Diagnosing Esophageal Cancer

NYU Langone doctors have extensive experience diagnosing esophageal cancer, which develops in the lining of the esophagus, the muscular tube that carries food and liquid from the mouth to the stomach.

There are two main types of esophageal cancer. Squamous cell carcinoma occurs in the flat cells that line the esophagus. Adenocarcinoma develops in gland cells—which secrete and produce fluid—near the junction where the esophagus meets the stomach.

Squamous cell carcinoma generally occurs higher up in the esophagus, whereas adenocarcinoma develops further down in the organ.

Normally, the gland cells in which adenocarcinoma arises are not found in the esophagus. However, when acid from the stomach repeatedly rises, or refluxes, into the esophagus—a condition called gastroesophageal reflux disease, or GERD—these gland cells can develop in the esophagus.

Usually, gland cells are found in the lining of the stomach, where they help protect the stomach lining from acidic digestive contents. The presence of gland cells in the lower esophagus is called Barrett’s esophagus and increases the risk of esophageal cancer.

Other risk factors for esophageal cancer include smoking, heavy alcohol use, and consuming a diet low in fruits, vegetables, and whole grains. Being overweight or obese is another risk factor, as is having human papillomavirus, or HPV, infection.

Achalasia, a disorder in which the muscles in the lower esophagus stop working, causing food to sit in the esophagus for long periods, also raises your risk. Other risk factors include prior surgery or injury to the esophagus from head and neck radiation therapy and some rare genetic conditions.

Symptoms of esophageal cancer include difficulty swallowing, reflux, vomiting blood, dark stool, and weight loss. Some people may not experience any symptoms until esophageal cancer is advanced.

After conducting a physical exam and asking about your medical history and symptoms, NYU Langone doctors may conduct several diagnostic tests.

Barium Swallow Study

A barium swallow study is often performed when a person has symptoms of GERD. It can reveal abnormalities related to swallowing, but also can show abnormal growths or masses.

During this test, you swallow a liquid containing barium, which coats the esophagus and highlights structures involved in the swallowing process on an X-ray of the mouth, neck, and chest.

If the results show abnormalities, further testing—including an upper endoscopy with biopsy—may be necessary.

Upper Endoscopy with Biopsy

To diagnose esophageal cancer, doctors insert an endoscope, a thin, lighted tube with a tiny camera on the end, through the nose or mouth and into the esophagus, stomach, and first part of the small intestine. The procedure requires sedation, which helps you relax and lessens pain.

The endoscope allows physicians to view the lining of the esophagus, as well as the junction where the esophagus meets the stomach. This is where cancers related to Barrett’s esophagus start.

If the results of the endoscopy show abnormalities in the lining of the esophagus, doctors may insert small surgical tools through the endoscope to biopsy the lining. In a biopsy, the doctor removes tissue samples to check for signs of cancer.

The samples are sent to a laboratory. A pathologist, a physician who studies diseases in a laboratory, examines the tissue. He or she can determine whether a person has either squamous cell cancer or adenocarcinoma and how aggressive the cancer is. Lab results are available within a few days.

The pathologist may also test the tissue to see whether esophageal cells have too much of a protein called human epidermal growth factor receptor 2, also called HER2. In healthy cells, HER2 enables the cells to grow and repair themselves. Too much of the protein, however, can cause cells to grow uncontrollably. Some people with HER2-positive cancer may respond well to targeted drug therapy.

Endoscopic Ultrasound

If a biopsy shows that esophageal cancer is present, our doctors may perform an endoscopic ultrasound—a test that uses sound waves to create images of tissues and structures in the body.

An endoscopic ultrasound can determine the size of the tumor, how deeply into the wall of the esophagus it has grown, and whether it has spread to surrounding lymph nodes. Lymph nodes are small glands that trap organisms, such as bacteria and viruses. They are often the first place cancer spreads.

To perform this test, doctors insert an endoscope with an ultrasound probe through the mouth or nose and into the esophagus, near the tumor. Sedation is used to help you relax and feel less pain.

If a physician detects swollen lymph nodes, he or she can perform a biopsy through the endoscope, using a small needle to take a tissue sample to check for signs of cancer. Results generally are available within one or two days.

CT Scan

To find out whether the cancer has spread, our physicians may order a CT scan, which uses X-rays and a computer to create cross-sectional, three-dimensional images of the esophagus.

A CT scan can reveal whether cancer has spread to surrounding organs and tissues. These include the pleura, which is the thin layer of tissue that wraps around the lungs, as well as the pericardium, which is the sac of tissue that contains the heart. Cancer can also spread to the diaphragm, the muscle below the lungs that helps you breathe.

Doctors also check to see whether the cancer has spread to the trachea, also known as the windpipe. It carries air from the nose and mouth to the lungs or to the aorta, the body’s main artery, which carries blood from the heart. The scan also shows whether cancer has spread to any of the abdominal organs, such as the liver.

You may need to drink a liquid contrast agent or receive an injection of a special dye in a vein. These help highlight any abnormalities of the organs and tissue in the CT image.

Information from a CT scan can help our doctors decide whether surgery is an option.

PET/CT Scan

If a CT scan does not provide enough detailed information, doctors may order a PET/CT scan to evaluate whether esophageal cancer has spread and to what extent.

The CT portion of the test provides cross-sectional, three-dimensional images of the body. In the PET scan, a small amount of radioactive glucose is injected into a vein to determine a tumor’s activity level. This material collects in cancer tissue and is detected with a special camera and computer.

This imaging approach may also be used after treatment to tell doctors whether any cancer cells remain.

Bronchoscopy

Sometimes a CT or PET/CT scan does not provide enough information about whether esophageal cancer has spread to the trachea, or windpipe, or larger airways of the lungs. Doctors may then perform a bronchoscopy to see whether cancer has invaded these structures.

During this test, doctors insert a bronchoscope, a thin, lighted tube with a small video camera on the end of it, through the nose or mouth and into the larger airways of the lungs. If doctors find a suspicious growth, they can pass small surgical tools through the scope to take a tissue sample for evaluation under a microscope.

The procedure is performed using sedation.

Thoracoscopy

If other tests do not provide enough information about the potential spread of esophageal cancer to the chest, doctors may perform a thoracoscopy.

During this procedure, which requires general anesthesia, doctors insert a thoracoscope, a thin, lighted tube with a video camera on the end of it, into small incisions in the chest wall. This allows them to view the structures near the esophagus, such as the pleura, the diaphragm, the pericardium, and nearby lymph nodes. Doctors can pass small surgical tools through the scope to perform a biopsy of suspicious tissue.

Thoracoscopy may require a short hospital stay while doctors monitor your recovery and manage any pain.

Laparoscopy

A laparoscopy is similar to a thoracoscopy, except that doctors make small incisions in the abdomen through which they pass a laparoscope, a thin, lighted tube with a camera on it. This allows them to see whether the cancer has spread to the abdomen or liver. This test may be used when a PET/CT scan does not provide enough information about whether cancer has invaded these structures.

Laparoscopy, which requires general anesthesia, is usually an outpatient procedure when it’s performed to help diagnose and determine the spread of esophageal cancer.