Esophageal Cancer Staging

by Specialist

After esophageal cancer is diagnosed, the healthcare provider will perform tests to determine if the cancer has spread inside the esophagus or has spread to other parts of the body.

The procedure used to determine whether the cancer has spread inside the esophagus or has spread to other parts of the body is called staging. The information obtained from the staging process determines the stage of the cancer. Understanding cancer staging is important for specifying a treatment plan. The following tests and procedures may be used in the staging process:

  • Echo-endoscopy (EUS): A test in which an endoscope is inserted into the body – usually through the mouth or rectum. For esophageal cancer screening, the endoscope is inserted through the oral cavity. An endoscope is a thin tube-like instrument with a light and lens that allows for visualization. A probe at the end of the endoscope is used to reflect back high-energy sound waves (ultrasound) from the internal tissues or organs to form echoes. These echoes form an image of the body tissues called a sonogram. A biopsy may also be performed during the examination. This type of exam is also known as ultrasound endoscopy.
  • CT scan (CAT scan): A procedure in which the internal areas of the body (such as the chest, abdomen, and pelvis) are photographed from different angles to form a series of detailed images. The images are drawn by a computer connected to an X-ray machine. A contrast agent may be injected into the patient’s blood vessels or the patient may swallow the contrast agent to help the organs or tissues to be able to be seen more clearly. This procedure is called computed tomography, or computed tomography or computed axial tomography.
  • PET scan (positron emission tomography): This is a way to look for malignant cells in the body. A small amount of radioactive glucose (sugar) is injected into a blood vessel. the PET scanner rotates around the body and draws a picture of the part of the body that is using the glucose. The brighter part of the picture is the malignant tumor cell because malignant cells are more active and take up more glucose than normal cells. the PET scan and CT scan can be done at the same time. This is called PET-CT.
  • MRI (magnetic resonance imaging): This is a procedure that uses magnets, radio waves, and a computer to map out a series of details inside the body. This procedure is called nuclear magnetic resonance imaging (NMRI).
  • Thoracoscopy: This is a procedure that looks at the internal organs of the chest to check for abnormal areas. The surgeon makes an incision between the two ribs and then sticks a thoracoscope into the chest cavity. The thoracoscope is a thin tube-like instrument with a light and a viewing scope. The thoracoscope may also be equipped with tools to remove tissue or lymph node samples that will be viewed under a microscope to check for signs of cancer. In some cases, this method may be used to remove part of the esophagus or lung.
  • Laparoscopy: This is a surgical procedure that looks at the organs inside the abdomen to check for the presence of cancer. Small incisions (multiple) are made in the abdominal wall, and a laparoscope (light, thin tube) is then inserted into one of the small incisions. Other tools can be used to reach into the abdominal cavity through the same or other incisions to perform operations such as removing organs, collecting tissue samples, and examining them under a microscope to look for signs of cancer.
  • Ultrasound: An examination in which high-energy sound waves (ultrasound) are reflected back by the body’s internal tissues or organs (such as neck tissues or organs) and produce echoes. These echoes form an image of the body’s tissues, called a sonogram. This image can be printed out for later viewing.

    There are three ways that cancer cells can spread through the body.

    Cancer cells can spread through the tissues, the lymphatic system, and the blood:

  • Tissues. Cancer cells spread by growing from the primary site to nearby areas
  • Lymphatic system. Cancer cells spread from the primary site by entering the lymphatic system. Spread through the lymphatic vessels to other parts of the body.
  • Blood. Cancer cells spread from the primary site by entering the bloodstream. Spread through blood vessels to other parts of the body.

    Cancer cells may spread from the primary site to other parts of the body.

    When cancer cells spread to other parts of the body, the phenomenon is called metastasis. The cancer cells leave the site of occurrence (the primary tumor) and then spread through the lymphatic system and bloodstream.

  • Lymphatic system. Cancer cells enter the lymphatic system, spread through the lymphatic vessels, and then form tumors elsewhere in the body (metastases).
  • Blood. Cancer cells enter the bloodstream, spread through blood vessels, and then form tumors elsewhere in the body (metastases)

    Metastases and primary tumors are the same type of cancer. For example, if esophageal cancer spreads to the lungs, the cancer cells in the lungs are actually esophageal cancer cells. Such a disease is metastatic esophageal cancer, not lung cancer.

    Many cancer deaths are due to cancer cells that have metastasized and spread from the primary tumor to other tissues and organs. This is called metastatic cancer. This animation shows how cancer cells metastasize from where they first formed in the body to other parts of the body.

    The grading of tumors is also used to describe the cancer and to develop a treatment plan.

