How Esophageal Cancer Is Diagnosed

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The diagnosis of esophageal cancer may include tests such as a barium swallow, endoscopy, and endoscopic ultrasound. You may need an evaluation for possible esophageal cancer if you have difficulty swallowing, a persistent cough, or risk factors for the disease such as long-standing acid reflux. Other procedures and imaging tests such as CT, PET, and bronchoscopy can be helpful in determining the stage of the disease. Staging is important for selecting the best treatment options.

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Labs and Tests

There is no at-home test for esophageal cancer. It's helpful to be aware of the risk factors and the potential warning signs and symptoms of esophageal cancer so you can get medical attention if you need it.

Lab tests are not specific for diagnosing esophageal cancer, but they are used in combination with other tests to evaluate some effects of the disease.

A complete blood count (CBC) may show anemia (a low red blood cell count) if cancer is bleeding. Liver function tests may be elevated if cancer has spread to the liver.

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Procedures

The diagnosis of esophageal cancer relies on invasive procedures that may require some preparation in advance, such as stopping blood thinners for a few days or abstaining from food and drink for a specified number of hours.

Endoscopy

Upper endoscopy (esophagoscopy or esophagus-gastric-duodenoscopy) is the primary method of diagnosing esophageal cancer.

During this procedure, a flexible, lighted tube is inserted through the mouth and advanced down through the esophagus. The tube has a camera at the end that allows your healthcare provider to directly visualize the inner (superficial) lining of your esophagus. If abnormalities are detected, a biopsy can be performed at the same time.

Before your procedure, you will be given a sedative that causes sleepiness, and the procedure is usually well tolerated.

Endoscopic Ultrasound (EUS)

During an upper endoscopy, an ultrasound probe at the end of the scope can be used to create an image of the deeper tissues of the esophagus.

EUS is helpful for determining the depth of the tumor, which is important in staging it. It can also be helpful for evaluating nearby lymph nodes and guiding biopsies.

Biopsy

A biopsy is often taken during endoscopy, but may also be done via bronchoscopy or thoracoscopy.

A pathologist will stain the sample and examine it with a microscope to figure out if the tissue is cancerous. A biopsy is used to determine whether esophageal cancer is squamous cell carcinoma or adenocarcinoma, and for grading the tumor. A grade is a number that describes how aggressive the tumor appears.

Other tissue tests may be done that look at the molecular characteristics of the tumor, such as HER2 status (like breast cancers HER2 positive, esophageal cancers may also be HER2 positive).

Bronchoscopy

bronchoscopy is usually done to evaluate esophageal tumors that are located in the middle to upper third of the esophagus when involvement of the trachea (airway) is suspected.

A bronchoscope (a thin, lighted tube) is inserted through the nose or mouth into the trachea and down to the bronchi (the large airways of the lungs). The procedure allows your healthcare provider to directly observe abnormalities in these areas and collect a biopsy if needed.

Bronchoscopy is done with sedation, usually as an outpatient procedure.

Thoracoscopy

During a thoracoscopy, an incision (cut) is made between two ribs, and a thoracoscope, which is a thin, lighted tube, is inserted into the chest. Healthcare providers use this to look at the organs in the chest and check for cancer.

Tissue samples and lymph nodes may be biopsied. In some cases, this procedure may be used to remove portions of the esophagus or lung.

Laparoscopy

During a laparoscopy, small cuts are made in the wall of the abdomen. A laparoscope, which is a thin, lighted tube, is inserted through one of the incisions to observe the organs inside the abdomen and check for signs of disease. Procedures such as removing organs or taking tissue samples for biopsy may be done as well.

Laryngoscopy

A small lighted tube is inserted down the throat to look at the larynx (voice box). This test can detect the spread of cancer to the larynx or pharynx (throat). 

Imaging

Imaging tests may be part of the early diagnostic workup for esophageal cancer, but they are more commonly used to stage cancer.

Barium Swallow

The first test done to evaluate a possible esophageal cancer is often a barium swallow or an upper endoscopy, although proceeding directly to an endoscopy is preferred if there's a high suspicion of esophageal cancer.

