Diagnosis

Testing people at high risk.

Barrett’s esophagus

If you’re someone at a high risk of esophageal cancer (including those with Barrett’s esophagus), one of the best ways to get an accurate diagnosis is to get regularly tested with an upper endoscopy. The test is fairly simple, with the doctor using an endoscope to look at the inside of your esophagus. The doctor will typically remove some abnormal tissue (called a biopsy) so it can be scanned in the lab to look for cancer or pre-cancer.

Inherited syndromes

It’s also important for people with certain inherited syndromes to get tested with regular endoscopies to look for cancer or pre-cancer. For example, people over the age of 20 with Tylosis or Bloom syndrome should get an upper endoscopy. And people over the age of 40 who have family members with familial (inherited) Barrett’s esophagus should also consider an upper endoscopy screening.

The process of determining if cancer is spread, and how far, is called staging. Staging gives doctors and patients a universal language to describe how much cancer is in the body, how serious the cancer is and how best to treat it. Staging is also useful in helping doctors talk about survival statistics.

The range of stages for esophageal cancers is stage 0 through stage 4. The lower the number, the less severe the cancer is and the less it has spread. Conversely, the higher the number, the more the cancer has spread.

How is the stage determined?

The staging system most often used for esophageal cancer is the American Joint Committee on Cancer (AJCC) TNM system, which is based on 3 key pieces of information:

  • The extent (size) of the tumor (T): How far has the cancer grown into the wall of the esophagus? Has the cancer reached nearby structures or organs?
  • The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes?
  • The spread (metastasis) to distant sites (M): Has the cancer spread to distant lymph nodes or distant organs such as the lungs or liver?

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once a person’s T, N, and M categories have been determined, this information is combined in a process called stage grouping to assign an overall stage.

Staging systems for esophageal cancer

Since esophageal cancer can be treated in different ways, different staging systems have been created for each situation:

  • Pathological stage (also called the surgical stage). If surgery is done first, the pathological stage is determined by examining tissue removed during an operation. This is the most common system used.
  • Clinical stage. If surgery might not be possible or will be done after other treatment is given, then the clinical stage is determined based on the results of a physical exam, biopsy, and imaging tests. The clinical stage will be used to help plan treatment, but it might not predict outlook as accurately as the pathologic stage. This is because sometimes the cancer has spread further than the clinical stage estimates.
  • Postneoadjuvant stage. If chemotherapy or radiation is given before surgery (this is called neoadjuvant therapy), then a separate postneoadjuvant stage will be determined after surgery.

Grade

Another factor that can affect your treatment and your outlook is the grade of your cancer. The grade describes how closely the cancer looks like normal tissue when seen through a microscope.

The scale used for grading esophagus cancers is from 1 to 3.

  • GX: The grade cannot be evaluated. (The grade is unknown).
  • Grade 1 (G1: well differentiated; low grade) means the cancer cells look more like normal esophagus cells.
  • Grade 3 (G3: poorly differentiated, undifferentiated; high grade) means the cancer cells look very abnormal.
  • Grades 2 (G2: moderately differentiated; intermediate) falls somewhere in between Grade 1 and Grade 3.

Low-grade cancers tend to grow and spread more slowly than high-grade cancers. Most of the time, the outlook is better for low-grade cancers than it is for high-grade cancers of the same stage.

Location

Some stages of early squamous cell carcinoma also take into account where the tumor is in the esophagus. The location is assigned as either upper, middle, or lower based on where the middle of the tumor is.

The tables below are simplified versions of the TNM system, based on the most recent AJCC systems effective January 2018. They include staging systems for squamous cell carcinoma and adenocarcinoma.

It’s important to know that esophageal cancer staging can be complex. If you have any questions about the stage of your cancer or what it means, please ask your doctor to explain it to you in a way you understand.

Squamous cell carcinoma stages

AJCC Stage Stage description: squamous cell carcinoma
0 The cancer is only in the epithelium (the top layer of cells lining the inside of the esophagus). It has not started growing into the deeper layers. This stage is also known as high-grade dysplasia. It has not spread to any lymph nodes or distant organs.

The cancer grade does not apply. The cancer can be located anywhere in the esophagus.

IA The cancer is growing into the lamina propria or muscularis mucosa (the tissue under the epithelium). It has not spread to any lymph nodes or distant organs.

The cancer is grade 1 or an unknown grade and located anywhere in the esophagus.

IB The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium), submucosa or the thick muscle layer (muscularis propria). It has not spread to nearby lymph nodes or to distant organs.

The cancer can be any grade or an unknown grade and located anywhere in the esophagus.

 

IIA

The cancer is growing into the thick muscle layer (muscularis propria). It has not spread to nearby lymph nodes or to distant organs.

The cancer can be grade 2 or 3 or an unknown grade and located anywhere in the esophagus.

OR
The cancer is growing into the outer layer of the esophagus (the adventitia). It has not spread to nearby lymph nodes or to distant organs.

