successfully predicts T stage in over 80% of cases when performed by an experienced endoscopist.

Regional lymph nodes can also be visualized and sampled by FNA. This aids in determining the N stage.

The sensitivity of EUS alone to predict N stage is 85% and increases to 95% when FNA is added.47

At present there are no serum markers that have been found in esophageal cancer patients that would

consistently yield meaningful clinical data. Standard serum cancer markers including CEA, CA19-9, and

CA-125 have no value in the preoperative evaluation of the patient with esophageal cancer. The most

useful laboratory parameters used clinically outside of a hemoglobin and electrolyte panel include

nutritional parameters (albumin, prealbumin).

A CT scan of the chest, abdomen, and pelvis with contrast is a valuable tool for assessing tumor,

lymph nodes, and the general anatomy related to the patient. Additionally, metastases to the liver and

lung are assessed via this method. Positron emission tomography (PET) with 18F-fluorodeoxyglucose

(FDG) is a physiologic unique test that detects metabolic activity within tissues. It is invaluable in the

assessment and clinical staging of patients with esophageal cancer as it provides information on N and

M stage to help guide clinical staging. PET scans are routinely obtained for the clinical staging of

esophageal cancer patients prior to and after treatment to evaluate for disease and disease progression,

respectively.

Additional staging modalities attempt to improve the accuracy of clinical staging. We use laparoscopic

staging quite liberally in our practice. This allows us to perform endoscopy and bronchoscopy on every

patient. In the laparoscopic staging procedure we can examine the extent of nodal involvement in the

celiac lymph nodes and evaluate for local tumor advancement and any diaphragmatic invasion.

Importantly, many patients present with significant dysphagia and weight loss, so nutritional needs can

be addressed at the time of this procedure either with an esophageal stent or feeding jejunostomy.

Finally, a chemotherapy port can be placed for easier access during treatment. We acknowledge that

staging laparoscopy is not absolutely required, however we feel there are many advantages that it has

to offer if planning further surgical intervention in the future.

Cervical Esophageal Cancer

Cancer of the cervical esophagus represents a very small subset of primary tumors. Direct extension into

the esophagus by tumors of the thyroid and trachea are much more common. These tumors are

challenging to treat and generally do not respond to surgical resection as a primary modality.

Traditionally, chemoradiotherapy has been the standard treatment for these tumors. Those who get

treated and have a good response may represent a small subset of patients that are referred

esophagectomy with laryngectomy and tracheostomy.

Adenocarcinoma

5 Adenocarcinoma of the esophagus is the most common esophageal tumor in the United States and

Western world, accounting for more than 50% of cases. The rise of this histologic subtype correlates

with the incidence of gastreoesophageal reflux disease (GERD) and obesity in the Western world, and

the overall prevalence of BE appears to be rising within the West. Whether this finding is related to a

true increased incidence or heightened surveillance is not clear. Although the overall incidence of BE is

unknown, autopsy series have estimated the prevalence to be 376 cases per 100,000 in Olmsted County,

MN, USA.48 Remarkably, this rate is five times the clinical prevalence in the same geographic area (82.6

per 100,000). As a result of findings such as these, it is generally well accepted that the subclinical

prevalence is underestimated. These cohort studies suggest that the majority of patients with BE are

undiagnosed because they experience minimal to no symptoms.

The sequence leading from chronic GERD to the development of Barrett esophagus, the precursor of

adenocarcinoma of the esophagus, is well defined. The esophagus is normally lined by squamous

mucosa, and repeated injury from chronic reflux leads to transformation of the normal squamous

mucosa into columnar epithelium. This is likely a two-step process, with the first step involving the

transformation of normal esophageal squamous mucosa to simple columnar epithelium. This initial step

takes place relatively quickly over the course of a few years, while the second step, the development of

intestinal metaplasia, proceeds over 5 to 10 years.49 Once present, Barrett can progress to low-grade

and high-grade dysplasia. With progression to dysplasia, the nuclei become more crowded and the

normal glandular architecture is lost. Patients with high-grade dysplasia carry a significant risk of the

development of adenocarcinoma, and at 5 years 10% to 30% of patients will develop invasive findings.

The annual rate of neoplastic transformation is 0.5%.50 Patients with recurring symptoms of reflux have

an eightfold increase in the risk of adenocarcinoma. Patients with nondysplastic Barrett’s have a 0.5%

per patient-year rate of progression to esophageal adenocarcinoma.51,52 At the time of espophagectomy

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for high-grade dysplasia, invasive carcinoma is identified in as many as 30% to 40% of patients.53

Squamous Cell Carcinoma

Squamous cell carcinoma is more frequent world wide with the primary risk factor for development

being chronic irritation of the esophageal mucosa. This is hypothesized to be associated most frequently

with prolonged alcohol consumption which is believed to be enhanced with concomitant tobacco

exposure. Nitrosamines and other nitrosyl compounds found in smoked meats are especially important

carcinogens that the native populations rely on heavily. Hot beverages in Asian countries have been

theorized to be associated with a high incidence. Medical conditions such as achalasia, caustic strictures,

Plummer–Vinson syndrome, and tylosis also increase the risk of incidence. The risk with long-standing

achalasia is in the range of 5% to 7%, thus surveillance with biopsies is recommended in these

patients.54

Staging

In 2009, the American Joint Committee on Cancer (AJCC) published the seventh edition AJCC Cancer

Staging Manual. Table 43-4 summarizes the seventh edition AJCC TNM system for staging esophageal

cancers. This new staging system has significant revisions from the previous sixth edition which are

summarized in Table 43-5. Several stages and categories are redefined and subclassified. Tumors arising

in the stomach less or equal to 5 cm away from the esophagogastric (EG) junction and tumors arising

from or crossing the EG junction are all staged under this new system. The stage groupings have all

been reassigned, with the new pathologic stage relying all on the number of nodes containing

metastasis, tumor grade, tumor location, and histologic cell type in the seventh edition staging criteria.

The revised staging groupings and current recommended treatment strategies for each stage are

displayed in Table 43-6.

The importance of a cancer staging protocol lies in the strong association between stage of the disease

and outcomes. The seventh edition AJCC TNM staging system is data driven and harmonized. It will

allow physicians to clinical stage esophageal cancers accurately, which is of paramount importance

during the formulation of an appropriate treatment plan. Preoperative evaluation is necessary to

identify the extent of disease and help elicit the clinical stage. CT scans of the chest and abdomen are

crucial to preoperative evaluation and should be ordered in all patients. We also recommend PET

scanning in conjunction with CT imaging to detect distant metastatic disease. In the absence of liver,

lung, or other distant metastatic disease, esophageal ultrasound should be used to assess regional lymph

nodes and define the depth of tumor invasion. Patients with stage-appropriate disease should be

optimized from a medical standpoint prior to undergoing resection.

Table 43-4 T, N, and M Status and Histologic Grade Definitions for Esophagus

and Esophagogastric Junction Cancer in the Seventh Edition of the

American Joint Committee on Cancer (AJCC) Cancer Staging Manual

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