Diagnostic Imaging Pathways - Oesophageal Cancer (Staging)
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This pathway provides guidance on imaging patients with proven oesophageal cancer, indicating how imaging helps determine management.
Date reviewed: March 2015
Date of next review: 2017/2018
Published: July 2015
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| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Oesophageal Carcinoma Image 1a and 1b (Barium Swallow): Malignant stricture located at the junction of the middle and distal third of the oesophagus, over a length of 2-3cm. Immediately distal to this is a segment of normal calibre oesophagus, followed by a further segment of narrowing immediately proximal to the gastro-oesophageal junction which has herniated above the diaphragm. |
| 1b |  |
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| 2a |  |
Oesophageal Carcinoma Image 2a (Endoscopic Ultrasound) and 2b (Computed Tomography): Images from the same patient showing oesophageal carcinoma with aortic involvement. |
| 2b |  |
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| 3a |  |
Oesophageal Carcinoma Image 3a, 3b and 3c (Computed Tomography): Images from the same patient showing oesophageal carcinoma. There is thickening of the distal oesophagus with enlarged para-aortic, para-oesophageal, retrocrural and coeliac axis lymph nodes (arrows). Multiple metastatic lesions are also present in the liver. |
| 3b |  |
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| 3c |  |
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| 4a |  |
Oesophageal Carcinoma Image 4a (H&E, x2.5) and 4b (H&E, x10): Histological sections of a poorly differentiated squamous cell carcinoma of the oesophagus. There are sheets and nests of malignant squamous cells infiltrating through the oesophageal wall. Note the extensive lymphovascular space invasion (arrows). The cells demonstrate marked nuclear atypia with frequent mitotic figures at high power. |
| 4b |  |
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Teaching Points
Teaching Points
- Staging of oesophageal malignancy is aimed at assessing the extent of local invasion of the primary tumour and for the presence or absence of nodal / distal metastatic disease
- CT chest, abdomen and pelvis is suitable initial staging modality
- If this initial investigation demonstrates a lesion that is amenable to potential curative resection, further staging should include a PET-CT scan
- If a PET-CT scan shows no distal metastatic disease, endoscopic ultrasound (EUS) is indicated for local staging
ct
Computed Tomography (CT) Chest, Abdomen and Pelvis
- Initial staging test of choice for oesophageal cancer 2,3
- A positive CT finding enables stratifying patients with unresectable disease due to locally advanced tumour and / or with distant metastasis. If CT shows advanced local disease or distant metastases, no further staging is required, as palliative treatment is the only option 6
- CT is specific in assessing local unresectability with a specificity for T4 tumours >90% but a low sensitivity of 25%. Furthermore, CT is moderately sensitive and is specific for metastatic disease (M1) 7-13
- The importance of N-staging in recent years has also seen a drop following the introduction of neoadjuvant therapy
- Limitations
eus
Endoscopic Ultrasound ± Fine Needle Aspiration (FNA)
- EUS has shown to be the most accurate modality for loco-regional tumour and lymph node staging. Accuracy of EUS alone without fine needle aspiration (FNA) is approximately 70%
- High frequency catheter probe (HFCP) is useful for distinguishing between mucosal cancer and cancer invading the submucosa, with an accuracy of 81-100%. However despite using a higher frequency, it has been difficult to distinguish between tumour invasion and inflammatory cell infiltration 25
- Hence employing FNA in the same setting, in selected cases increases the accuracy of N-staging to >90 per cent 7,8,26,27
- Indicated in patients with oesophageal cancer in whom a CT scan has ruled out T4 and M1 disease 13
- 30% of PET node negative (N0) patients were EUS node positive (N+) emphasizing the prognostic value of EUS has for nodal staging in this group of patients 28
- The low number of false-negative results for EUS meant that a negative EUS result will be in most patients a truly negative one. 7 Other advantages include assisting in patient selection for endoscopic therapy 7,8,26
