What is the best management for a patient with mid-esophageal cancer, a 4 cm tumor in the muscularis propria, and positive celiac lymph nodes (LN), with normal preoperative functional workup for surgery?

From the Guidelines

The best management for a patient with midesophageal cancer in the muscularis propria measuring 4 cm with positive celiac lymph nodes is neoadjuvant chemotherapy (option D). This approach is recommended because the presence of positive celiac lymph nodes indicates locally advanced disease, which benefits from systemic therapy before surgery 1. Neoadjuvant chemotherapy can downstage the tumor, potentially eradicate micrometastatic disease, and improve surgical outcomes. According to the ESMO clinical practice guideline for diagnosis, treatment, and follow-up of oesophageal cancer, preoperative chemoradiotherapy (CRT) or perioperative chemotherapy (CT) is recommended for patients with locally advanced esophageal adenocarcinoma 1.

Key Considerations

• The patient's functional workup is normal, indicating they can tolerate surgery after neoadjuvant therapy.
• Neoadjuvant chemotherapy has been shown to improve overall survival compared to surgery alone in patients with locally advanced esophageal cancer.
• A typical regimen might include a platinum agent (cisplatin or oxaliplatin) combined with a fluoropyrimidine (5-FU or capecitabine) for 2-3 cycles before reassessment.
• After completion of neoadjuvant therapy, restaging would be performed to assess response, followed by surgical resection if appropriate.

Surgical Approach

• Radical transthoracic oesophagectomy with en bloc two-field lymphadenectomy is the procedure of choice in fit patients 1.
• Minimally invasive oesophagectomy (MIO) techniques have become increasingly implemented into clinical practice and have been shown to have lower post-operative morbidity and better quality of life compared to open oesophagectomy 1.
• Transhiatal esophagectomy might be considered later in the treatment course, but immediate surgery without neoadjuvant therapy would not address the systemic nature of the disease.

Conclusion Not Applicable - Direct Answer Only

The patient should undergo neoadjuvant chemotherapy, followed by restaging and surgical resection if appropriate, as this approach has been shown to improve overall survival and reduce morbidity in patients with locally advanced esophageal cancer 1.

From the Research

Patient Management

The patient has midesophageal cancer with a tumor length of 4 cm, positive celiac lymph nodes, and normal functional workup for surgery. Considering the evidence, the best management for this patient would be:

• Neoadjuvant chemotherapy followed by surgery, as the presence of celiac lymph node metastases is a significant prognostic factor 2, 3
• The location of lymph node metastases, including those near the celiac trunk, is an independent predictor of survival 3
• Neoadjuvant treatment and surgery can improve outcomes for patients with esophageal cancer and celiac node involvement 4, 2

Treatment Options

The following treatment options are available:

• Transhiatal esophagectomy: may not be the best option as it may not address the celiac lymph node metastases effectively
• Chemotherapy: may be considered as part of the neoadjuvant treatment, but not as the sole treatment
• Prophylactic stent: not indicated in this case as the patient has a resectable tumor
• Neoadjuvant chemotherapy: the most appropriate option, followed by surgery, to address the celiac lymph node metastases and improve outcomes 2, 3

Evidence Summary

The evidence suggests that:

• Celiac node metastases are not an adverse prognostic indicator in patients with celiac node involvement compared to N1 patients without celiac node disease 4
• Location of lymph node metastases is an independent predictor of survival 3
• Neoadjuvant treatment and surgery can improve outcomes for patients with esophageal cancer and celiac node involvement 4, 2