Esophagus Cancer

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Early Detection, Diagnosis, and Staging TOPICS

How is cancer of the esophagus staged?

The stage of esophageal cancer is a standard way for doctors to sum up how far the cancer has spread. The treatment and outlook for people with esophageal cancer depend, to a large extent, on the cancer’s stage. Staging for esophageal cancer can be confusing, so ask your cancer care team to explain the stage of your cancer to you in a way you understand. This can help you make informed choices about your treatment.

Esophageal cancer is staged based on the results of exams, imaging tests, endoscopies, and biopsies, which are described in “How is cancer of the esophagus diagnosed?

TNM staging system

The most common system used to stage esophageal cancer is the TNM system of the American Joint Committee on Cancer (AJCC). The TNM system is based on several key pieces of information:

  • T refers to how far the primary tumor has grown into the wall of the esophagus and into nearby organs.
  • N refers to cancer spread to nearby lymph nodes.
  • M indicates whether the cancer has metastasized (spread to distant organs).
  • G describes the grade of the cancer, which is based on how the patterns of cancer cells look under a microscope.

Staging also takes into account the cell type of the cancer (squamous cell carcinoma or adenocarcinoma). For squamous cell cancers, the location of the tumor can also be a factor in staging.

T categories

This describes how deeply the cancer has grown into the wall of the esophagus or into nearby structures. Most esophageal cancers start in the innermost lining of the esophagus (the epithelium) and then grow into deeper layers over time. (See “What is esophagus cancer?” for a description of the layers of the esophagus wall.)

TX: The primary tumor can’t be assessed.

T0: There is no evidence of a primary tumor.

Tis: The cancer is only in the epithelium (the top layer of cells lining the inside of the esophagus). It has not started growing into the deeper layers. This stage is also known as high-grade dysplasia. In the past it was called carcinoma in situ.

T1: The cancer is growing into the tissue under the epithelium, such as the lamina propria, muscularis mucosa, or submucosa.

  • T1a: The cancer is growing into the lamina propria or muscularis mucosa
  • T1b: The cancer has grown through the other layers and into the submucosa

T2: The cancer is growing into the thick muscle layer (muscularis propria).

T3: The cancer is growing into the outer layer of the esophagus (the adventitia).

T4: The cancer is growing into nearby structures.

  • T4a: The cancer is growing into the pleura (the thin layer of tissue covering the lungs), the pericardium (the thin sac surrounding the heart), or the diaphragm (the thin sheet of muscle below the lungs that separates the chest from the abdomen). The cancer can be removed with surgery.
  • T4b: The cancer cannot be removed with surgery because it has grown into the trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures.

N categories

NX: Nearby lymph nodes can’t be assessed.

N0: The cancer has not spread to nearby lymph nodes.

N1: The cancer has spread to 1 or 2 nearby lymph nodes.

N2: The cancer has spread to 3 to 6 nearby lymph nodes.

N3: The cancer has spread to 7 or more nearby lymph nodes.

M categories

M0: The cancer has not spread (metastasized) to distant organs or lymph nodes.

M1: The cancer has spread to distant lymph nodes and/or other organs. (Common sites of spread include the liver and lungs.)

Grade

The grade of a cancer is based on how normal (or differentiated) the cells look under the microscope. The higher the number, the more abnormal the cells look. Higher grade tumors tend to grow and spread faster than lower grade tumors.

GX: The grade cannot be assessed (treated in stage grouping as G1).

G1: The cells are well-differentiated.

G2: The cells are moderately differentiated

G3: The cells are poorly differentiated

G4: The cells are undifferentiated (these cells are so abnormal that doctors can’t tell if they are adenocarcinoma or squamous cell carcinoma). For stage grouping (see below), G4 cancers are grouped with G3 squamous cell cancers.

Location

Some stages of early squamous cell carcinoma also take into account where the tumor is in the esophagus. The location is assigned as either upper, middle, or lower based on where the upper edge of the tumor is.

Stage grouping

Once the T, N, M, and G categories have been assigned, this information is combined into an overall stage of 0, I, II, III, or IV. This process is called stage grouping. Some stages are further subdivided into A, B, or C. The stages identify cancers that have a similar prognosis (outlook). Patients with lower stage numbers tend to have a better prognosis.

The stage groupings for squamous cell carcinoma and adenocarcinoma are different. Cancers that have features of both squamous cell and adenocarcinoma are staged as squamous cell carcinomas.

Squamous cell carcinoma stages

Stage 0: Tis, N0, M0, GX or G1; any location: This is the earliest stage of esophageal cancer. It is also called high-grade dysplasia. The cancer cells are found only in the epithelium (the layer of cells lining the esophagus). The cancer has not grown into the connective tissue beneath these cells (Tis). The cancer has not spread to nearby lymph nodes (N0) or other organs (M0). The tumor is well differentiated (G1) or grade information is not available (GX), and it can be anywhere along the esophagus.

Stage IA: T1, N0, M0, GX or G1; any location: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). The tumor is well differentiated (G1) or grade information is not available (GX). It can be anywhere along the esophagus.

Stage IB: Either of the following:

T1, N0, M0, G2 or G3; any location: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is moderately (G2) or poorly differentiated (G3). The tumor can be anywhere in the esophagus.