- Limitations 27
- Incomplete examinations due to impassable stenosing tumours (which may be overcome by the use of miniprobes) 10,29
- Difficulties with specificity for nodal involvement (reactive versus malignant). However, it can be overcome by the ability to combine fine needle aspiration with EUS, allowing histological verification of identified lymph nodes (e.g. coeliac lymph nodes) 7,8
- Note: suspicion of tracheo-bronchial involvement may require bronchoscopy or bronchoscopic ultrasonography 30
oes_c
Staging of Oesophageal Cancer
- Accurate staging of cancer is important for prognostication and directing further therapy. The most common staging system used for oesophageal malignancy is the American Joint Committee on Cancer tumour-node-metastases (AJCC TNM) score 1,2
|
Site |
Description |
Significance |
|
Upper |
20-25cm * |
Important for stent planning if required. Proximal margin predicts upper / mid thoracic nodal disease 3 |
|
Mid |
25-30cm * |
- |
|
Lower |
30-40cm * |
- |
|
Gastro-oesophageal junction (GOJ) |
Includes tumours whose epicentres are in the distal thoracic oesophagus, GOJ or within the proximal 5cm of the stomach (cardia) that extends into the GOJ or distal thoracic oesophagus (Siewert III). These stomach cancers are stage grouped similarly to adenocarcinoma of the oesophagus |
Important for the nature of surgery in resectable disease. GOJ carcinomas are less accurate for local staging |
* distance from the incisors
Primary tumour (T) stages
T0 - No evidence of primary tumour
Tis - High grade dysplasia
T1a - Tumor invades lamina propria or muscularis mucosae
T1b - Tumor invades submucosa
T2 - Tumour invades muscularis propria
T3 - Tumour invades adventitia
T4a - Resectable tumour invades adjacent structures (e.g. pleura, pericardium, diaphgram)
T4b - Unresectable tumour invades adjacent structures (e.g. aorta, vertebral body, trachea)
Regional lymph node (L) stages
A regional lymph node is defined as any perioesophageal lymph node from the cervical nodes to the celiac node
N0 - No regional lymph node mestastasis
N1 - 1-2 positive regional lymph nodes
N2 - 3-6 positive regional lymph nodes
N3 - ≥7 positive regional lymph nodes
Metastases stages
M0 - No distant metastases
M1 - Distant metastases
| Stage | Tumour | Nodes | Metastases | Grade | Location |
|---|---|---|---|---|---|
| IA | 1 | 0 | 0 | 1 | Any |
| IB | 1 | 0 | 0 | 2-3 | Any |
| 2-3 | 0 | 0 | 1 | Lower | |
| IIA | 2-3 | 0 | 0 | 1 | Upper / middle |
| 2-3 | 0 | 0 | 2-3 | Lower | |
| IIB | 2-3 | 0 | 0 | 2-3 | Upper / middle |
| 1-2 | 1 | 0 | Any | Any | |
| IIIA | 1-2 | 2 | 0 | Any | Any |
| 3 | 1 | 0 | Any | Any | |
| 4a | 0 | 0 | Any | Any | |
| IIIB | 3 | 2 | 0 | Any | Any |
| IIIC | 4a | 1-2 | 0 | Any | Any |
| 4b | Any | 0 | Any | Any | |
| Any | 3 | 0 | Any | Any | |
| IV | Any | Any | 1 | Any | Any |
- Plain chest radiographs can be used to identify pulmonary or mediastinal disease 4
pet
Positron Emission Tomography-Computed Tomography (PET-CT)
- PET-CT is more sensitive than CT for metastatic disease (M1) and is moderately specific 12,15
- It is more accurate compared to the combination of CT and EUS 16-19
- PET-CT can detect occult metastases in up to 13% and change management in 38% of patients 20 and have been shown to be of prognostic value independent of TNM stage 21,22
- Improves diagnostic specificity for lymph node staging 15-17,19
- Co-registration of PET and CT images using PET-CT systems may be more accurate than PET alone. 23, 24 PET-CT offers additional information over conventional CT and EUS for the staging of oesophageal cancer 24
- Limitations 7,8,16,17
- Inability to determine T-stage of the oesophageal tumour
- Inaccurate in the detection of local lymph node metastases
- Lack of anatomical detail
- Expensive and limited availability
treat
Treatment
T1N0
- Surgery with curative intent is still considered the criterion standard treatment for resectable oesophageal cancer 4
- However mortality and morbidity rates associated with oesophageal surgery is notable thus minimally invasive endoscopic therapy is favoured if available, particularly in suspected T1N0 staged tumours diagnosed with EUS 4
- Depth of tumour invasion, tumour free margins, lymphatic and venous invasion, and grade of differentiation can be assessed with EUS 8
