Esophageal Cancer Staging

Author: Jason Muesse, MD
Institution: University of Arkansas
Date Reviewed: December 2024
Learning Domain: General Thoracic
Learning Objective: Staging and diagnosis of esophageal cancer
PowerPoint File: Esophageal Cancer Staging

Workup of Esophageal Cancer

• History and Physical
  • Determine functional status and nutritional needs
• CT Chest abdomen and Pelvis with PO and IV contrast
  • Mets, small lymph nodes & anatomy (replaced vessels, celiac a. stenosis)
• Endoscopic Ultrasound 
  • Determines T stage and often N stage
  • Often trouble passing probe if have significant mass effect
  • If they have dysphagia, it’s at least T3.  CT should help to tell if its T4.
• PET/CT scan
  • Determines N stage and M stage
  • Looks at hypermetabolic lymph nodes > 1cm
  • Good at finding bony mets, characterizing liver masses
    • Paratracheal, subcarinal and celiac/perigastric nodes - locoregional
    • Perihepatic nodes - considered by some to be in operative field / locoregional 
      • Most surgeons in US consider these distant
  • Supraclavicular nodes – locoregional for upper esophageal squamous cell cancers (controversial)
    • Some surgeons in US will operate with good response

Esophageal Cancer Staging

• T stage based on depth 
• N stage based on number of regional nodes (that are potentially resectable / in operative field)
• M stage based on presence or absence of distant metastatic disease (liver, lung, etc but also including lymph node stations outside resection area)
• Histologic grade sometimes determined on biopsy, often on final pathology

8th Edition Changes

• Gastric cancers are treated with different chemotherapy regimen (FLOT) & behave differently
• Radiation is often omitted from gastric cancer therapy 
• Although distal esophagectomy / proximal gastrectomy can be performed for tumors of proximal stomach if there is no esophageal involvement total gastrectomy and esophagojejunostomy is usually recommended
• If any esophageal involvement, usually needs esophagectomy
• If have dysphagia, probably has some esophageal component and will benefit from neoadjuvant radiation  

Rice TW, Ishwaran H, Ferguson MK, Blackstone EH, Goldstraw P. Cancer of the Esophagus and Esophagogastric Junction: An Eighth Edition Staging Primer. J Thorac Oncol. 2017;12(1):36-42. 

The Siewert Classification of GE Tumors: 

• Type I: Center 1–5 cm above GEJ
• Type II: Center 1 cm above to 2 cm below GEJ arises from cardia
• Type III: Center 2–5 cm below GEJ, below cardia

Staging Guides Therapy

Endoluminal Therapy for T1a Esophageal Cancer

• First Line Therapy for T1a tumors or dysplasia (but esophagectomy should be offered)
  • The resected specimen is the ultimate T (depth) staging tool 
  • If deeper than a T1a (invading into or past submucosa in any way), patient is recommended to have esophagectomy
    • b/c incidence of nodal metastasis goes from 7 percent to 21 percent when go from T1a to T1b
• Must be done with endoscopic ultrasound first  
• Must still obtain full metastatic workup
• RFA or PDT for coexisting Barrett’s must be performed as a supplement
• Must have very aggressive short and long term follow up 

Stage II-III Neoadjuvant Therapy

• 5-6 weeks of chemotherapy with platinum based drug + paclitaxel or 5FU
  • MAGIC trial, NEJM 2006
    • (improves 5 yr survival v surgery alone from 23% to 36%, p<0.001)
  • <10 percent of tumors are Her2 receptor positive, target for trastuzimab/Herceptin (adjuvant)
  • PD-L1 testing for Keytruda (adjuvant)
• Concurrent radiotherapy for 6 weeks (daily treatments for 5 days a week, 30 treatments total) 50.4 Gy of radiation total
  • CROSS trial, NEJM 2012 
  • (improves 5 yr survival v surgery alone from 34% to 47%, p=0.003)
  • Radiation helps you with the radial margins
• Repeat PET or CT scan at the end of treatment, 
  • if no evidence of progression then wait 5-6 week and have esophagectomy
  • If progress, continue to definitive chemoradiotherapy (70 Gy)
• Before starting therapy , determine nutritional needs – esophageal stent versus feeding tube; should see nutritionist
  • Try not to interrupt therapy for feeding access 

Surgeon’s Role before Esophagectomy

• Set expectations. 
• Assess if patient will ever be a surgical candidate.
  • If not surgical candidate, radiation doses will be adjusted. 
• Feeding gastrostomy or jejunostomy may be required preoperatively
• Laparoscopic placement is ideal
  • Along fundus well away from right gastroepiploic artery
  • PEG is ok, but ideal placement can be confirmed with laparoscopy
  • Laparoscopy can help staging but not required
  • IR placed gastrostomy tube is probably the most problematic for conduit
• Document distance of tumor from incisors preoperatively 
  • May be difficult to locate after neoadjuvant treatment
• Bronchoscopy for mid thoracic tumors, especially squamous cell
  • To rule out invasion into membranous portion of airway