopic ultrasound and PET-CT 1
• Celiac lymph node size may be prognostically important - nodes <2cm have been associated with better survival outcomes (13.5 months vs. 7.0 months for nodes >2cm) 4

Surgical Approach Details

For mid-esophageal tumors with celiac node involvement:

• Extended lymph node dissection should include the whole posterior mediastinum, superior gastric region, and celiac region 5
• Subtotal esophagectomy with extended 2-field lymph node dissection through the Ivor Lewis approach has demonstrated safety with long-term survival being stage-dependent 2