Initial Diagnosis
We conduct a number of tests to determine whether there is cancer in the esophagus. Your doctor will likely conduct or review a combination of the procedures and tests listed below:
Physical exam and history: Your doctor examines your body to check general signs of health, including checking for signs of disease, such as lumps and swollen lymph nodes.
Chest X-ray: An X-ray of the organs and bones inside the chest. An X-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
Barium swallow: For this series of X-rays of the stomach, you drink a liquid that contains barium (a silver-white metallic compound). The liquid coats your stomach, and we take X-rays of it. This procedure is also called an upper GI series.
Esophagoscopy: A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope is inserted through the mouth or nose and into the esophagus. The esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
Endoscopy: Your doctor uses an endoscope (a thin tube) to look inside your stomach. You may receive medications to help you relax during the procedure. At the Center for Esophageal and Gastric Cancer, we use an endoscope that allows us to look at individual cells through a powerful microscope. If there is an abnormality in the lining or a growth, we'll do further testing of a biopsy.
Blood chemistry studies: Your doctor takes a blood sample to check the amounts of certain substances released into the blood by organs and tissues in the body.
Complete blood count (CBC): Your doctor takes a sample of blood to check for:
- The number of red blood cells, white blood cells, and platelets.
- The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.
- The portion of the sample made up of red blood cells.
Endoscopic ultrasound (EUS) or endosonography: A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
Tests that are required less commonly are:
Fecal occult blood test: This test checks your stool for blood that can be seen only with a microscope.
Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope, a thin, tube-like instrument with a light, is inserted through the nose or mouth into the trachea and lungs. It may also have a tool to remove tissue samples.
Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision is made between two ribs and a thoracoscope is inserted into the chest. The thoracoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples. In some cases, this procedure may be used to remove part of the esophagus or lung.
Laryngoscopy: A procedure in which the doctor checks the larynx (voice box) with a mirror or with a laryngoscope. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing.
Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions.
Staging Esophageal Cancer
The process used to find out if cancer has spread within the esophagus or to other parts of the body is called staging.
The staging process is the most important factor in determining your treatment plan. The stage is determined based on your team's estimate of the extent of the cancer, which come from the results of physical exams and any imaging tests (such as CT and PET scans) that have been done. In order to get a more accurate understanding of the cancer and to precisely stage it, your surgeon may remove cells from the affected area (biopsy) and send them to a pathologist to study.
Pathologists' findings are critical to determining the best treatment, and, at our center, pathologists are key members of your medical team. Our pathologists not only evaluate tissues in order to characterize your cancer, but they also investigate any unusual or unexpected findings, using microscopes and analysis to observe and test tissue.
Pathologists also conduct a new test to evaluate whether the cancer has an expression of a certain protein (HER2/neu) on its cells. About 20 percent of esophageal cancers have tumors that express this protein, and if it is present, we can consider a specific antibody to attack this protein.
A Better Way to Stage Cancer
We've found that it's critical for pathologists to study tissue samples from the tumor bed that contain enough lymph nodes. When too few nodes are taken and examined, it can lead to under-staging and treatments that aren't optimal.
Our surgeons are careful to remove enough lymph nodes to be able to correctly stage your cancer and get you on the proper treatment plan. What's more, our team is working to standardize our approach nationally to improve the level of care for all patients with esophageal cancer.
Diagnosing Barrett's Esophagus
When this condition is found, it presents a rare opportunity for your doctors to try to prevent it from progressing into esophageal cancer. During our assessment, which may involve advanced, high-resolution visualization techniques, we determine if you have Barrett's esophagus, and if it is high- or low-grade. The low-grade form isn't considered cancerous and usually calls for surveillance measures only; high-grade requires treatment that may be less aggressive than treatment for esophageal cancer.
Our pathologists wrote one of the definitive texts about diagnosing Barrett's esophagus, and we regularly assess patients seeking second opinions to accurately describe the disease.
Stages of Esophageal Cancer and Barrett's Esophagus
The stage of cancer is carefully divided into categories based on the size and spread of cancer beyond the esophagus and into other places in the body (metastasis).
As esophageal cancer progresses from Stage 0 to Stage IV, the cancer cells grow through the layers of the esophagus wall and spread to lymph nodes and other organs.