Right before a barium swallow (also called an upper GI series), you would be given a drink containing barium (which is safe). Then you would have series of X-rays. The barium in the drink lines the esophagus and stomach, allowing your healthcare provider to see abnormalities in the wall of the esophagus.

A barium swallow may be helpful in diagnosing strictures (narrowing within the esophagus), but is used less than endoscopy because a biopsy cannot be performed at the same time.

CT Scan

A CT scan (computerized tomography) uses a cross-section of X-rays to create a 3D picture of internal organs. With esophageal cancer, the test is not usually used as part of the diagnosis but it's important in staging the disease.

CT is particularly good at looking for evidence of metastasis (spread) of the tumor to lymph nodes or other regions of the body, such as the lungs or liver. 

PET Scan

A PET scan measures metabolic activity in a region of the body. A small amount of radioactive sugar is injected into the bloodstream and allowed time to be taken up by cells. Cells that are more metabolically active, such as cancer cells, show up brighter than normal areas (that are less active). This test may be used to look for evidence of metastasis.

X-Ray

In addition to the above tests for diagnosing and staging esophageal cancer, a chest X-ray to look for spread to the lung may be conducted, especially when a quick test is needed.

Differential Diagnoses

There are a number of conditions that may cause symptoms similar to those of esophageal cancer.

Some of these include:

  • Esophageal stricture: A stricture is scar tissue that forms in the esophagus causing narrowing. It often occurs due to trauma, such as complications of endoscopy for esophageal varices (varicose veins of the esophagus often associated with alcoholism), after a person has had a nasogastric tube (NG tube) for an extended period of time, or due to accidental ingestion of drain cleaner as a child. Severe longstanding gastroesophageal reflux is also an important cause of stricture (peptic stricture).
  • Stomach cancer (gastric cancer): Cancers in the stomach may cause symptoms similar to those of esophageal cancer.
  • Benign esophageal tumors (such as esophageal leiomyoma): Most tumors of the esophagus (around 99%) are cancerous. Benign tumors may, however, occur, and the majority of these are leiomyomas.
  • Achalasia: Achalasia is a rare condition in which the band of tissue between the lower esophagus and stomach (the lower esophageal sphincter) doesn't relax properly, making it difficult for food to pass from the esophagus into the stomach.

Staging

Determining the stage of cancer is important in choosing the best treatment options. A combination of imaging tests and biopsy results is used to determine the stage.

Healthcare providers use the TNM staging method to classify an esophageal tumor; this system is used for other cancers as well. With esophageal cancer, an additional letter—G—is added to account for tumor grade. L is also added for squamous cell carcinomas.

The specifics of staging are complex, but learning about them can help you better understand your disease.

T stands for tumor: The number for T is based on how deep into the lining of the esophagus the tumor extends. The layer closest to food passing through the esophagus is the lamina propria. The next two layers are known as the submucosa. Beyond that lies the lamina propria and, finally, the adventitia—the deepest layer of the esophagus.

  • Tis: This stands for carcinoma in situ, a tumor that involves only the very top layer of cells in the esophagus.
  • T1: The tumor extends through the lamina propria and muscularis musculae. (In T1a, the tumor has invaded the lamina propria or muscularis mucosae. In T1b, the tumor has invaded the submucosa).
  • T2: The tumor has invaded the muscle (the muscularis propria).
  • T3: The tumor has spread to the adventitia. It has now penetrated all the way through the muscle into surrounding tissues.
  • T4: T4a means that the tumor has spread beyond the esophagus to involve adjacent structures such as the pleura (lining of the lungs), pericardium (lining of the heart), the azygous vein, the diaphragm, and the peritoneum (the lining of the abdomen). T4b means that the tumor has spread to the aorta, vertebrae, or trachea.

N stands for lymph nodes:

  • N0: There are no lymph nodes involved.
  • N1: The tumor has spread to one or two nearby (regional) lymph nodes.
  • N2: The tumor has spread to three to six nearby lymph nodes.
  • N3: The tumor has spread to seven or more nearby lymph nodes.