    Grades of tumors describe what abnormal cancer cells look like under the microscope and how fast the tumor grows and spreads. grades 1 to 3 are used to describe esophageal cancer:

  • Grade 1, where cancer cells look more like normal cells under the microscope, grows and spreads more slowly than grades 2 and 3 cancer cells.
  • Grade 2, cancer cells that look more like abnormal cells under the microscope and grow and spread more rapidly than grade 1 cancer cells.
  • Grade 3, cancer cells that look more like abnormal cells under the microscope and grow and spread faster than grade 1 and 2 cancer cells.

    Esophageal squamous cell carcinoma is staged as follows:

    Stage 0 (highly heterogeneous hyperplasia)

    In stage 0, cancer cells have formed in the lining of the esophageal wall. stage 0 is also called highly heterogeneous hyperplasia.

    Stage 0 esophageal squamous cell carcinoma. Cancer cells have formed in the lining of the esophageal wall.

    Squamous cell carcinoma of the esophagus Stage I

    Stage I can be divided into stage IA and stage IB depending on where the cancer cells have spread.

  • Stage IA: The cancer cells have spread to the intrinsic mucosal layer or mucosal muscle layer of the esophageal wall. The cancer cells are grade 1, or of unknown grade.
    Stage IA esophageal squamous cell carcinoma. The cancer has spread to the intrinsic mucosal layer or mucosal muscle layer of the esophageal wall. The cancer cells are of grade 1, or of unknown grade. Under the microscope, grade 1 cancer cells look more like normal cells and grow and spread more slowly than grade 2 and 3 cancer cells.
  • Stage IB: The cancer has spread.
  • Invasion of the mucosal layer, mucosal muscle layer, or submucosal layer of the esophageal wall. The cancer cells can be of any grade, or of unknown grade; or
  • invaded the intrinsic muscular layer of the esophageal wall. The cancer cells are of grade 1.
    Stage IB esophageal squamous cell carcinoma. The cancer has spread to the mucosal, thin muscle or submucosal layers of the esophageal wall. The cancer can be of any grade, or of unknown grade; or the cancer has spread to the thick muscular layer of the esophageal wall. The cancer cells are of grade 1. Under the microscope, grade 1 cancer cells look more like normal cells and grow and spread more slowly than grade 2 and 3 cancer cells.

    Esophageal squamous cell carcinoma stage II

    Stage II can be divided into stage IIA and stage IIB, depending on where the cancer cells have spread.

  • Stage IIA: The cancer has spread.
  • Invasion of the thick muscular layer of the esophageal wall. The cancer cells are grade 2 or 3, or grade unknown; or
    Stage IIA squamous cell carcinoma of the esophagus(1) . The cancer has spread to the thick muscular layer of the esophageal wall. The cancer cells are grade 2 or 3 or of unknown grade. Under the microscope, grade 2 and 3 cancer cells look abnormal and grow and spread more rapidly than grade 1 cancer cells.
  • Invasion of the connective tissue layer of the esophageal wall. The tumor is located in the lower part of the esophagus; or
    Stage IIA esophageal squamous cell carcinoma (2). The cancer cells have spread to the connective tissue layer of the esophageal wall. The tumor was located in the lower part of the esophagus.
  • Invasion of the connective tissue layer of the esophageal wall. The cancer cells belong to grade 1. The tumor is located in the upper or middle segment of the esophagus.
    Stage IIA esophageal squamous cell carcinoma (3) with cancer cells that have spread to the connective tissue layer of the esophageal wall. The cancer cells are of grade 1. Under the microscope, grade 1 cancer cells look more like normal cells and grow and spread more slowly than grade 2 and 3 cancer cells. The tumor is located in the upper or middle part of the esophagus.
  • Stage IIB: The cancer has spread.
  • Invasion of the connective tissue layer of the esophageal wall. The cancer cells are of grade 2 or 3. The tumor is located in the upper or middle part of the esophagus; or
    Stage IIB esophageal squamous cell carcinoma (1). The cancer has spread to the connective tissue layer of the esophageal wall. The cancer cells are of grade 2 or 3. Under the microscope, grade 2 and 3 cancer cells look abnormal and grow and spread more rapidly than grade 1 cancer cells. The tumor is located in the upper or middle part of the esophagus.
  • Invasion of the connective tissue layer of the esophageal wall. The grade of the cancer cells is unknown, or the primary site of the tumor in the esophagus is not known; or
    Stage IIB squamous cell carcinoma of the esophagus ( 2). The cancer has spread to the connective tissue layer of the esophageal wall. The grade of the cancer is unknown, or the tumor is not known to be in the primary site of the esophagus.
  • Invasion of the mucosal layer, thin muscular layer, or submucosal layer of the esophageal wall. Metastases are found in 1 or 2 lymph nodes near the tumor.
    Stage IIB esophageal squamous cell carcinoma (3). The cancer cells have spread to the mucosal layer, thin muscular layer or submucosal layer of the esophageal wall. Metastases were found in 1 or 2 lymph nodes near the tumor.

