Oesophageal cancer (staging)

Population Covered By The Guidance

This pathway provides guidance on imaging patients with proven oesophageal cancer, indicating how imaging helps determine management.

Lead Researcher: Gurjeet Dulku

Experts & Contributors: Emmeline Lee, William Macdonald, Richard Mendelson, Peter Scally

Editorial Panel: Core membership
Link to Editorial Panel

Date reviewed: March 2015

Date Published: July 2015

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.

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.

Oesophageal Carcinoma

Image 2a (Endoscopic Ultrasound) and 2b (Computed Tomography): Images from the same patient showing oesophageal carcinoma with aortic involvement.

Oesophageal Carcinoma

Image 2a (Endoscopic Ultrasound) and 2b (Computed Tomography): Images from the same patient showing oesophageal carcinoma with aortic involvement.

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.

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.

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.

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

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

Oesophageal Carcinoma

  • 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

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

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  5. 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
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  8. 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
  9. 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
  10. 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
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  13. 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
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  15. 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
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  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
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  26. 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
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  28. 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
  29. 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
  30. 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
  31. 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
  32. 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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Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Gastrointestinal