The diagnosis and prognosis of esophageal cancer includes the following:

Review of Medical History

Your doctor will ask about your symptoms and medical history. Significant elements in your medical history include your country of origin, race, symptoms of chronic reflux esophagitis (heartburn or gastroesophageal reflux disease), and exposure to substances that irritate and damage the throat. Your doctor may also ask about rare congenital conditions.

Physical Exam

No part of your physical exam points directly to this disease, but your doctor will do a thorough exam to evaluate your overall health and look for associated conditions, like malnutrition, pneumonia, and head, neck, and lung cancer.

Diagnostic Testing

Your doctor may do the following tests:

X-rays —This series of x-rays will be taken while you are swallowing contrast medium (barium). The barium makes it easier for the doctor to see abnormalities on the x-ray.

Endoscopy—This test involves the insertion of a fiberoptic tube with a lighted tip (an endoscope) through the mouth and down through the gastrointestinal (GI) tract to examine the entire passageway from mouth to stomach. This allows your doctor to look for abnormalities and perhaps to obtain a biopsy specimen of the cancer. A similar examination of the lungs (bronchoscopy) may also be done.

Endoscopic ultrasonography (EUS)—During this procedure, a thin, lighted tube (endoscope) is passed into the esophagus. The endoscope has a miniscule ultrasound transducer within it.

CT scan—This is a type of x-ray, done to determine the extent of your cancer, that uses a computer to produce cross-sectional images of the inside of the body.

MRI —This test uses magnetic waves to produce images of the inside of the body. Using a large magnet, radio waves, and a computer, an MRI produces two-dimensional and three-dimensional pictures. This is done to determine the extent of your cancer.

PET scan —This test assesses metabolic activity in the tissue, since cancer cells typically generate more activity than noncancerous cells. A PET scan can be performed on a variety of body tissues. A nurse or technologist administers a radioactive substance by an intravenous injection. It takes between 60 to 90 minutes for the substance to be absorbed by the tissue under study. You lie on a table and are moved into a machine that looks like a large, square-shaped doughnut. This machine detects and records the energy levels emitted from the substance that was injected earlier. The images are viewed on a nearby computer monitor.

Bone scan —An injection of a radioactive compound called technetium- methylen diphosphonate is given. Three hours later, you lie on a table while special cameras move slowly above and below the table taking pictures. These cameras detect small amounts of radioactivity in the injected technetium. This test is performed to detect if you have cancer cells in the bone. Usually a bone scan is performed if you complain from bone pain.

Laparoscopy —Tiny incisions are made in the abdomen, and a small fiberoptic tube with a lighted tip (a laparoscope) is inserted. This allows for a visual examination of the abdomen. Miniature surgical tools can also be inserted into the abdomen for biopsies.

Cytology

Cytology is the study of cells. The cytology of cancer cells differs significantly from normal cells, and physicians use the unique cellular features seen on biopsy samples to determine the diagnosis and assess the prognosis of a cancer.

It may be difficult to remove a sample of tissue for biopsy, because it is often covered with a thick layer of normal tissue. Cells may be obtained by brushing the tissue during endoscopy. At the present time, due to the grim prognosis for this disease, biopsy and tissue identification is not particularly helpful other than to confirm the diagnosis.

Staging

Staging is the process by which physicians determine the anatomical extent of the cancer disease. Accurate staging is considered one of the main prognostic factors that determine the fate of the disease. Staging is also essential for making treatment decisions, such as surgery vs. chemotherapy. Several features of the cancer are used to arrive at a staging classification, the most common being the size of the original tumor (T), lymph nodes involvement (N), and spread to distant sites (M), called metastasis. Low staging classifications (1-2) imply a favorable prognosis, whereas high staging classifications (3-4) imply an unfavorable prognosis.

The TNM system of classification is used to stage esophageal cancer. The stage may be predicted by the use of radiologic data, such as that from CT scans, MRI, endoscopy, endoscopic ultrasound, and biopsies. The stage is comprised of a T (size of the tumor), N (presence of cancer in lymph nodes), and M (presence of cancer in distant sites like bone, liver, and lung).

Staging Classifications I through IV

Stage I: Cancer is found only in the innermost layers of the esophagus.

Stage II: Cancer penetrates deeper into the esophagus, or it has spread to nearby lymph nodes.

Stage III: Cancer is found still deeper in the wall of the esophagus or has spread to tissues or nearby lymph nodes.

Stage IV: Cancer has spread to other parts of the body.

Tumor (T) Stages

Tx: The cancer cannot be evaluated.

T0: No cancer is present.

Tis: Cancer does not invade beyond the superficial mucosa (in situ).

T1: Cancer is present in the lamina propria or submucosa.

T2: Cancer is present in muscularis propria.

T3: Cancer is present in adventitia.

T4: Cancer is growing directly into an adjacent structure.

Staging Based on T, N, and M
Lymph Nodes (N) Stages

Nx: Lymph node involvement by tumor cannot be assessed.

N0: Cancer cells are not present in local (regional) lymph nodes.*

N1: Cancer cells are present in local lymph nodes.*

*In esophagus cancer, a regional lymph node is based on the location of the tumor in the esophagus.

Metastasis (M) Stages

Mx: Metastasis cannot or has not been assessed.

M0: Metastases are not present.

M1a: Metastases are present in nonregional lymph nodes.

M1b: Metastases are present in other organs.

Overall Stage, Based on T, N, and M
Overall Stage T, N, and M Stages
Stage 0 Tis, N0, M0
Stage I T1, N0, M0
Stage IIA T2, N0, M0
T3, N0, M0
Stage IIB T1, N1, M0
T2, N1, M0
Stage III T3, N1, M0
T4, any N, M0
Stage IVA Any T, any N, M1a
Stage IVB Any T, Any N, M1b