The cancer can be any of the following:

  • Any grade and located in the lower esophagus OR
  • Grade 1 and located in the upper or middle esophagus.
IIB

 

The cancer is growing into the outer layer of the esophagus (the adventitia). It has not spread to nearby lymph nodes or to distant organs.

The cancer can be any of the following:

  • Grade 2 or 3 and located in the upper or middle of the esophagus OR
  • An unknown grade and located anywhere in the esophagus OR
  • Any grade and have an unknown location in the esophagus.
OR
The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium) or into the submucosa. It has spread to 1 or 2 nearby lymph nodes.

The cancer can be any grade and located anywhere in the esophagus.

IIIA The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium), submucosa or the thick muscle layer (muscularis propria). It has spread to no more than 6 nearby lymph nodes. It has not spread to distant organs.

The cancer can be any grade and located anywhere in the esophagus.

IIIB The cancer is growing into:

  • The thick muscle layer (muscularis propria) and spread to no more than 6 nearby lymph nodes OR
  • The outer layer of the esophagus (the adventitia) and spread to no more than 6 nearby lymph nodes OR
  • The pleura (the thin layer of tissue covering the lungs), the pericardium (the thin sac surrounding the heart), or the diaphragm (the muscle below the lungs that separates the chest from the abdomen) and spread to no more than 2 nearby lymph nodes.

It has not spread to distant organs.

The cancer can be any grade and located anywhere in the esophagus.

IVA The cancer is growing into:

  • The pleura (the thin layer of tissue covering the lungs), the pericardium (the thin sac surrounding the heart), or the diaphragm (the muscle below the lungs that separates the chest from the abdomen) and spread to no more than 6 nearby lymph nodes OR
  • The trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures and no more than 6 nearby lymph nodes OR
  • Any layers of the esophagus and spread to 7 or more nearby lymph nodes.

It has not spread to distant organs.

The cancer can be any grade and located anywhere in the esophagus.

IVB The cancer has spread to distant lymph nodes and/or other organs. such as the liver and lungs. The cancer can be any grade and located anywhere in the esophagus.

Andenocarcinoma stages

The location of the cancer in the esophagus does not affect the stage of adenocarcinomas.

AJCC Stage Stage description: adenocarcinoma
0 The cancer is only in the epithelium (the top layer of cells lining the inside of the esophagus). It has not started growing into the deeper layers. This stage is also known as high-grade dysplasia. It has not spread to any lymph nodes or distant organs.

The cancer grade does not apply.

IA The cancer is growing into the lamina propria or muscularis mucosa (the tissue under the epithelium). It has not spread to any lymph nodes or distant organs.

The cancer is grade 1 or an unknown grade.

IB The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium), or the submucosa. It has not spread to nearby lymph nodes or to distant organs.

The cancer can be grade 1 or 2 or an unknown grade.

IC The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium), submucosa or the thick muscle layer (muscularis propria). It has not spread to nearby lymph nodes or to distant organs.

The cancer can be grade 1, 2 or 3.

 

IIA

The cancer is growing into the thick muscle layer (muscularis propria). It has not spread to nearby lymph nodes or to distant organs.

The cancer can be grade 3 or an unknown grade.

IIB

 

The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium), or the submucosa. It has spread to 1 or 2 nearby lymph nodes. It has not spread to distant organs.

The cancer can be any grade.

OR
The cancer is growing into the outer layer of the esophagus (the adventitia). It has not spread nearby lymph nodes.

The cancer can be any grade.

IIIA The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium), the submucosa, or the thick muscle layer (muscularis propria).

It has spread to no more than 6 nearby lymph nodes. It has not spread to distant organs.

The cancer can be any grade.

IIIB The cancer is growing into:

  • The thick muscle layer (muscularis propria) and spread to no more than 6 nearby lymph nodes OR
  • The outer layer of the esophagus (the adventitia) and spread to no more than 6 nearby lymph nodes OR
  • The pleura (the thin layer of tissue covering the lungs), the pericardium (the thin sac surrounding the heart), or the diaphragm (the muscle below the lungs that separates the chest from the abdomen) and spread to no more than 2 nearby lymph nodes.

It has not spread to distant organs.

The cancer can be any grade.

IVA The cancer is growing into:

  • The pleura (the thin layer of tissue covering the lungs), the pericardium (the thin sac surrounding the heart), or the diaphragm (the muscle below the lungs that separates the chest from the abdomen) and spread to no more than 6 nearby lymph nodes OR
  • The trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures and no more than 6 nearby lymph nodes OR
  • Any layers of the esophagus and spread to 7 or more nearby lymph nodes.

It has not spread to distant organs.

The cancer can be any grade.

IVB The cancer has spread to distant lymph nodes and/or other organs. such as the liver and lungs. The cancer can be any grade.

Source: American Cancer Society