brief presentation on staging of carcinoma esophagus

1. Dr. Sreejith P S

2.  Complete history, physical examination – cornerstone of diagnostic evaluation.
 Laboratory profile - anemia, hypoalbuminemia, elevated PT/INR (vitamin K
deficiency, possibly elevated liver function tests if metastatic disease).
 Serological markers of cancer – No high Sn/Sp in esophageal SCC.
 Evaluation - dependent on tissue diagnosis through biopsy f/b staging for
prognosis & therapeutic planning.

3.  BARIUM SWALLOW
- Was used traditionally when UGIscopy was not commonly available.
- Identifies polypoid tumors, Apple core constrictions, strictures with mucosal
integrity
- DCBS is more useful & informative in the absence of UGIscopy availability –
PPV – 42%.
- CURRENT INDICATIONS –
- Dysphagia & weight loss – endoscopy not readily available.
- Stricture precludes complete endoscopic evaluation – barium studies -
demarcate distal extent
of the tumor.

4. 
Cancer lower 1/3
Filling defect (ulcerative type)
Rat tail appearance
Apple core appearance

5.  Standard initial diagnostic modality if Ca esophagus is a D/D
 Scopy should include - tumor morphology, distance from incisors, length of
lesion, % of circumferential involvement, position wrt GEJ (length of extension
into cardia if present).
 Skip lesions; Presence, location, and length of Barrett esophagus
 Several Biopsies - increase the diagnostic accuracy.
 To increase diagnostic yield –
- >= 6 biopsies
- Don’t biopsy necrotic/ fibrotic area
 Brush Cytology – tight malignant strictures – Obtain Brushings Before Biopsy

6. Early, superficial
cancer
Circumferential ulceration
esophageal cancer
Malignant stricture
of esophagus

7.  First radiologic test in staging evaluation endoscopically diagnosed esophageal
cancer.
 Esophageal wall thickness > 5 mm on CT scan – abnormal.
 Main utility - CT – detect distant systemic disease (hepatic, adrenal, lung
mets).
 In AdenoCa of GEJ and gastric cardia, peritoneal mets - more likely than with
SCC. – CT inferior to D-lap in peritoneal mets detection.
 Can exclude T4 d/s – Sn – 25, Sp-94%

8.  Obliteration of fat plane between esophagus & Aorta, TB, Pericardium -
suggestive of invasion.
 Thickening/ indentation of membranous trachea & L main bronchus -suggestive
of invasion
 Ao-Eso contact angle extends beyond 90 degrees of the circumference - 80%
accuracy infiltration.
 CT scan cannot reliably distinguish the various T stages
 T1 & T2 lesions - esophageal wall thickness -5 -15 mm, and T3 lesions > 15 mm
thickness
 MS, Abd Lymphadenopathy - suboptimal with CT (CT diagnostic criteria - Size
alone)
 Intrathoracic, abd nodes > 1 cm; SCLN short axis > 0.5 cm; retrocrural nodes >
0.6 cm – Pathologic
 LN in CT - Sn – 50%, Sp - 83%

9.  Staging:
Figure Esophageal cancer with tracheal invasion. CT scan shows
circumferential wall thickening of the proximal esophagus (arrowheads),
which shows irregular interface with the posterior wall of the trachea
(arrows), indicating direct extension into the lumen
Figure Esophageal cancer with aortic invasion. An arc (bent arrow) of
the contact between the esophageal cancer (arrows) and the aorta
(arrowheads) is more than 90 degrees, indicating aortic invasion.

11.  Now routinely used in the staging of esophageal cancer.
 Detect primary tumors – Sn – 78 – 95%(less for T1/T2) -
 Functional assessment of metabolically active LN/ mets
 Distinguish between inflammatory and malignant LN involvement
 SCC > EAC in FDG avidity
Parameter Sn Sp Accuracy
Primary Tumor 78-95 %
LN 38 – 82%(lower in
mid & lower MS)
76 – 95%
Distant Mets 69% 93% 84%
Management
strategies
changed due to
PET
3 – 20%

12.  Routinely performed when - standard staging methods (CT and EUS) show
regional invasive cancer with no distant metastatic disease
 Is an independent predictor of OS in patients with non-metastatic
esophageal cancer.
 Poor spatial resolution – insufficient to separate the primary Tr & juxtatumoral
lymph LN nodes secondary to the interference from the primary tumor.

13. Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT PET demonstrates para-aortic lymph node
metastases showing increased FDG uptake (arrowheads). B, Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in
diameter. Based on size criteria, these lymph nodes may be considered benign on CT scan

14.  Assess depth of invasion of cancer.
 Dedicated
 EUS operating at frequencies of 7.5 and 12 MHz
 The deeper the tumor the higher the sensitivity of EUS.
 Discrimination of invasion of mucosa & submucosa (i.e., the T1a versus T1b stages) –
controversy
 Drawbacks – Overstaging(MC in T2; peritumoral edema); Understaging(Tr penetration
below resoln of EUS.
Parameter Sn Sp Accuracy
T staging
T1a
T1b
T4
85%
86%
87%
86%
84%
N (EUS FNA) > 85?% >85% >85%

15.  Modified EUS criteria – for identifying Malignant LN
 Standard criteria -
- hypoechoic
- smooth border
- round
-width >5 to 10 mm
 Extra-criteria -
- EUS-identified celiac lymph nodes
- >5 lymph nodes
- EUS T3/4 tumor.

16.  EUS:
 assess the depth of penetration and LN involvement. Limited by the degree of obstruction.
 Compared with EUS, CT is not a reliable tool for evaluation of the extent of tumor in the esophageal wall.
Fig. —55-year-old man with T2 esophageal tumor (m) shown on endoscopic
sonogram. Note alternating hyperechoic and hypoechoic layers (arrowheads) of
normal esophageal wall as seen on sonography. Innermost layer is hyperechoic
and corresponds to superficial mucosa. Second layer is hypoechoic and
corresponds to deep mucosa and muscularis mucosae. Third layer is again
hyperechoic and corresponds to submucosa and its interface with muscularis
propria. Fourth layer is hypoechoic and corresponds to muscularis propria, and
outer fifth layer is hyperechoic and corresponds to adventitia.

19.  Accurate assessment of depth of infiltration, LVI, degree of differentiation
 Estimates Local LN Mets
 Used predominantly in therapeutics in superficial EAC.

20.  INDICATIONS –
- obstructing esophageal tumor – inability to progress scope & do EUS.
- Mid- and upper esophahgeal Trs.
 SIGNS OF TB INVOLVEMENT -
- widened carina
- external compression
- tumor infiltration and fistulization – contraindicate resection
 If erythema, edema - Brush cytology/ Bronchial Biopsy
 Recent studies – EBUS - greater accuracy in evaluating TB invasion by esophageal
neoplasia compared with conventional bronchoscopy, CT, and EUS.
 EBUS combined with EUS – Libermann et al – in upper & middle eso Trs – easier sampling
of periTr LN- Less false positivity

21.  Selectively done –
 Excludes small volume intraperitoneal mets(Occult IP/IT distant mets)
 Excludes Liver Cirrhosis
 GEJ/ Distal esophagus Trs (mainly EAC) with extensive gastric involvement –
sampling regional LN
 Liver/ peritoneal mets are suspected, confirmation required.
 Limits unnecessary negative laparotomy
 SOS Lap US of liver
 With better PET-CT & EUS – staging lap – less indicated.
Effect on CT &
EUS nodal status
Upstaged in Downstaged in Changed
management in
Laparoscopy 0 – 21% 4 – 19% 20%

22.  No serosal covering, direct invasion of contiguous structures occurs early.
 Commonly spread by lymphatics (70%)
 Lymph node involvement increases with T stage.
 T1 – 14 to 21%
 T2 – 38 to 60%
 25% - 30% hematogenous metastases at time of presentation.
 Most common site of metastases are
 lung, liver, pleura, bone, kidney & adrenal gland
 Median survival with distant metastases – 6 to 12 months

24.  a: Includes nodes previously labeled
as “M1a”
 b : “M1a” designation is no longer
recognized in the 7th edn. of the
AJCC system

26. Chauges.in 8th edition
Classification Staging was separated clinical, pathological
and pathological prognostic staging
L-category The definition of EGJ cancer was changed to
tumors centered within 2 cm of the IDG
T-category Subcategorized Tla and Tlb were used for
pathological and pathological prognostic
staging. T4a includes the peritoneum
G-categor G4 was eliminated and undifferentiated type
was categorized as G3
Notable changes between the 7th and 8th editions
EGJ: esophagogastric junction.

29. Group T N M Grade
0 Tis (HGD)
N0
M0
1, X
IA T1 1-2, X
IB T1 3
T2 1-2, X
IIA T2 3
IIB T3
Any
T1-2 N1
IIIA T1-2 N2
T3 N1
T4a N0
IIIB T3 N2
IIIC T4a N1-2
T4b Any
Any N3
IV Any Any M1

30. cStage group cT cN cM
Squamous cell carcinoma
0 Tis N0 M0
I T1 N0–1 M0
II T2 N0–1 M0
T3 N0 M0
III T3 N1 M0
T1–3 N2 M0
IVA T4 N0–2 M0
T1–4 N3 M0
IVB T1–4 N0–3 M1
Adenocarcinoma
0 Tis N0 M0
I T1 N0 M0
IIA T1 N1 M0
IIB T2 N0 M0
III T2 N1 M0
T3–4a N0–1 M0
IVA T1–4a N2 M0
T4b N0–2 M0
T1–4 N3 M0
IVB T1–4 N0–3 M1
Table 2
Clinical (cTNM) stage groups