Tests for Esophageal Cancer

Esophagus cancers are usually found because of signs or symptoms a person is having. If esophagus cancer is suspected, exams, tests, and a biopsy (a sample of esophagus cells) will be needed to confirm the diagnosis. If cancer is found, further tests will be done to help determine the extent (stage) of the cancer.

Medical history and physical exam

If you have symptoms that might be caused by esophageal cancer, the doctor will ask about your medical history to learn about your symptoms and possible risk factors.

Your doctor will also examine you closely to look for possible signs of esophageal cancer and other health problems.

If the results of your history and physical exam suggest you might have esophageal cancer, more tests will be done. These could include imaging tests and/or biopsies of the esophagus.  You may also be referred to a gastroenterologist (a doctor specializing in digestive system diseases) for further tests and treatment.

Imaging tests for esophagus cancer

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests might be done for a number of reasons both before and after a diagnosis of esophageal cancer, including:

  • To look at a suspicious area that might be cancer
  • To learn how far cancer might have spread
  • To help determine if the treatment is working
  • To look for possible signs of cancer coming back after treatment

Barium swallow test

If you're having trouble swallowing, sometimes a barium swallow is the first test done. In this test, you will be asked to swallow a thick, chalky liquid called barium to coat the walls of the esophagus. When x-rays are taken, the barium outlines the esophagus. This test can be done by itself, or as a part of a series of x-rays called an upper gastrointestinal (GI) series, that includes the stomach and part of the intestine

A barium swallow test can show any abnormal areas in the normally smooth inner lining of the esophagus, but it can't be used to determine how far a cancer may have spread outside of the esophagus.

This test can show even small, early cancers. Early cancers can look like small round bumps or flat, raised areas (called plaques), while advanced cancers look like large irregular areas and can cause narrowing of the inside of the esophagus.

This test can also be used to diagnose one of the more serious complications of esophageal cancer called a tracheo-esophageal fistula. This occurs when the tumor destroys the tissue between the esophagus and the trachea (windpipe) and creates a hole connecting them. Anything that is swallowed can then pass from the esophagus into the windpipe and lungs. This can lead to frequent coughing, gagging, or even pneumonia. This problem can be helped with surgery or an endoscopy procedure.

Computed tomography (CT) scan

CT scan uses x-rays to make detailed cross-sectional images of your body. Instead of taking 1 or 2 pictures, like a regular x-ray, a CT scanner takes many pictures and a computer then combines them to show a slice of the part of your body being studied. 

This test can help tell if esophageal cancer has spread to nearby organs and lymph nodes (bean-sized collections of immune cells to which cancers often spread first) or to distant parts of the body.

Before the test, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the esophagus and intestines. If you are having any trouble swallowing, you need to tell your doctor before the scan.

CT-guided needle biopsy: If a suspected area of cancer is deep within your body, a CT scan might be used to guide a biopsy needle into this area to get a tissue sample to check for cancer.

Magnetic resonance imaging (MRI) scan

Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. MRI can also be used to look for possible cancer spread to the brain and spinal cord.

Positron emission tomography (PET) scan

For a PET scan, a slightly radioactive form of sugar (known as FDG) is injected into the blood and collects mainly in cancer cells. These areas of radioactivity can be seen on a PET scan using a special camera.

PET/CT scan: Sometimes a PET scan is combined with a CT scan using a special machine that can do both at the same time. This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed picture of that area on the CT scan.

PET/CT scans can be useful:

  • In diagnosing esophageal cancer. 
  • If your doctor thinks the cancer might have spread but doesn’t know where. They can show spread of cancer to the liver, bones, or some other organs. They are not as useful for looking at the brain or spinal cord.

Endoscopy

An endoscope is a flexible, narrow tube with a tiny video camera and light on the end that is used to look inside the body. Tests that use endoscopes can help diagnose esophageal cancer or determine the extent of its spread.

Upper endoscopy

This is an important test for diagnosing esophageal cancer. During an upper endoscopy, you are sedated (made sleepy) and then the doctor passes an endoscope( a thin, flexible tube with a light and a small video camera on the end) down your throat and into the esophagus and stomach. The endoscope's camera is connected to a monitor, which lets the doctor see any abnormal areas in the wall of the esophagus clearly.

The doctor can use special instruments through the scope to remove (biopsy) tissue samples from any abnormal areas. These samples are sent to the lab to check if they contain cancer.

If the esophageal cancer is blocking the opening (called the lumen) of the esophagus, certain instruments can be used to help enlarge the opening to help food and liquid pass.

Upper endoscopy can give the doctor important information about the size and spread of the tumor, which can be used to help determine if the tumor can be removed with surgery.

