Diagnosis and Management of Esophageal Cancer

Esophageal cancer ranks 11th worldwide by incidence and 7th by mortality, and the burden falls hardest on Eastern Asia, Eastern and Southern Africa, and South East Asia, where many patients still present only once the disease is locally advanced. Dr. Preeti Vijayakumaran, a surgical oncologist trained at Tata Memorial Hospital, Mumbai, and now practising at Artemis Hospital, Gurugram, walked doctors across Africa through how the disease is picked up, staged and treated, from a single endoscopic resection for the earliest lesions to full multimodality care involving chemotherapy, radiation and esophagectomy for locally advanced disease. This guide introduces a complete series on diagnosing and managing esophageal cancer.

Why Early Detection Is So Difficult

Most patients who eventually reach a full-blown malignancy started with symptoms subtle enough to ignore: mild discomfort while swallowing, or a slight, slowly progressive difficulty that affects solid food well before it ever affects liquids. Left unaddressed, this pattern typically isn't caught until the disease has already reached stage two, three, or in many cases stage four. The genuine early-stage cases that do get picked up are almost always found through screening endoscopy in settings with a stringent screening protocol, rather than through a patient presenting with symptoms on their own.

From Suspicion to Staging

Endoscopy with biopsy remains the essential technique for confirming the diagnosis, identifying both the intraluminal cause of the swallowing difficulty and the exact length of the lesion. Staging then follows a separate track: a whole-body PET-CT, where available, adds metabolic information to the CT's anatomical detail to map the tumour's local extent, its lymph node involvement across the cervical, thoracic and abdominal regions, and any distant metastasis. Endoscopic ultrasound sharpens T- and N-staging further in early disease, though a tight, strictured tumour can make it impossible, in which case axial imaging alone has to carry the staging. Bronchoscopy and laparoscopy are added selectively: bronchoscopy where imaging suggests the tumour may be invading the airway, and laparoscopy for adenocarcinoma near the gastroesophageal junction, to rule out peritoneal spread before committing to a treatment plan.

Staging Decides the Treatment, Not the Other Way Around

Esophageal cancer is staged by the AJCC TNM system, with the esophagus divided into a short cervical segment and a longer thoracic segment running from 20 to 40 cm from the incisors. T-stage tracks how deep the tumour has grown, from the mucosa through the submucosa and muscularis to the adventitia, and finally into adjacent structures. N-stage counts involved lymph nodes, from one or two nodes at N1 up to seven or more at N3, and disease that reaches organs beyond the regional nodes, such as the liver or lung, is classed as metastatic. As the stage advances, five-year survival drops sharply: at stage two it still sits around 30 to 40 percent for both major histological subtypes, with adenocarcinoma doing marginally better than squamous cell carcinoma.

Three Factors That Decide Every Treatment Plan

Three things drive every management decision: the stage of disease, whether the histology is adenocarcinoma or squamous cell carcinoma, and, just as importantly, how fit the patient actually is. Esophageal cancer is a disease of an older population, patients in their fifties, sixties and seventies with multiple comorbidities, which is often the single biggest constraint on what treatment can realistically be offered. Early-stage disease, clinically T1 N0, can sometimes be managed endoscopically alone. Intermediate and advanced disease needs a multimodality plan, individualised to the patient, that typically combines chemotherapy, radiation and surgery in some sequence.

What the Major Trials Have Settled, and What They Haven't

A run of large trials has shaped current practice. The CROSS trial established that neoadjuvant chemoradiation followed by surgery beats surgery alone, for both major histologies. For locally advanced adenocarcinoma, the ESOPEC trial then showed perioperative chemotherapy under the FLOT protocol outperforming the CROSS chemoradiation approach outright, with a median overall survival of 66 months against 37. For locally advanced squamous cell carcinoma, the JCOG trial found that a triple-drug perioperative chemotherapy regimen beat both a two-drug regimen and neoadjuvant chemoradiation. Two questions remain genuinely open: whether neoadjuvant immunotherapy, already established in the adjuvant setting, will improve outcomes when added before surgery, and whether organ preservation is realistic given that even a PET scan and endoscopy cannot yet reliably confirm a complete pathological response.

In This Series

The articles below walk through the early warning signs and how they're distinguished from advanced-stage symptoms, how the diagnostic and staging workup proceeds, how gastroesophageal junction cancer is told apart from lower esophageal cancer, when endoscopic treatment can substitute for surgery in early disease, what the CROSS, FLOT, ESOPEC and JCOG trials mean for locally advanced disease, how esophagectomy and its minimally invasive and robotic variants are performed, where immunotherapy currently fits in, how the disease can be screened for and prevented, and how patients are followed up after treatment.

This article is based on a Jivo Masterclass session conducted by Dr. Preeti Vijayakumaran, Consultant, Surgical Oncology, Artemis Hospital, Gurugram. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording