Initial Staging of Esophageal Cancer: Systematic Review of the Performance of Diagnostic Methods

Esophageal cancer is rare and its prognosis remains poor. Staging esophageal cancer is a key step to determine the feasibility of curative treatment and, if so, to establish an optimal therapy plan.

Esophageal cancer is rare and its prognosis remains poor. In Québec, it is estimated that 339 people were diagnosed with esophageal cancer and that 319 died from the disease in 2007.

Staging esophageal cancer is a key step to determine the feasibility of curative treatment and, if so, to establish an optimal therapy plan. There are various diagnostic techniques for the clinical staging of esophageal cancer: computed tomography (CT), endoscopic ultrasound (EUS) with and without ultrasound-guided fine-needle aspiration, positron emission tomography with CT (PET CT), magnetic resonance imaging (MRI) and minimally invasive surgical procedures (thoracoscopy and laparoscopy).

This report is a systematic review of the scientific literature published on the performance of the diagnostic tests used for the clinical staging of cancer of the esophagus and gastroesophageal junction not associated with stomach cancer. It does not cover organizational and economic issues.

Conclusions

Most of the studies we reviewed were of poor methodological quality and there was few evidence on certain technologies. Taking these limitations into account, AETMIS has drawn several conclusions and proposes the following diagnostic test sequence for the clinical staging of esophageal cancer:

• Start with a CT scan of the neck, thorax and abdomen to determine if there are distant metastases;

• If no distant metastases are present, use EUS to evaluate locoregional invasion (Stages T and N) and celiac lymph nodes and EUS FNA if the tumour does not obstruct the needle; if a stenosing tumour is present, the optimal approach is not known, but dilation is indicated, except in the case of severe stenosis, and it should be done in centres with considerable expertise;

• Add PET-CT to the cancer staging if the patient is judged eligible for curative treatment after a CT scan and EUS (however, further research is needed to confirm the utility of this approach);

• Use MRI if CT cannot be performed (even though this option is mentioned in only some practice guidelines);

• Perform MISPs (laparoscopy, thoracoscopy) in certain situations, such as laparoscopy to evaluate abdominal metastases (e.g., in the peritoneum) when the cancer is located in the gastroesophageal junction.