T2 or T3, N0, M0, GX or G1; location lower: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is well differentiated (G1) or grade information is not available (GX). Its highest point is in the lower part of the esophagus.

Stage IIA: Either of the following:

T2 or T3, N0, M0, GX or G1; location upper or middle: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0).The cancer is in the upper or middle part of the esophagus and is well differentiated (G1) or grade information is not available (GX).

T2 or T3, N0, M0, G2 or G3; location lower: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to lymph nodes (N0) or to distant sites (M0).The cancer is in the lower part of the esophagus and is moderately (G2) or poorly differentiated (G3).

Stage IIB: Either of the following:

T2 or T3, N0, M0, G2 or G3; location upper or middle: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is in the upper or middle part of the esophagus and is moderately (G2) or poorly differentiated (G3).

T1 or T2, N1, M0, any G; any location: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 1 or 2 lymph nodes near the esophagus (N1) but has not spread to lymph nodes further away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Stage IIIA: Any of the following:

T1 or T2, N2, M0, any G; any location: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 3 to 6 lymph nodes near the esophagus (N2) but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

T3, N1, M0, any G; any location: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 1 or 2 lymph nodes near the esophagus (N1), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

T4a, N0, M0, any G; any location: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Stage IIIB: T3, N2, M0, any G; any location: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 3 to 6 lymph nodes near the esophagus (N2), but has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Stage IIIC: Any of the following:

T4a, N1 or N2, M0, any G; any location: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has spread to 1 to 6 lymph nodes near the esophagus (N1 or N2), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

T4b, any N, M0, any G; any location: The cancer cannot be removed with surgery because it has grown into the trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures (T4b). It may or may not have spread to nearby lymph nodes (any N), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Any T, N3, M0, any G; any location: The cancer has spread to 7 or more nearby lymph nodes (N3), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade and can be anywhere along the esophagus.

Stage IV: Any T, any N, M1, any G; any location: The cancer has spread to distant lymph nodes or other sites (M1). It can be any grade (G) and can be anywhere along the esophagus.

Adenocarcinoma stages

The location of the cancer along the esophagus does not affect the stage of adenocarcinomas.

Stage 0: Tis, N0, M0, GX or G1: This is the earliest stage of esophageal cancer. It is also called high-grade dysplasia. The cancer cells are found only in the epithelium (the layer of cells lining of the esophagus). The cancer has not grown into the connective tissue beneath these cells (Tis). The cancer has not spread to nearby lymph nodes (N0) or other organs (M0). It is well differentiated (G1) or grade information is not available (GX).

Stage IA: T1, N0, M0, GX, G1, or G2: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is well (G1) or moderately differentiated (G2), or grade information is not available (GX).

Stage IB: Either of the following:

T1, N0, M0, G3: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is poorly differentiated (G3).

T2, N0, M0, GX, G1, or G2: The cancer has grown into the muscle layer called the muscularis propria (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is well (G1) or moderately differentiated (G2), or grade information is not available (GX).

Stage IIA: T2, N0, M0, G3: The cancer has grown into the muscle layer called the muscularis propria (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is poorly differentiated (G3).

Stage IIB: Either of the following:

T3, N0, M0, any G: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It can be any grade.

T1 or T2, N1, M0, any G: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 1 or 2 lymph nodes near the esophagus (N1), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade.

Stage IIIA: Any of the following:

T1 or T2, N2, M0, any G: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 3 to 6 lymph nodes near the esophagus (N2) but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

T3, N1, M0, any G: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 1 or 2 lymph nodes near the esophagus (N1), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

T4a, N0, M0, any G: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It can be any grade (G).

Stage IIIB: T3, N2, M0, any G: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 3 to 6 lymph nodes near the esophagus (N2), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

Stage IIIC: Any of the following:

T4a, N1 or N2, M0, any G: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has spread to 1 to 6 lymph nodes near the esophagus (N1 or N2), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

T4b, any N, M0, any G: The cancer cannot be removed with surgery because it has grown into the trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures (T4b). It may or may not have spread to nearby lymph nodes (any N), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

Any T, N3, M0, any G: The cancer has spread to 7 or more nearby lymph nodes (N3), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

Stage IV: Any T, any N, M1, any G: The cancer has spread to distant lymph nodes or other sites (M1). It can be any grade (G).

Resectable versus unresectable cancer

The AJCC staging system provides a detailed summary of how far the cancer has spread. But for treatment purposes, doctors are often more concerned about whether the cancer can be removed completely with surgery (resected). If, based on where the cancer is and how far it has spread, it could be removed completely by surgery, it is considered potentially resectable. If the cancer has spread too far to be removed completely, it is considered unresectable.

As a general rule, all stage 0, I, and II esophageal cancers are potentially resectable. Most stage III cancers are potentially resectable as well, even when they have spread to nearby lymph nodes, as long as the cancer has not grown into the trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other nearby crucial structures. Unfortunately, many people whose cancer is potentially resectable may not be able to have surgery to remove their cancers because they aren’t healthy enough.

Cancers that have grown into these structures or that have spread to distant lymph nodes or to other organs are considered unresectable, so treatments other than surgery are usually the best option.


Last Medical Review: 03/20/2014
Last Revised: 11/06/2014