The 7 th edition stage groupings were also defined to consider the importance of histopathologic cell type, tumor grade, and tumor location. Table 2 shows stage grouping for adenocarcinoma and squamous cell carcinoma, which are no longer equivalent in the 7 th edition. The Society of Thoracic Surgeons has published guidelines on the diagnosis and staging of patients with esophageal cancer The work-up for esophageal cancer often starts when patients present with symptoms such as dysphagia and weight loss in the setting of an unremarkable physical exam 2 , Therefore, the most common tests used to initially identify and diagnosis esophageal cancer are upper gastrointestinal GI tract contrast studies and upper endoscopy with biopsy.
An upper GI contrast study typically shows a stricture or ulceration when malignancy is present.
Upper GI endoscopy identifies tumor location and length and allows biopsy for pathologic examination. After a histologic cancer diagnosis has been obtained, subsequent studies are performed to determine clinical stage as accurately as possible before treatment is initiated. Obtaining a computed tomographic CT scan of the chest and abdomen with both oral and intravenous contrast should be the first staging study when esophageal cancer is diagnosed histologically.
The CT scan is somewhat limited in defining the local extent and nodal involvement of esophageal cancer but is most useful in identifying the presence of distant disease such as liver or lung metastases. Further studies that evaluate T and N status would not typically impact treatment and therefore are generally unnecessary if distant disease is identified and subsequently confirmed by biopsy. However, EUS is less accurate for early-stage lesions such as T1 or T2 compared to more advanced tumors 18 - Most incidences of understaging are due to missing nodal disease.
Performance of the above staging modalities establishes the pre-treatment clinical stage which can be used to guide subsequent treatment, as will be discussed in the following sections. However, occasionally additional studies may be worthwhile before initiation of treatment. First, bronchoscopy should be considered for tumors in the upper and middle esophagus to rule out airway invasion. CT scan and EUS can be suggestive of airway involvement but are not as accurate as direct visualization of the airway.
In addition, distant metastases are unfortunately missed even with completion of the staging evaluation described above. Small liver or lung metastases can be missed by both PET and CT scans, and patients can also have undetected pleural or peritoneal disease Staging via minimally invasive surgical techniques of thoracoscopy and laparoscopy improves the accuracy of the above non-invasive testing 23 - Use of these invasive techniques is relatively uncommon but should be considered in select patients, such as those who may be considered to have a high risk of treatment-related complications.
Staging laparoscopy in particular may have a role for patients with adenocarcinoma of the esophagus or esophagogastric junction Treatment options include local mucosal resection or ablation therapies, esophagectomy, chemotherapy, and radiation therapy. However, definitive data from randomized trials to guide the treatment of esophageal cancer is lacking for many clinical situations. Outcomes also generally are relatively poor with many treatment strategies, so establishing optimal treatment for different clinical situations remains an area of active research The NCCN guidelines reflect the lack of definitive evidence and often allow a spectrum of potential treatments for many clinical situations.
Given both the generally poor overall prognosis and the potential morbidity associated with therapy, multidisciplinary evaluation by surgery, medical oncology, and radiation oncology should be considered for all patients before a treatment strategy is initiated. Treatment that does not follow guidelines should probably only be used in the context of clinical trials. The stage groupings described above are very useful for both providing prognosis and guiding treatment. However, patients can be categorized even more simply when considering treatment.
When considering treatment for esophageal cancer patients, the approach is initially dictated by whether the patients have been determined to have early stage superficial cancers, cancers that are locally advanced with locoregional disease but no distant metastases, and cancers with distant disease. The general treatment guidelines for each of these categories will be discussed in the following sections. Patients with TN0 esophageal cancer typically are recommended to undergo surgery without induction treatment The prognosis for patients treated for intra- and submucosal T1 esophageal cancers is significantly better than the prognosis for all other patients found to have esophageal cancer, even those also found in other relatively early-stage disease 8.
Akce specializes in the treatment of patients with gastrointestinal malignancies. Alese specializes in the treatment of gastrointestinal cancers, particularly colorectal cancer. Al-Majed works with patients with brain and spine tumors, and aerodigestive malignancies at Winship Cancer Institute. Argenbright works with medical oncology and radiation oncology patients treated at Emory University Hospital Midtown. Arnold works with patients of all cancer types providing resource referrals and counseling services.
Baer helps patients and their families deal with the stress of receiving a cancer diagnosis and subsequent treatment. An Oncology Certified Nurse, Mrs. Brosius is a nurse navigator working with patients with solid gastrointestinal tumors. Brown works with gastrointestinal, genitourinary, breast cancer, brain cancer, gynecological, aerodigestive, and sarcoma patients at Emory University Hospital Midtown.
Campbell works with the medical oncology team to assist patients with neurological, aerodigestive, breast and gastrointestinal malignancies. A Registered Dietitian, Ms. Chertin provides cancer patients who are undergoing treatment at Winship Cancer Institute with personalized nutrition advice.
Cohen assists radiation oncology patients at Winship Cancer Institute. Curseen is the primary provider for the Supportive Oncology Clinic at Winship. Eady assists genitourinary, gastrointestinal and surgical oncology patients treated at Winship. El-Rayes is the chief clinical research scientist responsible for coordinating and providing high-level direction to the clinical cancer research programs and clinical cancer trials across the Emory campuses. Fernandez specializes in lung transplantation and the minimally invasive treatment of thoracic malignancies. Fischer-Valuck practices general radiation oncology and specializes in the treatment of lung, prostate and gastrointestinal cancers.
Force has a national reputation as an outstanding thoracic surgeon whose research focuses on outcomes in lung transplantation and thoracic diseases. Goldman practices general medical oncology and hematology with a focus on treating patients with genitourinary cancer at Emory Saint Joseph's Hospital. Henderson assists radiation oncology and medical oncology patients at Emory University Hospital Midtown.
Diagnosing Your Cancer
Huskey provides cancer patients who are undergoing treatment at Winship Cancer Institute with personalized nutrition advice. Javidfar specializes in lung cancer surgery, end-stage lung disease, venovenous and venoarterial ECMO, benign lung disease surgery, and bronchial and tracheal surgery. Kane works with the gastrointestinal medical oncology team at Winship Cancer Institute. Karem works at Emory Saint Joseph's Hospital with patients of all cancer types providing resource referrals and counseling services.
An attending gastroenterologist with expertise in advanced endoscopy, Dr. Keilin works with Winship's gastrointestinal teams to deliver top cancer care. Khullar specializes in thoracic oncology and minimally invasive thoracic surgery. Klimansky assists gynecologic and gastrointestinal cancer patients throughout their treatment.
Esophageal Cancer - UAB Medicine
Kooby is involved in multicenter clinical research and is an international leader in minimally invasive pancreatic, liver and biliary tract surgery. Landry specializes in the treatment of gastrointestinal malignancies.
We outline the services available to our patients at every point in their care. In addition, the Esophagectomy Support Group is available to patient through the Department of Surgery. Our Patient Care Center is staffed by oncology nurses and is just a phone call away to answer your questions or to assist you in making an appointment. Please call to make an appointment or for the answers to questions you may have.