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Incidental pulmonary nodules are frequently identified during staging investigations for esophageal cancer patients. However, the clinical significance of such nodules is unclear and may bias treatment decisions towards palliative options. This study is aimed to determine the value of an aggressive surgical approach in patients with esophageal cancer and incidental pulmonary nodules.

From 2005-2012, a prospectively entered institutional clinical database of esophageal cancer patients was accessed to identify patients with incidental pulmonary nodules. Those patients who underwent combined esophageal and lung resection (EL) were compared to those who had esophagectomy alone (E) in terms of demographics, tumor characteristics and peri-operative outcomes. Fishers exact and MWU-test determined significance (*p<0.05).

During the study period, 424 patients were treated for esophageal cancer, of which 93 (22%) had lung nodules. Of these, 29 (31%) were treated non-surgically either due to their poor performance status or extra-pulmonary distant metastasis on CT and/or PET. The remaining 64 patients had no evidence of extra-pulmonary metastasis and underwent neo-adjuvant therapy (35 (55%)) followed by curative en-bloc esophagectomy (with lung resection, 33 (50%), or without lung resection, 31 (47%) as per a tumor board consensus). Of 33 lung resections, there were 27 benign lesions (mostly granulomas or fibrotic scars), 4 primary stage I lung cancers and 2 metastases (1 esophageal cancer and 1 renal cell carcinoma). Of the 31 patients with lung nodules who underwent curative esophagectomy without lung resection, only 1 (3.2%) showed interval size increase on follow-up imaging (median 9 months (3-40)). A total of 308 patients underwent a curative esophagectomy, of which 33 had a combined esophagectomy and wedge lung resection (EL) and 275 had an esophagectomy alone (E). There were no differences in age or gender, but the EL group had more smokers (EL:25 (77%) vs E:130 (47%)*). There was no difference in pulmonary complications, anastomotic leak, overall complications, operative time, blood loss, length-of-stay, or post-operative mortality (Table 1).

The presence of incidental pulmonary nodules in the absence of extra-pulmonary metastases in esophageal cancer patients are rarely distant metastases, and should not bias caregivers towards palliative therapy. In addition, should a nodule be of uncertain etiology, resection of lung nodules during the esophagectomy is safe.
Table 1: Outcomes of patients with curative esophagectomy alone compared to those with esophagectomy and lung resection. Data presented as median (range) and N(%). * = p<0.05

	Esophagectomy Only (E)	Esophagectomy and Lung Resection (EL)
	(N = 275)	(N = 33)
Age	62 (43-78)	65 (24-91)
Gender (% M)	73%	76%
Smoking History	130 (47%)*	25 (77%)*
Pulmonary Complications	70 (25%)	6 (19%)
Anastamosis Leak	26 (9%)	2 (6%)
Overall Complications	151 (55%)	15 (45%)
Estimated Blood Loss	310 mL (100-3500)	300 mL (150-2000)
Length of Stay	11 days (5-185)	10 days (7-86)
Operative Time	285 min (100-600)	310 min (220-510)
Post-Operative Mortality	9 (3%)	1 (3%)