Cervical lymph node metastases in thoracic esophageal cancer: a systematic review

Summary: Cervical lymph node metastases in thoracic esophageal cancer represent a controversial pattern of nodal spread, with inconsistent classification across staging systems and substantial variation in reported management and outcomes. Although frequently categorized as distant metastatic disease, their location within the longitudinal lymphatic drainage pathways of the esophagus raises uncertainty regarding their biological and clinical impact. A systematic review was conducted. PubMed, Embase, and the Cochrane Library were searched for studies reporting treatment strategies and survival outcomes in patients with thoracic esophageal cancer (squamous cell carcinoma or adenocarcinoma) presenting with cervical and/or supraclavicular lymph node metastases at initial staging. The primary outcome was overall survival. In total, 19 studies comprising 1669 patients were included, predominantly retrospective in design. Most cohorts consisted primarily of squamous cell carcinoma, with limited representation of adenocarcinoma. Definitions and classification of cervical nodal disease varied widely, with inconsistent anatomical stratification and limited reporting of disease extent and nodal burden. Survival outcomes differed substantially. In selected patients treated with curative intent, 3-year overall survival reached up to 72%, and 5-year overall survival up to 41%. Favorable outcomes were most often observed in anatomically defined and carefully selected cohorts. Cervical lymph node metastases in thoracic esophageal cancer should not be regarded as a uniform disease entity. Available evidence suggests that involvement confined to the longitudinal paraesophageal and parajugular drainage pathway may behave more similarly to locoregional (N) disease than to unequivocal M1 systemic metastatic spread. In selected patients treated with curative intent, including neoadjuvant therapy followed by esophagectomy with three-field lymphadenectomy, long-term survival has been reported. Anatomically precise stratification and consistent reporting are essential to improve prognostic interpretation and guide treatment decisions.