Stages of Barrett's Esophagus
The stages of Barrett's esophagus are broken down into high- or low-grade. We consider high-grade to be an early form of esophageal cancer.
Stages of Esophageal Cancer
The following stages are used for squamous cell carcinoma of the esophagus:
Stage 0 (High-Grade Dysplasia)
In stage 0, abnormal cells are found in the inner (mucosal) layer of the esophageal wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called high-grade dysplasia.
Stage I Squamous Cell Carcinoma of the Esophagus
Stage I is divided into Stage IA and Stage IB, depending on where the cancer is found.
- Stage IA: Cancer has formed in the inner (mucosal) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.
- Stage IB: Cancer has formed:
- in the inner (mucosal) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope; or
- in the inner (mucosal) layer and spread into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells look like normal cells under a microscope. The tumor is in the lower esophagus or it is not known where the tumor is.
Stage II Squamous Cell Carcinoma of the Esophagus
Stage II is divided into Stage IIA and Stage IIB, depending on where the cancer has spread.
- Stage IIA: Cancer has spread:
- into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope. The tumor is in either the upper or middle esophagus; or
- into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope. The tumor is in the lower esophagus or it is not known where the tumor is.
- Stage IIB: Cancer:
- has spread into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope. The tumor is in either the upper or middle esophagus; or
- is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in one or two lymph nodes near the tumor.
Stage III Squamous Cell Carcinoma of the Esophagus
Stage III is divided into Stage IIIA, Stage IIIB, and Stage IIIC, depending on where the cancer has spread.
- Stage IIIA: Cancer:
- is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in three to six lymph nodes near the tumor; or
- has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in one or two lymph nodes near the tumor; or
- has spread into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity. The cancer can be removed by surgery.
- Stage IIIB: Cancer has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in three to six lymph nodes near the tumor.
- Stage IIIC: Cancer has spread:
- into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity; the cancer can be removed by surgery. Cancer is found in one to six lymph nodes near the tumor; or
- into other nearby organs such as the aorta, trachea, or spine, and the cancer cannot be removed by surgery; or
- to seven or more lymph nodes near the tumor.
Stage IV Squamous Cell Carcinoma of the Esophagus
In stage IV, cancer has spread to other parts of the body.
The following stages are used for adenocarcinoma of the esophagus:
Stage 0 (High-Grade Dysplasia)
In stage 0, abnormal cells are found in the inner (mucosal) layer of the esophageal wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called high-grade dysplasia.
Stage I Adenocarcinoma of the Esophagus
Stage I is divided into Stage IA and Stage IB, depending on where the cancer is found.
- Stage IA: Cancer has formed in the inner (mucosal) layer of the esophageal wall. The tumor cells look like normal cells under a microscope.
- Stage IB: Cancer has formed:
- in the inner (mucosal) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope and they grow quickly; or
- in the inner (mucosal) layer and spread into the middle (muscle) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.
Stage II Adenocarcinoma of the Esophagus
Stage II is divided into Stage IIA and Stage IIB, depending on where the cancer has spread.
- Stage IIA: Cancer has spread into the middle (muscle) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope and they grow quickly.
- Stage IIB: Cancer:
- has spread into the outer (connective tissue) layer of the esophageal wall; or
- is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in one or two lymph nodes near the tumor.
Stage III Adenocarcinoma of the Esophagus
Stage III is divided into Stage IIIA, Stage IIIB, and Stage IIIC, depending on where the cancer has spread.
- Stage IIIA: Cancer:
- is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in three to six lymph nodes near the tumor; or
- has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in one or two lymph nodes near the tumor; or
- has spread into the diaphragm, sac around the heart, or tissue that covers the lungs, and lines the inner wall of the chest cavity. The cancer can be removed by surgery.
- Stage IIIB: Cancer has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in three to six lymph nodes near the tumor.
- Stage IIIC: Cancer has spread:
- into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity; the cancer can be removed by surgery. Cancer is found in one to six lymph nodes near the tumor; or
- into other nearby organs such as the aorta, trachea, or spine, and the cancer cannot be removed by surgery; or
- to seven or more lymph nodes near the tumor.
Stage IV Adenocarcinoma of the Esophagus
In Stage IV, cancer has spread to other parts of the body.
