How do you approach borderline non-regional mediastinum lymph nodes when treating locally advanced esophageal cancer?

I basically consider any nodal disease in the mediastinum from esophageal cancer to be operationally regional disease and would include those areas in the radiation fields if feasible. The comment about the nodes being borderline positive is an ambiguity that cannot be resolved in a forum like this. In all diseases, there are often uncertainties and one treats based on issues of possible toxicity vs likely benefit. Esophageal cancer has a high likelihood of PET positivity so that study can be very useful in decision making.

I agree with Dr. @Dr. First Last and Dr. @Dr. First Last. It’s not clear what is meant by non-regional, but essentially – mediastinal disease can be considered regional – though the extent and location may dictate (based on toxicity profile) what is a reasonable RT field, etc. And certainly, there is much to nuance re if this is GEJ primary with upper paratracheal or hilar nodes and the discussion of regional vs non-regional (as Dr. Meyer mentioned). If truly significant changes in management are being considered (i.e., being presumed metastatic or locoregional disease), then discussion of risks vs benefits on toxicity profile of treating (chemoRT, or even induction chemo --> chemoRT in certain high risk contexts), investigating mediastinal...