    Esophageal squamous cell carcinoma stage III

    Stage III can be divided into stage IIIA and stage IIIB according to the site of cancer cell spread.

  • Stage IIIA: The cancer has spread.
  • Invasion of the mucosal layer, thin muscular layer, or submucosal layer of the esophageal wall. Metastases are found in 3 to 6 lymph nodes near the tumor; or
  • invasion of the thick muscular layer of the esophageal wall. Metastases were found in 1 or 2 lymph nodes in the vicinity of the tumor.
    Stage IIIA squamous cell carcinoma of the esophagus. The cancer has spread to the mucosal layer, thin muscular layer, or submucosal layer of the esophageal wall. Metastases are found in 3 to 6 lymph nodes near the tumor; or the cancer has spread to the thick muscular layer of the esophageal wall. Metastases were found in 1 to 2 lymph nodes near the tumor.
  • Stage IIIB: The cancer has spread.
  • Invasion of the thick muscular layer or connective tissue layer of the esophageal wall. Metastases found in 1 to 6 lymph nodes near the tumor; or
    Stage IIIB esophageal squamous cell carcinoma (1). Cancer cells have spread to the thick muscular or connective tissue layer of the esophageal wall. Metastases are found in one to six lymph nodes near the tumor.
  • Invasion of the diaphragm, odd vein, pleura, pericardium, or peritoneum. Metastases may be found in 0 – 2 lymph nodes near the tumor.
    Stage IIIB esophageal squamous cell carcinoma (2). The cancer has spread to (a) the diaphragm, (b) the odd vein, (c) the pleura, and (d) the pericardium or peritoneum (not shown). Metastases were found in 0 – 2 lymph nodes near the tumor.

    Esophageal squamous cell carcinoma stage IV

    Stage IV is divided into IVA and IVB depending on the location of cancer spread.

  • Stage IVA: The cancer has spread.
  • invasion of the diaphragm, odd vein, pleura, pericardium, or peritoneum. metastases are found in 3 to 6 lymph nodes near the tumor; or
    Stage IVA squamous cell carcinoma of the esophagus (1). cancer cells have spread to (a) the diaphragm, (b) the odd vein, (c) the pleura, (d) the pericardium, or the peritoneum (not shown). metastases are found in 3 to 6 lymph nodes near the tumor.
  • invasion of nearby structures such as the aorta, airway, or spine. metastases are found in 0 to 6 lymph nodes near the tumor; or
    Stage IVA squamous cell carcinoma of the esophagus (2). cancer cells have spread to nearby structures such as the airway, aorta, or spine. metastases are found in 0 to 6 lymph nodes near the tumor.
  • 7 or more lymph nodes near the tumor are reached.
    Stage IVA esophageal squamous cell carcinoma (3). cancer has spread to 7 or more lymph nodes near the tumor.
  • Stage IVB: Cancer cells have spread to other parts of the body, such as the liver or lungs.
    Stage IVB squamous cell carcinoma of the esophagus. the cancer has spread to other parts of the body, such as the liver or lungs.

    The following are the stages of adenocarcinoma of the esophagus:

    Stage 0 (highly heterogeneous hyperplasia)

    In stage 0, cancer cells form in the lining of the esophageal wall. stage 0 is also called high-grade heterogeneous hyperplasia.

    Stage 0 esophageal adenocarcinoma. cancer cells have formed in the lining of the esophageal wall.

    Stage I esophageal adenocarcinoma

    Stage I can be divided into stage IA, stage IB, and stage IC depending on where the cancer cells have spread.

  • Stage IA: The tumor has spread to the mucosal layer or thin muscular layer of the esophageal wall. cancer cells are of grade 1, or of unknown grade.
    Stage IA esophageal adenocarcinoma. cancer cells have spread to the mucosal layer or thin muscle layer of the esophageal wall. cancer cells are grade 1, or the grade is unknown. under the microscope, grade 1 cancer cells look more like normal cells and grow and spread more slowly than grade 2 and 3 cancer cells.
  • Stage IB: cancer cells have spread.
  • invading the mucosal, thin muscular or submucosal layers of the esophageal wall. cancer cells are grade 2; or
  • invasion of the submucosal layer of the esophageal wall. cancer cells are grade 1 or 2, or grade unknown.
    Stage IC esophageal adenocarcinoma. cancer cells have spread to the mucosa layer, thin muscle layer, or submucosa layer of the esophageal wall. cancer cells are grade 3. under the microscope, grade 3 cancer cells look abnormal and grow and spread more rapidly than grade 1 and 2 cancer cells; or cancer cells have spread to the thick muscle layer of the esophageal wall. cancer cells are grade 1 or 2.