M stands for metastasis (distant spread) of cancer:

  • M0: Metastases are not present.
  • M1: Metastases are present.

G stands for grade:

This is different for adenocarcinoma and squamous cell carcinoma.

For adenocarcinoma:

  • G1: The cells look like normal cells (well-differentiated), and at least 95% of the tumor has well-formed glands.
  • G2: The cells look a little different from normal cells (moderately differentiated), and 5 to 95% of the tumor exhibits gland formation.
  • G3: The cells look very abnormal (poorly differentiated) with less than 50% of the tumor showing gland formation.

For squamous cell carcinoma:

  • G1: The cells look like normal cells (well-differentiated) and are arranged in sheets.
  • G2: The cells look a little different than normal cells (somewhat differentiated).
  • G3: The cells look much different from healthy cells (poorly differentiated) and are arranged in nests.

L stands for location (squamous cell carcinoma only):

  • Upper: The tumor is present in the cervical esophagus to the lower border of the azygous vein.
  • Middle: The tumor is present from the lower border of the azygous vein to the lower border of the inferior pulmonary vein.
  • Lower: The tumor is found between the lower border of the inferior pulmonary vein and the stomach (including tumors that involve the esophagogastric junction).

Using the above, oncologists then assign a stage. This is considered a pathological stage, rather than a clinical one, which is more accurate in terms of prognosis.

Esophageal Adenocarcinoma Stages

Stage 0: The cancer is found only in the innermost layer of cells lining the esophagus (Tis, N0, M0). This is also known as carcinoma in situ

Stage I: Stage I tumors can be found in any location and are broken down into stage IA, stage IB, and stage IC.

  • Stage IA: Stage IA tumors involve superficial layers but have not spread to the submucosa (T1a, N0, M0, G1).
  • Stage IB: These tumors may be similar to stage IA but more abnormal appearing (T1a, N0, M0, G2), or have invaded the submucosa (T1b, N0, M0, G1-2).
  • Stage IC: These tumors may involve only the superficial layers but appear very abnormal (T1, N0, M0, G3), or have spread into the muscle (T2, N0, M0, G1-2).

Stage II: Depending on where the cancer has spread, stage II esophageal cancer is divided into stage IIA and stage IIB.

  • Stage IIA: In stage IIA, the tumor has spread to the muscle and has a higher grade (T2, N0, M0, G3).
  • Stage IIB: In stage IIB there are also two basic situations. In one, the tumor involves only the superficial layers of tissue, but has spread to one or two nearby lymph nodes (T1, N1, M0, any G). In the other, the tumor has spread to the adventitia but no lymph nodes (T3, N0, M0, any G).

Stage III: There are two substages of stage III.

  • Stage IIIA: This includes tumors that only involve the superficial layers but have spread to three to six lymph nodes (T1, N2, M0, any G, any location), or tumors that have spread to the muscle as well as one to two lymph nodes (T2, N1, M0, any G, any location).
  • Stage IIIB: There are three different types of tumors that may be classified as stage IIIB. In one, the tumor has spread beyond the esophagus to adjacent structures and may or may not have spread to lymph nodes (T4a, N0-1, M0, any G). In another, the tumor has spread to one or two lymph nodes and extends to the adventitia (T3, N1, M0, any G). In the third, the tumor has spread past the superficial layers to some degree and involves three to six lymph nodes (T2-3, N2, M0, any G).

Stage IV:  Adenocarcinoma is divided into stage IVA and stage IVB.

  • Stage IVA: The tumor has spread to areas near the esophagus and to no lymph nodes or as many as three to six lymph nodes.
  • Tumor has spread to seven or more lymph nodes.
  • Stage IVB: Cancer has spread to another body part.

Squamous Cell Carcinoma of the Esophagus Stages

Unlike adenocarcinoma, the staging for and prognosis of squamous cell carcinoma also includes the location of the tumor.

Stage 0: The cancer is found only in the layer of cells lining the esophagus (Tis, N0, M0). This is also known as carcinoma in situ. Stage 0 tumors may be found in any location.

