From the Guidelines
The initial workup for a patient suspected of having esophageal cancer should include a thorough history and physical examination, followed by upper endoscopy with biopsy, which is the gold standard diagnostic procedure, as recommended by the NCCN Guidelines 1. The workup should also include a complete blood count, comprehensive metabolic panel, and nutritional assessment. Imaging studies are essential for staging and include a CT scan of the chest and abdomen with contrast, and possibly a PET-CT scan to evaluate for metastatic disease, as suggested by the NCCN Guidelines 1 and other studies 1. Some key points to consider in the workup include:
- Endoscopic ultrasound (EUS) is recommended to assess the depth of tumor invasion and regional lymph node involvement, as stated in the NCCN Guidelines 1 and other studies 1.
- For patients with dysphagia, a barium swallow may help characterize the location and extent of obstruction, as mentioned in the NCCN Guidelines 1.
- Bronchoscopy should be considered for mid to upper esophageal lesions to rule out airway invasion, as recommended by the NCCN Guidelines 1.
- Patients should also undergo a thorough assessment of their performance status and comorbidities to determine their candidacy for various treatment options, as suggested by the NCCN Guidelines 1 and other studies 1.
- Early referral to a multidisciplinary team including gastroenterology, surgical oncology, medical oncology, radiation oncology, and nutrition is crucial for optimal management, as recommended by the NCCN Guidelines 1 and other studies 1. This comprehensive approach ensures accurate diagnosis, appropriate staging, and development of a personalized treatment plan, ultimately prioritizing morbidity, mortality, and quality of life as the outcome, as emphasized by the NCCN Guidelines 1 and other studies 1.
From the Research
Initial Workup for Esophageal Cancer
The initial workup for a patient suspected of having esophageal cancer involves several diagnostic tests to determine the stage of the disease, patient performance status, and location of the primary cancer.
- Computed tomography (CT) and endoscopy/endoscopic ultrasonography are usually carried out to initially stage patients with esophageal cancer, to determine primary tumor response, and to detect nodal and distant metastases after preoperative therapy 2.
- Positron emission tomography (PET) with [18F]-fluoro-2-deoxy-D-glucose and integrated CT-PET are useful in the initial staging of patients with esophageal cancer and in the prediction of pathologic response, disease-free interval, and overall survival after preoperative therapy 2, 3.
- PET and integrated PET/CT are increasingly being used to initially stage patients who have esophageal and gastric cancers, although PET has a limited role in the evaluation of the primary tumor and in the detection of locoregional nodal metastases 3.
- PET/CT has limited utility in T staging of esophageal cancer and relatively limited utility in detection of dissemination to locoregional lymph nodes, but it allows detection of metastatic disease that may not be identifiable with other methods 4.
Role of PET/CT in Esophageal Cancer Workup
PET/CT scanning is valuable in the neoadjuvant chemotherapy assessment and predicting survival outcomes subsequent to surgery 5.
- FDG PET/CT scanning detects recurrent disease and metastases in follow-up 5.
- However, the use of SUV(max) on pretreatment PET scans as a prognostic tool for patients with esophageal cancer is not supported, especially in those who have received neoadjuvant therapy 6.
- Lymph node status is a more accurate predictor of outcome, and efforts to improve pretreatment staging should focus on this factor 6.