The Society of Thoracic Surgeons (STS) has released new clinical-practice guidelines that feature evidence-based recommendations to help clinicians diagnose and stage esophageal cancer.
“The optimal treatment for localized esophageal cancer remains one of the most widely debated topics in oncology,” wrote Thomas K. Varghese, Jr, MD, MS, of the Division of Cardiothoracic Surgery at University of Washington in Seattle, and coauthors in the guidelines, which were published in The Annals of Thoracic Surgery (2013;96:346-356). “Accurate staging information is … critical for the determination of appropriate therapeutic intervention.”
The recommendations tout flexible endoscopy, with biopsy as the diagnostic test of choice for esophageal cancer. Clinicians should note the location of the tumor relative to the teeth and gastroesophageal junction, the length of the tumor, the extent of circumferential involvement, and the degree of obstruction. If Barrett’s esophagus is present, its location and extent should be documented as well.
Barium studies may help make the diagnosis and are essential when a tracheoesophageal fistula is suspected.
Early cancers of the esophagus are generally asymptomatic, but some patients might have ulcerated lesions with evidence of gastrointestinal bleeding. Most, however, present at an advanced stage, with dysphagia being the most common symptom.
The guidelines deem computed tomography (CT) of the chest and abdomen to be an optional test for staging early esophageal cancer but a recommended test for staging locoregionalized disease. Positron emission tomography (PET), too, is considered optional for staging early disease but recommended for staging locoregionalized cancer.
In the absence of metastatic disease, endoscopic ultrasonography should be used to improve the accuracy of clinical staging. Laparoscopy is recommended to improve the accuracy of staging in certain cases of locally advanced adenocarcinoma of the esophagogastric junction. But because data on the use of staging thoracoscopy and laparoscopy are limited, these techniques should only be employed by those who have experience with them, the guidelines state.
According to the guidelines, endoscopic mucosal resection should be considered as a diagnostic/staging tool for small, discrete nodules or areas of dysplasia when esophageal cancer appears limited to the mucosa or submucosa as assessed by endoscopic ultrasonography.