- Endoscopic mucosal resection (EMR) specimens of T1 oesophageal carcinoma identified positive lymph node rates of <5% in T1a and between 12-46% in T1b. 31 Accuracy of EUS in staging of superficial oesophageal carcinoma, differentiating T1a from T1b is as high as 85% 8
T1N1 or T2-3 N0-1
- T1N1 or T2-3 N0-1 staged tumours with no evidence of metastatic disease benefited from preoperative chemoradiotherapy (five courses of carboplatin and paclitaxel and 41.4 Gy via external beam radiation) followed by surgery 13
- Not only was it safe but the therapy improved survival among patients with potentially curable adenocarcinoma or squamous cell carcinoma (SCC) of the oesophagus or esophagogastric-junction. 32 However SCC would require a more radical chemoradiotherapy especially for proximal lesions
References
References
Date of literature search: March 2015
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Edge S, Byrd D, Compton C, Fritz A, Greene F, Trotti A. AJCC Cancer staging manual. 7th ed. New York: Springer-Verlag; 2010. (Guideline)
- Compton C, Byrd D, Garcia-Aguilar J, Kurtzman S, Olawaiye A, Washington M. Esophagus and esophagogastric junction. AJCC Cancer staging atlas. 2nd ed. New York: Springer-Verlag; 2012. (Guideline)
- Mine S, Sano T, Hiki N, Yamada K, Kosuga T, Nunobe S, et al. Thoracic lymph node involvement in adenocarcinoma of the esophagogastric junction and lower esophageal squamous cell carcinoma relative to the location of the proximal end of the tumor. Ann Surg Oncol. 2014;21(5):1596-601. (Level III evidence). View the reference
- Lightdale CJ. Esophageal cancer. Am J Gastroenterol. 1999;94(1):20-9. (Guideline). View the reference
- Hadzijahic N, Wallace MB, Hawes RH, VanVelse A, LeVeen M, Marsi V, et al. CT or EUS for the initial staging of esophageal cancer? A cost minimization analysis. Gastrointest Endosc. 2000;52(6):715-20. (Level III evidence). View the reference
- Fockens P, Kisman K, Merkus MP, van Lanschot JJ, Obertop H, Tytgat GN. The prognosis of esophageal carcinoma staged irresectable (T4) by endosonography. J Am Coll Surg. 1998;186(1):17-23. (Level III evidence). View the reference
- van Vliet EP, Heijenbrok-Kal MH, Hunink MG, Kuipers EJ, Siersema PD. Staging investigations for oesophageal cancer: a meta-analysis. Br J Cancer. 2008;98(3):547-57. (Level II evidence). View the reference
- Thosani N, Singh H, Kapadia A, Ochi N, Lee JH, Ajani J, et al. Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis. Gastrointest Endosc. 2012;75(2):242-53. (Level II evidence). View the reference
- Lowe VJ, Booya F, Fletcher JG, Nathan M, Jensen E, Mullan B, et al. Comparison of positron emission tomography, computed tomography, and endoscopic ultrasound in the initial staging of patients with esophageal cancer. Mol Imaging Biol. 2005;7(6):422-30. (Level III evidence). View the reference
- Wu LF, Wang BZ, Feng JL, Cheng WR, Liu GR, Xu XH, et al. Preoperative TN staging of esophageal cancer: comparison of miniprobe ultrasonography, spiral CT and MRI. World J Gastroenterol. 2003;9(2):219-24. (Level III evidence). View the reference
- Weaver SR, Blackshaw GR, Lewis WG, Edwards P, Roberts SA, Thomas GV, et al. Comparison of special interest computed tomography, endosonography and histopathological stage of oesophageal cancer. Clin Radiol. 2004;59(6):499-504. (Level II evidence). View the reference
- Romagnuolo J, Scott J, Hawes RH, Hoffman BJ, Reed CE, Aithal GP, et al. Helical CT versus EUS with fine needle aspiration for celiac nodal assessment in patients with esophageal cancer. Gastrointest Endosc. 2002;55(6):648-54. (Level III evidence). View the reference
- Rice TW. Clinical staging of esophageal carcinoma. CT, EUS, and PET. Chest Surg Clin N Am. 2000;10(3):471-85. (Review article). View the reference
- Ba-Ssalamah A, Matzek W, Baroud S, Bastati N, Zacherl J, Schoppmann SF, et al. Accuracy of hydro-multidetector row CT in the local T staging of oesophageal cancer compared to postoperative histopathological results. Eur Radiol. 2011;21(11):2326-35. (Level II evidence). View the reference
- van Westreenen HL, Westerterp M, Bossuyt PM, Pruim J, Sloof GW, van Lanschot JJ, et al. Systematic review of the staging performance of 18F-fluorodeoxyglucose positron emission tomography in esophageal cancer. J Clin Oncol. 2004;22(18):3805-12. (Level II evidence). View the reference