Endoscopic ultrasound

This test is usually done at the same time as the upper endoscopy. For an endoscopic ultrasound, a probe that gives off sound waves is at the end of an endoscope. This allows the probe to get very close to tumors in the esophagus. This test is very useful in determining the size of an esophageal cancer and how far it has grown into nearby areas. It can also help show if nearby lymph nodes might be affected by the cancer. If enlarged lymph nodes are seen on the ultrasound, the doctor can pass a thin, hollow needle through the endoscope to get biopsy samples of them. This helps the doctor decide if the tumor can be removed with surgery.

Bronchoscopy

This exam may be done for cancer in the upper part of the esophagus to see if it has spread to the trachea (windpipe) or the bronchi (tubes leading from the windpipe into the lungs).

Thoracoscopy and laparoscopy

These exams let the doctor see lymph nodes and other organs near the esophagus inside the chest (by thoracoscopy) or the abdomen (by laparoscopy) through a hollow lighted tube and can be used to get biopsy samples.

These procedures are done in an operating room while you are under general anesthesia (in a deep sleep). A small incision (cut) is made in the side of the chest wall (for thoracoscopy) or the abdomen (for laparoscopy). Sometimes more than one cut is made. The doctor then inserts a scope (a thin, lighted tube with a small video camera on the end) through the incision to view the space around the esophagus. The surgeon can pass thin tools into the space to remove lymph nodes and biopsy samples to see if the cancer has spread. This information is often important in deciding whether a person is likely to benefit from surgery.

Lab tests of biopsy samples

Usually if a suspected esophageal cancer is found on endoscopy or an imaging test, it is biopsied. In a biopsy, the doctor removes a small piece of tissue with a cutting instrument passed through the scope.

HER2 testing: If esophageal cancer is found but is too advanced for surgery, your biopsy samples may be tested for the HER2 gene or protein. Some people with esophageal cancer make too much of the HER2 protein or gene which helps the cells grow. A drug called trastuzumab (Herceptin) that targets the HER2 protein may help treat these advanced cancers when used along with chemotherapy. Only cancers that have too much of the HER2 gene or protein are likely to benefit from this drug, which is why doctors may test tumor samples for it. (See Targeted Therapy for Esophageal Cancer.)

PD-L1 testing: An esophageal cancer that cannot be treated with surgery or has spread to distant sites may be tested to see if it makes a checkpoint protein called PD-L1. This protein is found in 35% to 45% of esophageal cancers. Tumors that make this protein might be treated with the immunotherapy drug pembrolizumab.  

MMR and MSI testing: Esophageal cancer cells might be tested to see if they show high levels of gene changes called microsatellite instability (MSI), or if they have changes in any of the mismatch repair (MMR) genes (MLH1, MSH2, MSH6, and PMS2).

Esophageal cancers that test positive for MMR or high MSI and cannot be treated with surgery, have come back after initial treatment, or have spread to other parts of the body might benefit from immunotherapy with the drug pembrolizumab.

See Testing Biopsy and Cytology Specimens for Cancer to learn more about the types of biopsies, how the tissue is used in the lab to diagnose cancer, and what the results may show.

Blood tests

Your doctor might order certain blood tests if they think you have esophageal cancer.

Complete blood count (CBC): This test measures the different types of cells in your blood. It can show if you have anemia (too few red blood cells). Some people with esophageal cancer have low red blood cell counts because the tumor has been bleeding.

Liver enzymes: You may also have a blood test to check your liver function, because esophageal cancer can spread to the liver.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

De Mello RA, Castelo-Branco L, Castelo-Branco P, et al.   What Will We Expect From Novel Therapies to Esophageal and Gastric Malignancies? In: Dizon DS, Pennell N, Rugo HS, eds. Am Soc Clin Oncol Educ Book. 2018: 249-261. 

Ku GY and Ilson DH. Chapter 71 – Cancer of the Esophagus. In: Niederhuber JE, Armitage JO, Dorshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 6th ed. Philadelphia, Pa. Elsevier: 2020.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Esophageal and Esophagogastric Junction Cancers. V.4.2019. Accessed at www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf on Jan 23, 2020.

Posner MC, Goodman KA, and Ilson DH. Ch 52 - Cancer of the Esophagus. In: DeVita VT, Hellman S, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott-Williams & Wilkins; 2019. 

References

De Mello RA, Castelo-Branco L, Castelo-Branco P, et al.   What Will We Expect From Novel Therapies to Esophageal and Gastric Malignancies? In: Dizon DS, Pennell N, Rugo HS, eds. Am Soc Clin Oncol Educ Book. 2018: 249-261. 

Ku GY and Ilson DH. Chapter 71 – Cancer of the Esophagus. In: Niederhuber JE, Armitage JO, Dorshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 6th ed. Philadelphia, Pa. Elsevier: 2020.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Esophageal and Esophagogastric Junction Cancers. V.4.2019. Accessed at www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf on Jan 23, 2020.

Posner MC, Goodman KA, and Ilson DH. Ch 52 - Cancer of the Esophagus. In: DeVita VT, Hellman S, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott-Williams & Wilkins; 2019. 

Last Revised: March 20, 2020

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