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Esophageal Cancer Workup

  • Author: Keith M Baldwin, DO; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
 
Updated: Sep 18, 2015
 

Approach Considerations

The goals of the workup are to establish the diagnosis and to stage the cancer. Esophagogastroduodenoscopy allows direct visualization and biopsies of the tumor. (See the image below.)

Endoscopy demonstrating intraluminal esophageal ca Endoscopy demonstrating intraluminal esophageal cancer.

Laboratory studies in patients with esophageal cancer focus principally on patient factors that may affect treatment. Nutritional status should be evaluated in patients with dysphagia; liver function studies should be performed in alcoholic patients.

In 2013, the Society of Thoracic Surgeons released clinical practice guidelines to assist in the diagnosis and treatment of localized esophageal cancer. Their recommendations include the following[29, 30] :

  • For the diagnosis of esophageal cancer, flexible endoscopy with biopsy is the primary method
  • For early-stage esophageal cancer, CT of the chest and abdomen is an optional test for staging; for locoregionalized esophageal cancer, CT of the chest and abdomen is a recommended test for staging
  • For early-stage esophageal cancer, PET is an optional test for staging. For locoregionalized esophageal cancer, PET is a recommended test for staging
  • In patients without metastatic disease, endoscopic ultrasonography is recommended to improve the accuracy of staging
  • In patients with small, discrete nodules or areas of dysplasia in whom disease appears limited to the mucosa or submucosa as assessed by endoscopic ultrasonography, endoscopic mucosal resection should be considered as a diagnostic/staging tool
  • In patients with locally advanced (T3/T4) adenocarcinoma of the esophagogastric junction infiltrating the anatomic cardia or Siewart type III esophagogastric tumors, laparoscopy is recommended to improve accuracy of staging
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Imaging Studies

Ultrasonography

Endoscopic ultrasonography (EUS) is the most sensitive test for determining the depth of tumor penetration (T staging) and the presence of enlarged periesophageal lymph nodes (N staging).[31]

CT scanning

Abdominal and chest computed tomography (CT) scans are useful for helping to exclude the presence of metastases (M staging) to the lungs and liver and may be useful for helping to determine whether adjacent structures have been invaded.[32] (See the image below.)

Chest CT scan showing invasion of the trachea by e Chest CT scan showing invasion of the trachea by esophageal cancer.

PET scanning

Positron emission tomography (PET) scanning is also a useful baseline imaging technique (see the image below) and is increasingly becoming standard in the staging of esophageal cancer. It may be particularly useful in detecting occult distant lymph node metastases and bone spread. In addition, the intensity of radiopharmaceutical uptake on PET scans may reflect the biology of the cancer and thus may have prognostic significance.[26]

Bronchoscopy

Bronchoscopy is indicated for cancers of the middle and upper third of the thoracic esophagus to help exclude invasion of the trachea or bronchi. Laparoscopy and thoracoscopy have a greater than 92% accuracy in staging regional nodes.

Barium swallow

Barium swallow is very sensitive for detecting strictures (see the first image below) and intraluminal masses (see the second image below) but does not allow staging and biopsy. It is now rarely used, but it may be helpful for studying the distal anatomy in obstructive tumors that are inaccessible by endoscopy.

Barium swallow demonstrating stricture due to canc Barium swallow demonstrating stricture due to cancer.
Barium swallow demonstrating an endoluminal mass i Barium swallow demonstrating an endoluminal mass in the mid esophagus.

For more information, see the Medscape Reference article Esophageal Carcinoma Imaging.

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Staging

Esophageal cancer staging follows the tumor-node-metastasis (TNM) classification of the American Joint Cancer Committee/Union for International Cancer Control/ (AJCC/UICC). The classification and staging scheme was changed in the 7th edition of the AJCC/UICC manual, published in 2010.[33]

No completely satisfactory method is available to clinically stage esophageal cancer. The difficulty of clinically assessing the disease is reflected by changes over time in the AJCC staging system. The 1983 system was based on the length of the intraluminal esophageal tumor, the presence of esophageal obstruction, and the involvement of palpable lymph nodes. This clinical staging system proved to be limited.

The 1988 revision defined a clinical and pathologic staging system based entirely on the depth of esophageal wall invasion and the presence or absence of local nodal involvement. Neither of these parameters is assessed easily on a clinical basis. Hofstetter et al therefore proposed incorporating the number of involved lymph nodes with regional and nonregional node location.[34] This modification, which seemed to be simpler and to better predict long-term survival, was adopted into the revised system.

