Treatment strategies of esophageal cancer with concurrent cervical node metastasis: a Dutch nationwide population-based cohort study

Cervical lymph node metastasis in thoracic esophageal cancer occupies a conceptual border zone between locoregional and distant disease. Evidence guiding treatment selection in this population remains limited in Western cohorts. The objective was to evaluate treatment strategies and overall survival outcomes for patients with resectable esophageal cancer and concurrent cervical lymph node metastasis in the Netherlands. This population-based cohort study used the Netherlands Cancer Registry to identify patients with resectable thoracic esophageal or gastroesophageal junction cancer and concurrent cervical lymph node metastasis. Treatment strategies included definitive chemoradiotherapy, neoadjuvant therapy followed by surgery, chemotherapy with or without limited radiotherapy (≤30 Gy), palliative radiotherapy, and best supportive care. Kaplan-Meier analysis and Cox regression adjusted with inverse probability of treatment weighting (IPTW) were used to assess overall survival and treatment effects. Between 2015 and 2021, 412 eligible patients were identified. Median overall survival was 24 months for patients treated with neoadjuvant therapy followed by surgery, 18 months for definitive chemoradiotherapy, 15 months for chemotherapy, 7 months for radiotherapy alone, and 3 months for best supportive care. In multivariable analysis, neoadjuvant therapy followed by surgery was associated with longer survival compared with definitive chemoradiotherapy (HR 0.56 [0.34-0.91]). Similar estimates were observed after IPTW. Higher cN stage and poorer performance status were independently associated with worse survival. Subgroup analysis of neoadjuvant chemoradiotherapy versus chemotherapy within the surgical cohort showed no significant survival difference. In this nationwide cohort, management of thoracic esophageal cancer with concurrent cervical lymph node metastasis was highly heterogeneous. Although neoadjuvant therapy followed by surgery was associated with longer survival, interpretation is limited by baseline differences and potential residual confounding. These findings suggest that surgery may be considered within a multimodality strategy in carefully selected patients and warrant prospective evaluation to better define its role.