Treatment Strategies of Esophageal Cancer With Concurrent Cervical Node Metastasis: A Dutch Nationwide Population-Based Cohort Study

Background In the West, standard curative treatment for resectable esophageal cancer without distant metastasis is neoadjuvant chemo(radio)therapy followed by esophagectomy. A small subset of patients presents with concurrent cervical lymph node metastasis (LNM). Historically this was considered as distant metastasis and surgical intervention was usually not an option for these patients. In the AJCC 8th edition TNM classification, cervical parajugular lymph node stations are now categorized as locoregional disease. Our study aims to describe current treatment strategies for patients presenting with esophageal cancer and concurrent cervical LNM in the Netherlands. Methods For this population-based cohort study data from the Netherlands Cancer Registry (NCR) was used. Patients with thoracic esophageal or gastroesophageal junction cancer and concurrent cervical lymph node metastasis were included in this study. Treatment modalities were categorized into either: neoadjuvant therapy followed by surgery (Neo + S), definitive chemo-radiotherapy (dCRT), chemotherapy without radiotherapy or < 30 Gy radiotherapy (CT), palliative radiotherapy (RT), and best supportive care (BSC). Overall survival (OS) was assessed using the Kaplan–Meier method and compared via the log-rank test. Hazard ratios were computed using Cox regression analysis, with adjustment for confounding through inverse probability of treatment weighting (IPTW). Results Between 2015 and 2021, 412 eligible patients were identified from the NCR database. Median OS durations were observed as follows: 24 months for Neo + S, 18 months for dCRT, 15 months for CT, 7 months for RT, and 3 months for BSC. A comparison between the Neo + S group and dCRT demonstrated a significant superiority in OS (p = 0.02) and a 44% lower risk compared to the dCRT group. Cox regression showed that Neo + S group had a 44% lower risk of death compared to the dCRT cohort. Utilizing IPTW to adjust for confounding factors, Neo + S maintained its survival advantage. Conclusion This study suggests that neoadjuvant therapy followed by surgery may be the optimal treatment strategy for patients with resectable esophageal cancer with concurrent cervical LNMs The results emphasize the importance of considering surgery as a viable option for these patients. The hypothesis-generating results undersacore the need for a prospective study.