On pre-operative staging (CT / EUS / PET) in oesophageal cancer; provided the patient has no other signs of distant metastases, what lymph nodes do you consider to be surgically incurable? Clearly this depends on where the primary tumour is, so.....
For example, if you have a patient with a lower third adenocarcinoma do you consider upper mediastinal or lower neck nodes to be incurable? Or would you offer a three field lymyphadenectomy? Subcarinal nodes in lower or GOJ adenocarcinoma?
Another example is Coeliac nodal involvement in mid third SCC tumours? Incurable? But still resectable. These are controversial areas and I would be grateful for your thoughts. My unit would generally offer neo-adjuvant therapy and restaging with CT. In unfit/elderly patients these would be considered metastatic and the patients would not be offered surgery. In younger patients, surgery would be offered, but the outcome is generally poor. What do you do? What lymph nodes do you excise routinely in your lymphadenectomy? Do you do anything else about nodal disease outside a normal resection field?
A few years ago we analysed the impact of regional abdominal lymphadenectomy in esophageal cancer surgery.
We consider neck LN in a lower 1/3 tumor as inopearble and so on. We consider subcarinal LN in lower 1/3 tumor and coeliac LN involvement in mid 1/3 cancer as operable. However, in patients with "possibly" involved lymphnodes on preop imaging, we offer neoajuvant therapy to those surgically fit. Though in Indian scenario we often tend to overstage LN on EUS / PET due to Tubercular LN involvement esp mediastinal. As for surgery we perform 2 field lymphadenectomy in our unit as a routine depending on the location of tumor.
We consider all patient with resectable LN suitable for surgery (ivor-lewis with 2field en-bloc lynphoadenectomy or akiyama with 2/3 field lymphoadenectomy depending on tumor location). More recently we start neoadiuvant CT for oesophagel or cardia adenocarcinoma. For upper third oesophageal tumors we perform surgical procedure with ORL èquipe for extended lymphoadenectomy +\- laringectomy
So what would everyone do with a patient with GOJ cancer (adeno ca) who had 'metastatic' para-aortic lymphadenopathy on PET scan. He was treated with palliative chemotherapy (6 cycles ECX). Now restaging CT and PET show an excellent response to treatment and he is now technically operable? The para-aortic nodes are not shown on CT or PET.
Choices
1. Not for surgery ? reasons
2. Standard surgical resection
3. Para-aortic nodal resection and only proceed with resection if these are truely negative.
Discuss please..............
Thank you.
If "technically operable" means a "feasable R0 surgical resection", I would consider intervention (i.e. esopagectomy + thoracic and abdominal en-bloc lymphoadenectomy, "standard" Ivor-Lewis operation). In fact in our experience R1 and R2 patients have the same post-op survival, so R1 intervention should be avoided (even after excellent response to treatment: I consider for surgery the CT scan performed befor chemotherapy ). We have not (yet) data regarding our series of N+/R0 patients that were treated with chemotherapy prior to surgery: really I don't know how chemotherapy increase the post-operative survival in these group. I hope I can show you our results in the next future.
Ewen. A very clinically relevant question. Advanced nodal disease outside the field but a young patient who then has an excellent response to chemotherapy. We would also give prolonged chemo up front (the test of time) and do maximal staging at the end to be as sure as we possibly can that there is no metastatic disease. If that is clear and if the patient understands the risk / benefit I believe offering surgery is reasonable. We have a small series of such cases (admittedly highly selected) that have a very acceptable survival after surgery >35% at 5 years
very good question and good discussion.Once para aortic LN mets are present it is usually considered advanced malignancy and we advice Neo adjuvant treatment.If the disease responds well as in this case where PET is negative and if the pt is young and fit ,Radical surgery is the best option.Interestingly very often this is not the scenario in Indian patients.
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