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Cervical Esophageal Cancer

Determining the Stage of the Cancer

The final step before discussing treatment options is a determination of the stage of the cancer. As with all cancers of the head and neck, doctors use the AJCC Cancer Staging Manual (7th Ed) to determine the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

At first, you will be given a clinical stage based on all of the available information.

  • Clinical staging (cTNM) is determined from any information your doctor might have about how extensive the cancer is BEFORE starting any treatment. Stage is determined based on your doctor’s physical exam, imaging studies, laboratory work and biopsies. Classification of clinical stage is described using the lowercase prefix c (e.g., cT, cN, cM).

If there is surgical removal of the cancer as part of your treatment, a pathologist will analyze the tumor and any lymph nodes that may have been removed. You will then be assigned a pathologic stage.

  • Pathologic staging (pTNM) provides more data. Classification of pathology stage is described using the lowercase prefix p (e.g., pT, pN, pM). This may or may not differ from the clinical stage.

There are also a number of other lowercase prefixes that might be used in the staging of your cancer.

  • The subscript y (yTNM) is used to assign a cancer stage after some sort of medical, systemic or radiation treatment is given (Posttherapy or Postneoadjuvant Stage). It is typically combined with either a clinical or pathologic stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new clinical stage is T2N0M0.
  • The subscript r (rTNM) is used when the tumor has recurred after some period of time in which it was gone. This is called Retreatment Classification Stage. Your doctor will use all the available information to assign you a retreatment stage.

T stage: the main tumor mass

31_esophagus_Tstages

Based on a physical examination and review of any imaging, your doctor should be able to give you a T stage that falls within one of the following categories.

Tx The doctor is unable to assess the primary tumor.
T0 The doctor is unable to find the primary tumor.
Tis(HGD) High grade dysplasia (HGD) is abnormal cells that have not invaded deeper cell layers. This term has replaced the term carcinoma in situ for columnar mucosa in the GI tract.
T1a The tumor invades into the lamina propria or muscularis mucosae.
T1b The tumor invades the submucosa.
T2 The tumor invades the muscularis propria.
T3 Tumor invades the adventia.
T4a Resectable tumor invading the pleura, pericardium or diaphragm.
T4b Unresectable tumor that invades other structures such as the aorta, spine, trachea, etc.

N stage: spread of cancer to the lymph nodes in the neck

Next, your doctor will use all the available information and assign you an N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 It looks like there are only one or two cancerous nodes in the region.
N2 It looks as though there are between three to six cancerous nodes in the region.
N3 There is spread to seven or more lymph nodes in the region.

M stage: spread of cancer outside the head and neck

Finally, based on an assessment on the entire body, you will be assigned an M stage.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

Your cancer stage

Staging gets a little complicated for esophageal cancer because:

  • The cancer staging system is different for squamous cell carcinomas and adenocarcinomas.
  • The cancer staging system takes into account the grade of the tumor.
  • For squamous cell cancers of the esophagus, the cancer staging system takes into account the location of the tumor.

For squamous cell carcinomas:

Stage T N M Grade Tumor Location
0 Tis (HGD) N0 M0 1, X Any
IA T1 N0 M0 1, X Any
IB T1 N0 M0 2-3 Any
T2-3 N0 M0 1, X Lower, X
IIA T2-3 N0 M0 1, X Upper, middle
T2-3 N0 M0 2-3 Any
IIB T2-3 N0 M0 Any Any
T1-2 N1 M0 Any Any
IIIA T1-2 N2 M0 Any Any
T3 N1 M0 Any Any
T4a N0 M0 Any Any
IIIB T3 N2 M0 Any Any
IIIC T4a N1-2 M0 Any Any
T4b Any M0 Any Any
Any N3 M0 Any Any
IV Any Any M1 Any Any

For adenocarcinomas (which are very rare in the cervical esophagus):

Stage T N M Grade
0 Tis (HGD) N0 M0 1, X
IA T1 N0 M0 1-2, X
IB T1 N0 M0 3
T2 N0 M0 1-2, X
IIA T2 N0 M0 3
IIB T3 N0 M0 2-3
T1-2 N1 M0 Any
IIIA T1-2 N2 M0 Any
T3 N1 M0 Any
T4a N0 M0 Any
IIIB T3 N2 M0 Any
IIIC T4a N1-2 M0 Any
T4b Any M0 Any
Any N3 M0 Any
IV Any Any M1 Any

Your clinical stage

Once the diagnostic tests are completed, before deciding what type of treatment you are going to undergo, you should be given a clinical stage that will look similar to the example below.

CLINICAL STAGE
Example
Site Esophagus
Subsite Cervical Esophagus
Type Squamous Cell Carcinoma
cT cT3
cN cN1
cM cM0
Grade 1
Location Upper
cStage cIIIA

* The lowercase subscript c indicates that this is a CLINICAL STAGE, the stage assigned based on all information available to your doctor before starting treatment.

After surgery, you should get a pathologic stage of your tumor. It will look almost like the clinical stage you received before starting treatment, but notice the “p” that indicates the stage group is based on an analysis of the entire tumor, with or without lymph nodes, under a microscope by a pathologist. In many cases, the pathologic stage will be the same as the clinical stage, but sometimes it will change.

After surgery, and after the pathologist has evaluated all of the tumor that was removed, you should be given a pathologic stage that looks something like this:

PATHOLOGIC STAGE
Example
Site Esophagus
Subsite Cervical Esophagus
Type Squamous Cell Carcinoma
pT pT3
pN pN1
cM cM0
Grade 1
Location Upper
pStage pIIIA
  • The lowercase subscript p indicates that this is a PATHOLOGIC STAGE, the stage assigned after tumor removal and confirmation of cancer by a pathologist.
  • Note also that the M stage is usually clinical, based on all available data without actually analyzing any tissue.
References

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9 Key C and Meisner ALW. Chapter 3: Cancer of the Esophagus, Stomach, and Small Intestine. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.