Treatment of a solitary cervical lymph node recurrence following curative resection for thoracic oesophageal cancer

A. Wilhelm, A. Rossetti, W. Nagel

Objective

Squamous cell esophagus carcinoma (SCEC) is an extremely aggressive cancer with poor survival. En bloc tumor resection with two or three-field lymphadenectomy is the recommended surgical therapy. The incidence of cervical lymph node recurrence after radical esophagectomy with two-field lymphadenectomy is comparatively low.

Here we present a case of late recurrence of a SCEC in a cervical node, half a year after thoraco-abdominal esophagus resection with two-field lymphadenectomy.

Methods

A 55-years-old man was diagnosed with SCEC in January 2012 (uT3 uN1 cM0). After neoadjuvant radiochemotherapy a thoraco-abdominal esophagectomy and two-field lymphadenectomy was performed (ypT3 yN0(0/16) LV1 TRG4).

In January 2013, after adjuvant chemotherapy with cetuximab a thoracoabdominal CT-scan showed a singular lymph node metastasis of the right neck region (retroclavicular region). Surgical exploration revealed tumor invasion of the carotid artery, jugular vein, inferior laryngeal nerve and vagus nerve, thus the tumor was not resected.

A second cycle of radiochemotherapy achieved no benefit.

Clinical and oncological re-evaluation showed no other signs for metastases, however worsening pain in the right arm and on urgent request from the oncologists, a radical resection was performed.

Results

Radical resection of the lymph node metastasis was accomplished via cervico-sternotomy, extending to the phrenic nerve, inferior laryngeal nerve, vagus nerve and the sympathetic trunk. A vascular resection of the carotid artery, jugular vein and the subclavian artery and vein was also performed. The carotid and subclavian artery were reconstructed with a 6mm-Dacron graft,  the subclavian vein with a 8mm-Dacron graft.

The initial post-operative course was very good. After 5 months a CT-scan showed distant lung metastasis and the patient was treated with palliative chemotherapy.

Conclusion

Although extended lymphadenectomy for thoracic esophageal cancer is widely practiced, solitary supraclavicular lymph node recurrence can occur.

Salvage lymphadenectomy for solitary supraclavicular lymph node recurrence should be performed only after careful patient selection considering among others, the extent of lymph node metastasis and the disease-free interval. For solitary lymph node recurrence, loco-regional therapy can lead to a substantial survival improvement.

Figure 1: PET-CT-Scan – lymph node metastasis supraclavicular in the right neck region
Figure 2: the tumor has infiltrated the carotid artery and other structures
Figure 3: en-bloc resection of the tumor, nerves and vessels
Figure 4: vascular reconstruction

References

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