The 2010 TNM classification for esophageal cancer is as follows (staging is detailed in Table 1, below):

  • Tis - Carcinoma in situ/high-grade dysplasia
  • T1 - Lamina propria or submucosa
  • T1a - Lamina propria or muscularis mucosae
  • T1b - Submucosa
  • T2 - Muscularis propria
  • T3 - Adventitia
  • T4 - Adjacent structures
  • T4a - Pleura, pericardium, diaphragm, or adjacent peritoneum
  • T4b - Other adjacent structures (eg, aorta, vertebral body, trachea)
  • N0 - No regional lymph node metastasis
  • N1 - 1-2 regional lymph nodes (N1 is site dependent)
  • N2 - 3-6 regional lymph nodes
  • N3 - More than 6 regional lymph nodes
  • M0 - No distant metastasis
  • M1 - Distant metastasis (M1a and M1b are site dependent)

Table 1. Staging Classification. (Open Table in a new window)

Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T1,T2 N1 M0
Stage IIIA T4a N0 M0
  T3 N1 M0
  T1,T2 N2 M0
Stage IIIB T3 N2 M0
Stage IIIC T4a N1,N2 M0
  T4b Any N M0
  Any T N3 M0
Stage IV Any T Any N M1

 

All esophageal tumors, as well as tumors with epicenters within 5 cm of the esophagogastric junction that also extend into the esophagus, are classified and staged according to the AJCC/UICC esophageal scheme. Tumors with an epicenter in the stomach that are more than 5 cm from the esophagogastric junction or those within 5 cm of the esophagogastric junction without extension into the esophagus are staged using the gastric carcinoma scheme.

Other classifications—such as that of the Japanese Society for Esophageal Diseases, which is widely used in Asia—differ from that of the AJCC/UICC, especially regarding lymph node distribution and nomenclature.[35]

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Contributor Information and Disclosures
Author

Keith M Baldwin, DO IMPH, Assistant Professor of Surgery, Boston University School of Medicine; Endocrine and Surgical Oncologist, Department of General Surgery, Roger Williams Cancer Center

Keith M Baldwin, DO is a member of the following medical societies: American College of Surgeons, Society of Surgical Oncology, American Association of Endocrine Surgeons, Americas Hepato-Pancreato-Biliary Association, Society of International Humanitarian Surgeons/Surgeons OverSeas (SOS)

Disclosure: Nothing to disclose.

Coauthor(s)

Marco G Patti, MD Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American Surgical Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, Western Surgical Association

Disclosure: Nothing to disclose.

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center

N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society

Disclosure: Nothing to disclose.

Fernando AM Herbella, MD, PhD TCBC, Affiliate Professor, Attending Surgeon in Gastrointestinal Surgery, Esophagus and Stomach Division, Department of Surgery, Federal University of Sao Paulo, Brazil; Private Practice; Medical Examiner, Sao Paulo's Medical Examiner's Office Headquarters, Brazil

Fernando AM Herbella, MD, PhD is a member of the following medical societies: Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Chief Editor

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center

N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society

Disclosure: Nothing to disclose.

Acknowledgements

Philip Schulman, MD Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center

Philip Schulman, MD, is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Endoscopy demonstrating intraluminal esophageal cancer.
Cascade of events that lead from gastroesophageal reflux disease to adenocarcinoma.
Barium swallow demonstrating stricture due to cancer.
Barium swallow demonstrating an endoluminal mass in the mid esophagus.
Chest CT scan showing invasion of the trachea by esophageal cancer.
Transhiatal esophagectomy in which (a) is the abdominal incision, (b) is the cervical incision, and (c) is the stomach stretching from abdomen to the neck.
Five-year survival for esophageal cancer based on TNM stage.
H and E, high power, showing junction of benign glands in the lower right, Barrett's columnar cell metaplasia with a large goblet cell containing blue mucin in the lower center and adenocarcinoma on the left.
Macroscopic image of a resection of the gastroesophageal junction. On the right is non-neoplastic esophagus, consisting of tan, smooth mucosa. On the left is the non-neoplastic rugal folds of the stomach. In the center of the picture is an ulcer with a yellow-green fibrinous exudate surrounded by irregular, heaped-up margins with almost a cobblestone appearance. The latter represents mucosal adenocarcinoma with probably some Barrett's metaplasia in the background.
H and E, high power, demonstrating invasive esophageal squamous cell carcinoma. This carcinoma does not form glands and instead shows features of squamous differentiation, including keratinization and intercellular bridges.
Macroscopic image of an esophageal resection. A polypoid squamous cell carcinoma is visible protruding from the esophageal mucosal surface (left center of specimen).
On this positron emission computed tomography (PET) scan, esophageal cancer is evident as a golden lesion in the chest.
Table 1. Staging Classification.
Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T1,T2 N1 M0
Stage IIIA T4a N0 M0
  T3 N1 M0
  T1,T2 N2 M0
Stage IIIB T3 N2 M0
Stage IIIC T4a N1,N2 M0
  T4b Any N M0
  Any T N3 M0
Stage IV Any T Any N M1
Table 1. Staging Classification.
Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T1,T2 N1 M0
Stage IIIA T4a N0 M0
  T3 N1 M0
  T1,T2 N2 M0
Stage IIIB T3 N2 M0
Stage IIIC T4a N1,N2 M0
  T4b Any N M0
  Any T N3 M0
Stage IV Any T Any N M1
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