    Stage II esophageal adenocarcinoma:

    Stage II can be divided into stage IIA and stage IIB depending on where the cancer cells have spread.

  • Stage IIA: Cancer cells have spread to the thick muscular layer of the esophageal wall. cancer cells are of grade 3, or grade unknown.Stage IIA esophageal adenocarcinoma. the cancer cells have spread to the thick muscular layer of the esophageal wall. the cancer cells are grade 3 or the grade is not known. under the microscope, grade 3 cancer cells look abnormal and grow and spread more rapidly than grade 1 and 2 cancer cells.
  • Stage IIB: the cancer cells have spread
  • invaded the connective tissue layer of the esophageal wall; or
  • invasion of the mucosal, thin muscular, or submucosal layers of the esophageal wall. metastases are found in 1 or 2 lymph nodes near the tumor.
    Stage IIB esophageal adenocarcinoma. cancer cells have spread to the connective tissue layer of the esophageal wall; or cancer cells have spread to the mucosal layer, thin muscle layer, or submucosa layer of the esophageal wall. metastases are found in 1 or 2 lymph nodes near the tumor.

    Esophageal adenocarcinoma stage III:

    Stage III can be divided into stage IIIA and stage IIIB depending on where the cancer cells have spread.

  • Stage IIIA: cancer cells have spread.
  • invasive to the mucosal layer, thin muscular layer or submucosal layer of the esophageal wall. metastases are found in 3 to 6 lymph nodes near the tumor; or
  • invasion of the thick muscular layer of the esophageal wall. metastases found in 1 or 2 lymph nodes near the tumor.
    Stage IIIA esophageal adenocarcinoma. cancer cells have spread to the mucosa layer, thin muscle layer, or submucosa layer of the esophageal wall. metastases are found in 3 to 6 lymph nodes near the tumor; or cancer cells have spread to the thick muscle layer of the esophageal wall. metastases are found in 1 to 2 lymph nodes near the tumor.
  • Stage IIIB: cancer cells have spread.
  • Invasion of the thick muscular layer of the esophageal wall. metastases found in 3 to 6 lymph nodes near the tumor; or
  • Invasion of the connective tissue layer of the esophageal wall. metastases found in 1 to 6 lymph nodes near the tumor; or
    Stage IIIB adenocarcinoma of the esophagus (1). cancer has spread to the thick muscle layer of the esophageal wall. metastases are found in 3 to 6 lymph nodes near the tumor; or cancer has spread to the connective tissue layer of the esophageal wall. metastases are found in 1 to 6 lymph nodes near the tumor.
  • invasion of the diaphragm, odd vein, pleura, pericardium, or peritoneum. metastases are found in 0 – 2 lymph nodes near the tumor.
    Stage IIIB esophageal adenocarcinoma (2). cancer has spread to (a) the diaphragm, (b) the odd vein, (c) the pleura, and (d) the pericardium or peritoneum (not shown). metastases are found in 0 – 2 lymph nodes near the tumor.

    Esophageal adenocarcinoma stage IV:

    Stage IV can be divided into stage IVA and IVB depending on where the cancer has spread.

  • Stage IVA: cancer has spread to.
  • invasion of the diaphragm, odd vein, pleura, pericardium, or peritoneum. metastases are found in 3 to 6 lymph nodes near the tumor; or
    Stage IVA adenocarcinoma of the esophagus (1). tumor has spread to (a) the diaphragm, (b) the odd vein, (c) the pleura, (d) the pericardium, or the peritoneum (not shown). metastases are found in 3 to 6 lymph nodes near the tumor.
  • invasion of nearby structures such as the aorta, airway, or spine. metastases are found in 0 – 6 lymph nodes near the tumor; or
    Stage IVA adenocarcinoma of the esophagus (2). cancer cells have spread to nearby structures such as the airway, aorta, or spine. metastases are found in 0 – 6 lymph nodes near the tumor.
  • Reaching 7 or more lymph nodes near the tumor.
    Stage IVA adenocarcinoma of the esophagus (3). cancer has spread to 7 or more lymph nodes near the tumor.
  • Stage IVB: cancer has spread to other parts of the body, such as the liver or lungs.
    Stage IVB esophageal adenocarcinoma. cancer cells have spread to other parts of the body, such as the liver or lungs.