- Flamen P, Lerut A, Van Cutsem E, De Wever W, Peeters M, Stroobants S, et al. Utility of positron emission tomography for the staging of patients with potentially operable esophageal carcinoma. J Clin Oncol. 2000;18(18):3202-10. (Level II/III evidence). View the reference
- Meltzer CC, Luketich JD, Friedman D, Charron M, Strollo D, Meehan M, et al. Whole-body FDG positron emission tomographic imaging for staging esophageal cancer comparison with computed tomography. Clin Nucl Med. 2000;25(11):882-7. Level III evidence). View the reference
- Lerut T, Flamen P, Ectors N, Van Cutsem E, Peeters M, Hiele M, et al. Histopathologic validation of lymph node staging with FDG-PET scan in cancer of the esophagus and gastroesophageal junction: A prospective study based on primary surgery with extensive lymphadenectomy. Ann Surg. 2000;232(6):743-52. (Level II evidence). View the reference
- Kato H, Miyazaki T, Nakajima M, Takita J, Kimura H, Faried A, et al. The incremental effect of positron emission tomography on diagnostic accuracy in the initial staging of esophageal carcinoma. Cancer. 2005;103(1):148-56. (Level II evidence). View the reference
- Turkington RC, Parkes E, Kennedy RD, Eatock MM, Harrison C, McCloskey P, et al. Clinical tumor Staging of adenocarcinoma of the esophagus and esophagogastric junction. J Clin Oncol. 2015:33(9):1088. (Level IV evidence). View the reference
- Hong D, Lunagomez S, Kim EE, Lee JH, Bresalier RS, Swisher SG, et al. Value of baseline positron emission tomography for predicting overall survival in patient with nonmetastatic esophageal or gastroesophageal junction carcinoma. Cancer. 2005;104(8):1620-6. (Level II evidence). View the reference
- Choi JY, Jang HJ, Shim YM, Kim K, Lee KS, Lee KH, et al. 18F-FDG PET in patients with esophageal squamous cell carcinoma undergoing curative surgery: prognostic implications. J Nucl Med. 2004;45(11):1843-50. (Level II evidence). View the reference
- Bar-Shalom R, Guralnik L, Tsalic M, Leiderman M, Frenkel A, Gaitini D, et al. The additional value of PET/CT over PET in FDG imaging of oesophageal cancer. Eur J Nucl Med Mol Imaging. 2005;32(8):918-24. (Level II evidence). View the reference
- Gillies RS, Middleton MR, Maynard ND, Bradley KM, Gleeson FV. Additional benefit of 18F-fluorodeoxyglucose integrated positron emission tomography/computed tomography in the staging of oesophageal cancer. Eur Radiol. 2011;21(2):274-80. (Level III evidence). View the reference
- Murata Y, Napoleon B, Odegaard S. High-frequency endoscopic ultrasonography in the evaluation of superficial esophageal cancer. Endoscopy. 2003;35(5):429-35; discussion 36. (Review article). View the reference
- van Zoonen M, van Oijen MG, van Leeuwen MS, van Hillegersberg R, Siersema PD, Vleggaar FP. Low impact of staging EUS for determining surgical resectability in esophageal cancer. Surg Endosc. 2012;26(10):2828-34. (Level III evidence). View the reference
- Kelly S, Harris K, Berry E, Hutton J, Roderick P, Cullingworth J, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut. 2001;49(4):534-9. (Level II evidence). View the reference
- Foley KG, Lewis WG, Fielding P, Karran A, Chan D, Blake P, et al. N-staging of oesophageal and junctional carcinoma: is there still a role for EUS in patients staged N0 at PET/CT? Clin Radiol. 2014;69(9):959-64. (Level III evidence). View the reference
- Bowrey DJ, Clark GW, Roberts SA, Maughan TS, Hawthorne AB, Williams GT, et al. Endosonographic staging of 100 consecutive patients with esophageal carcinoma: introduction of the 8-mm esophagoprobe. Dis Esophagus. 1999;12(4):258-63. (Level II evidence). View the reference
- Nishimura Y, Osugi H, Inoue K, Takada N, Takamura M, Kinosita H. Bronchoscopic ultrasonography in the diagnosis of tracheobronchial invasion of esophageal cancer. J Ultrasound Med. 2002;21(1):49-58. (Level II/III evidence). View the reference
- Kodama M, Kakegawa T. Treatment of superficial cancer of the esophagus: a summary of responses to a questionnaire on superficial cancer of the esophagus in Japan. Surgery. 1998;123(4):432-9. (Level III evidence). View the reference
- van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijnhoven BP, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366(22):2074-84. (Level I evidence). View the reference
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