Esophageal Cancer Stages

After someone is diagnosed with esophageal cancer, doctors will try to figure out whether it has spread, and if so, how far. This process is called staging. The stage of a cancer describes the extent of the cancer in the body. It helps determine how serious the cancer is and how best to treat it. The stage is one of the most important factors in deciding how to treat the cancer and determining how successful treatment might be.

To determine the cancer’s stage after an esophageal cancer diagnosis, doctors try to answer these questions:

  • How far has the cancer grown into the wall of the esophagus?

  • Has the cancer reached nearby structures?

  • Has the cancer spread to the nearby lymph nodes or to distant organs?

The stage of esopahgeal cancer is based on the results of physical exams, biopsies, and imaging tests (CT or MRI scan, x-rays, PET scan, etc.), which are described in Tests for Esophageal Cancer, as well as the results of surgery.

Understanding your esophageal cancer stage

After looking at your test results, your doctor will tell you the stage of your cancer. The staging system most often used for esophageal cancer is the American Joint Committee on Cancer (AJCC) TNM system. The TNM system is based on 3 key pieces of information:

  • How far the main (primary) tumor (T) has grown into the wall of the esophagus and whether it has grown into nearby areas.

  • If the cancer has spread to nearby (regional) lymph nodes (N). Lymph nodes are small bean-shaped collections of immune system cells to which cancers often spread first.

  • If the cancer has spread (metastasized) to other organs of the body (M).

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once a person’s T, N, and M categories have been determined, usually after surgery, this information is combined in a process called stage grouping to assign an overall stage.

The earliest stage cancers are called stage 0 (carcinoma in situ), and then range from stages I (1) through IV (4). Some of the stages have sub-stages with the letters A, B, and C.

As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means a more advanced cancer. And within a stage, an earlier letter means a lower stage. Cancers with similar stages tend to have a similar outlook and are often treated in much the same way.

The staging system in the table below uses the pathologic stage. It is based on the results of physical exam, biopsy, imaging tests, and the results of surgery. This is likely to be more accurate than clinical staging, which only considers the tests done before surgery.   

Esophageal cancer staging can be complex. If you have any questions about your stage, please ask your doctor to explain it to you in a way you understand.   

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.)

illustration showing the location of the esophagus in the body as well as a detailed cross section showing the layers of the esophagus including the mucosa (epithelium, lamina propria, muscularis mucosa), submucosa, muscularis propria and adventitia

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.

T1a: The cancer is growing into the lamina propria or muscularis mucosa (the tissue under the epithelium).

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).

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 muscle below the lungs that separates the chest from the abdomen).

T4b: The cancer 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:  No description of lymph node involvemnt poosible because of incomplete information.

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

Another factor that can affect your treatment and your outlook is the grade of your cancer. The grade describes how closely the cancer looks like normal tissue when seen under a microscope.

The scale used for grading esophagus cancers is from 1 to 4.

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

Grade 1 (G1: well differentiated) means the cancer cells look more like normal esophagus tissue.

Grade 4 (G4: undifferentiated) means the cancer cells look very abnormal.

Grades 2 and 3 (G2: moderately differentiated and G3: poorly differentiated) fall somewhere in between.

The grade is often simplified as either low grade (G1 or G2) or high grade (G3 or G4).

Low-grade cancers tend to grow and spread more slowly than high-grade cancers. Most of the time, the outlook is better for low-grade cancers than it is for high-grade cancers of the same stage.

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 with surgery. 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 with surgery. 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 important 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 with surgery. 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 important 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 an esophagus 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 located 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 also, 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 important 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 nearby 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.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master’s-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

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Kleinberg L, Kelly R, Yang S, Wang JS, Forastiere AA. Chapter 74 – Cancer of the Esophagus. In: Niederhuber JE, Armitage JO, Dorshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 5th ed. Philadelphia, Pa. Elsevier: 2014.

Posner MC, Minsky B, Ilson DH. Cancer of the esophagus. In: DeVita VT, Hellman S, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott-Williams & Wilkins; 2011:887–923.

Last Medical Review: June 14, 2017 Last Revised: June 14, 2017

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