Stage I: This stage is defined as stages IA and IB, and these tumors may be located anywhere in the esophagus.

  • Stage IA: The tumor involves only the superficial layers of tissue, but has not yet reached the submucosa. The cells appear normal (T1a, N0, M0, G1).
  • Stage IB: There are three situations in which a tumor could be stage IB. One is similar to stage IA, except the cells extend to the submucosa (T1b, N0, M0, G1). In another, the tumor remains in the superficial tissues, but the cells are more abnormal appearing (T1, N0, M0, G2-3). In the third, a tumor has spread to involve the muscle, but the cells appear normal and have not spread to lymph nodes (T2, N0, M0, G1). 

Stage II: Depending on where cancer has spread, stage II esophageal cancer is divided into stage IIA and stage IIB.

  • Stage IIA: There are three different ways in which a tumor can be classified as stage IIA. This includes tumors that have extended to the muscle (similar to stage IB), but the cells are very abnormal appearing (T2, N0, M0, G2-3). This stage also includes tumors that have invaded the adventitia and are either in the lower esophagus (T3, N0, M0, any G, lower) or mid to upper esophagus (T3, N0, M0, G1, upper middle).
  • Stage IIB: There are four different ways in which a tumor may be considered stage IIB. These include tumors that have spread to the adventitia and have abnormal appearing cells in any location (T3, N0, M0, G2-3); tumors that involve the adventitia and have an undefined grade in any location (T3, N0, M0, X) or have any grade but a location that is not defined (T3, N0, M0, any X), or those that only involved the superficial tissues but have spread to one or two lymph nodes (T1, N1, M0, any G, any location).

Stage III: Stage III tumors may be of any grade and found in any location.

  • Stage IIIA: Stage IIIA includes tumors that only involve the superficial layers but have spread to three to six lymph nodes (T1, N2, M0, any G, any location), or tumors that have spread to the muscle as well as one to two lymph nodes (T2, N1, M0, any G, any location).
  • Stage IIIB: These tumors comprise tumors that have spread beyond the superficial tissues and involve nodes, including tumors that are T4a, N0-1, M0, T3, N1, M0, and T2-3, N2, M0. 

Stage IV:  Squamous cell carcinomas are broken down into stage IVA and stage IVB. These tumors can be of any grade and in any location.

  • Stage IVA: Stage IVA tumors may involve many lymph nodes and have spread to structures nearby the esophagus, but not to distant regions. These include tumors defined as T4a, N2, M0, any G, any location; T4b, N0-2, M0, any G, any location; and T1-4, N3, M), any G, any location.
  • Stage IVB: These tumors have spread to distant regions of the body (T1-4, N0-3, M1, any G, any location).

Screening

Cancer screening tests are those that are done for people who do not have any symptoms. If symptoms are present, diagnostic tests are performed.

At present, there is no screening test for esophageal cancer that's available to the general public.

The risk of esophageal cancer is elevated in people who have Barrett's esophagus. Some healthcare providers have recommended periodic screening with endoscopy. If dysplasia (abnormal cells) is found, early treatments can be used to remove the abnormal cells in the precancerous stage.

That said, thus far, there is minimal to no evidence that this screening reduces the death rate from esophageal cancer. Screening can be potentially harmful and may cause bleeding, esophageal perforation, or other problems.

Frequently Asked Questions

  • What is the survival rate of esophageal cancer?

    The 5-year relative survival rate for localized esophageal cancer that has not spread outside of the esophagus is 47%. The rates for regionally metastasized cancer that has spread to nearby lymph nodes or tissues and distantly metastasized cancer that has spread to more distant areas (lymph nodes or organs that are not near the original tumor) are 25% and 5%, respectively.

  • What causes esophageal cancer?

    The cause of esophageal cancer is not known, but several risk factors increase the risk. These include age over 45, smoking, heavy alcohol use, poor diet and lack of exercise, being overweight, and GERD.

  • What are some symptoms of esophageal cancer?

    Symptoms of esophageal cancer include difficulty swallowing, throat pain, coughing up blood, consistent heartburn, chronic cough, and unintentional weight loss.

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