Turkish Journal of Thoracic and Cardiovascular Surgery · 7 authors, 2 centres
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Synchronous lung and esophageal carcinomas are rare (incidence 0.54–3.2%) and carry high postoperative complication risk. This case series of three patients demonstrates that curative resection with lymph node dissection is the optimal treatment, but decisions must be individualized via multidisciplinary tumor board evaluation. Two-stage surgery and careful patient selection can mitigate complications, though even optimal candidates may experience unforeseen adverse events.
**Background:** Synchronous lung and esophageal carcinomas are rare, with reported incidence between 0.54% and 3.2%. Morbidity and mortality increase significantly after combined esophagectomy and pulmonary anatomic resection with lymph node dissection (LND) performed in the same session. Correct staging is critical because a synchronous lung mass may represent metastasis of esophageal malignancy; synchronous primary tumors have a better prognosis than metastatic disease. The authors emphasize that a patient-specific, multidisciplinary approach is essential given the high risk of postoperative complications.
**Methods:** This is a retrospective case series of three male patients treated at a single institution. All patients underwent multidisciplinary tumor council (MTC) evaluation including thoracic surgeons, gastroenterologists, medical and radiation oncologists, pathologists, and radiologists. Staging included computed tomography (CT), fluorodeoxyglucose positron emission tomography (FDG-PET), endoscopic evaluation with biopsy, transthoracic aspiration biopsy (TTAB), and cranial MRI where indicated. Treatment decisions were individualized based on tumor stage, histology, performance status, and respiratory reserve.
**Key Results:** - **Case 1:** A 54-year-old male with esophageal squamous cell carcinoma (T3N?M0) and right lower lobe adenosquamous carcinoma (T3N0M0). After neoadjuvant chemoradiotherapy (50.4 Gy IMRT with concurrent paclitaxel/carboplatin), the esophageal lesion showed complete metabolic response, but the lung mass increased in size and metabolic activity. Single-stage surgery was performed: right lower lobectomy + mediastinal LND, followed by esophagectomy with cervical esophagogastrostomy. Postoperatively, the patient developed chylothorax (drainage reached 1000 mL/day), requiring re-exploration with thoracic duct reattachment on day 5. The patient was discharged on day 16 and was doing well at 1-month follow-up. - **Case 2:** A 75-year-old male with Siewert type 3 esophagogastric junction adenocarcinoma (T4aN2M0 after neoadjuvant chemotherapy with docetaxel, oxaliplatin, leucovorin, and 5-FU) and right upper lobe lung adenocarcinoma (pT3N0M0). Two-stage surgery was performed: first, total gastrectomy + esophagojejunostomy with lower mediastinal and D2 LND (11 metastatic lymph nodes identified). Three weeks later, mediastinoscopy (stations R2 and R4 negative) followed by right upper lobectomy and LND. No postoperative complications occurred. The patient was discharged on day 4 and was well at 1-month follow-up. - **Case 3:** A 75-year-old male with Siewert type III gastroesophageal junction adenocarcinoma and a left upper lobe lung mass (SUVmax 6.52). TTAB was non-diagnostic; repeat biopsy was refused by the patient. Due to poor ECOG performance status and limited respiratory reserve, the patient was deemed surgically and medically inoperable. A fully-coated nitinol esophageal stent was placed for enteral nutrition. The patient was discharged on postoperative day 2 without additional problems at 1-month follow-up.
**Clinical Implications:** This case series reinforces that curative resection with lymph node dissection remains the optimal treatment for synchronous lung and esophageal tumors when feasible. However, the high complication rate (20–50% in single-stage surgery per literature) mandates careful patient selection. The authors recommend two-stage surgery for patients with poor general condition or Type II–III gastroesophageal junction tumors extending less than 3 cm proximally. For cervical esophageal tumors, a three-stage approach is described. Ideal surgical candidates should have normal PO2 and PCO2, FEV1 >70%, and estimated postoperative vital capacity >50%. Minimally invasive approaches may reduce morbidity. Multidisciplinary decision-making involving pathologists and radiologists is critical, especially when both tumors share the same histology, to distinguish synchronous primaries from metastatic disease.