Esophageal Cancer Workup
- Author: Keith M Baldwin, DO; Chief Editor: N Joseph Espat, MD, MS, FACS more...
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.)
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
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).
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. (See the image below.)
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.
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 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.
For more information, see the Medscape Reference article Esophageal Carcinoma Imaging.
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.
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. 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 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.
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|Stage IV||Any T||Any N||M1|
|Stage IV||Any T||Any N||M1|