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Diagnosis and staging of esophageal cancer

John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Michael K Gibson, MD, PhD, FACP
Section Editors
Douglas A Howell, MD, FASGE, FACG
Richard M Goldberg, MD
Deputy Editor
Diane MF Savarese, MD


Squamous cell carcinoma (SCC) and adenocarcinoma account for over 95 percent of esophageal malignant tumors. For most of the twentieth century, SCC has predominated. In the 1960s, SCC accounted for more than 90 percent of all esophageal tumors in the United States, and adenocarcinomas were considered so uncommon that some authorities questioned their existence. For the past two decades, however, the incidence of esophageal adenocarcinoma has increased dramatically in Western countries, such that the adenocarcinoma now accounts for >60 percent of all esophageal cancers in the United States. In contrast, worldwide, squamous cell cancer still predominates [1]. (See "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer".)

Esophageal SCC and adenocarcinomas differ in a number of features, including tumor location and predisposing factors (table 1). Smoking and alcohol are major risk factors for SCC while Barrett's esophagus with specialized intestinal metaplasia (a complication of gastroesophageal reflux disease [GERD]), obesity, smoking, and possibly GERD itself are the risk factors for adenocarcinoma [2]. (See "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer".)

There seems little doubt that esophageal SCCs and adenocarcinomas represent two different diseases with characteristic pathogenesis, epidemiology, tumor biology, and outcomes. In acknowledgement of these differences, the current 2010 tumor, node, metastasis (TNM) staging system provides separate stage groupings (but similar definitions for tumor, nodal, and metastasis categories) for SCCs and adenocarcinomas of the esophagus and esophagogastric junction (table 2 and table 3) [3]. The newest TNM staging classification (eighth edition, 2017), which is scheduled to go into effect in the United States on January 1, 2018, has further refined these histology-specific prognostic stage groupings (table 4) [4]. Outside of the United States, the Union for International Cancer Control (UICC) has implemented the eighth edition changes as of January 1, 2017. (See 'TNM staging criteria' below.)

In clinical practice, however, there is controversy as to whether and how histology should influence the therapeutic approach. This issue is addressed elsewhere. (See "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus", section on 'Squamous cell versus adenocarcinoma'.)

Regardless of histology, approximately 50 to 60 percent of patients with esophageal cancer present with incurable locally advanced or metastatic disease. Prolonged progression-free survival is possible in only a few of such patients while palliation is the goal of treatment for the majority. (See "Management of locally advanced unresectable and inoperable esophageal cancer" and "Systemic therapy for locally advanced unresectable and metastatic esophageal and gastric cancer".)

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Literature review current through: Nov 2017. | This topic last updated: Feb 16, 2017.
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