Esophageal Cancer Diagnosis and Staging

January 6, 2026

This page was reviewed under our medical and editorial policy by Jae Y. Kim, M.D., associate professor, Division of Thoracic Surgery, Department of Surgery, City of Hope^® Cancer Center Duarte

An esophageal cancer diagnosis often starts with a patient visiting the doctor when symptoms are noticed. From there, a series of exams and tests may be performed to look for cancer.

A doctor performs a physical exam, reviews a patient’s medical history and considers individual risk factors. Doctors may order blood tests to look for abnormalities that may point to cancer or other medical conditions. If cancer is a possibility, the health care team will order other tests specifically used to detect esophageal cancer. These tests may also help rule out cancer.

After an esophageal cancer diagnosis, additional tests may be performed to gauge its characteristics. Imaging scans help check whether the cancer may have spread to other parts of the body. This information is needed to determine what type of esophageal cancer a patient has and its stage. The cancer care team will recommend treatment approaches suited for each patient’s cancer and unique needs.

The cancer care team will recommend treatment approaches suited for each patient’s cancer and unique needs.

How Is Esophageal Cancer Detected?

Several tests may be used to detect and diagnose esophageal cancer. Many of these tests also help to inform the stage of the cancer, or how far along it has grown or spread. Some of the tests may also have a later role in seeing if patients are responding to treatment.

Blood Tests

Some blood test results may suggest cancer, though other causes are also possible. Common blood tests ordered to assess a patient for esophageal cancer include the following.

Complete blood count (CBC): A tumor in the esophagus that bleeds may lower the number of red blood cells in a patient’s body. Over time, some patients may develop anemia if their hemoglobin (a part of red blood cells that carries oxygen) gets too low.

Liver function tests (LFTs): Esophageal cancer may spread to the liver. If this happens, liver damage may cause abnormally high levels of liver enzymes in the blood.

Barium Swallow Test

Often, patients with esophageal cancer first learn there is a problem when they start having trouble swallowing. A barium swallow test is used to see if cancer is causing the problem. While a patient drinks a thick, chalky liquid containing barium, a series of X-rays are taken that show its movement through the esophagus. From these images, doctors are able to tell if plaques (early cancers), tumors or fistulas (structural abnormalities) may be present.

Endoscopy

Endoscopy is an essential cancer-detecting tool. A thin, flexible tube (endoscope) with a video camera and light attached is inserted into a patient’s body so internal tissues and structures may be closely examined. Several types of endoscopy tests are used for diagnosing esophageal cancer.

Upper endoscopy: An endoscope is inserted into a patient’s mouth and down the throat. If a doctor sees suspicious-looking cells, they may perform a biopsy and send the tissue for laboratory testing. A local anesthetic spray or mouthwash is used to numb the throat. Intravenous (IV) sedatives may also be given to help the patient relax.

Endoscopic ultrasound: This test may be performed along with upper endoscopy to help determine the stage of cancer. A small ultrasound probe is attached to the endoscope. Ultrasound helps visualize abnormal-looking lymph nodes that may be present in the surrounding tissue. If any are found, the nearby lymph nodes may also be biopsied to look for cancer.

Bronchoscopy: This test checks to see if esophageal cancer has spread to the trachea (windpipe) or lungs. As with an upper endoscopy, patients are typically given a local anesthetic and sedative before the procedure. With bronchoscopy, the endoscope may be inserted through the nose or mouth.

Thoracoscopy: This test may be recommended to gauge the spread of esophageal cancer and determine whether surgery would be beneficial. Thoracoscopy is a surgical procedure performed under general anesthesia. An incision is made in the chest wall to create an opening for an endoscope to enter.

Laparoscopy: This surgical procedure is similar to thoracoscopy, except laparoscopy looks for esophageal cancer that may have spread lower in the abdomen. Therefore, a small abdominal incision is made for the endoscope to enter.

Tests on Biopsy Samples

When a doctor finds suspicious-looking cells or tissues during an endoscopy or surgical procedure, the only way to confirm that the cells are cancerous is to remove some tissue (biopsy) for examination under a microscope.

Sometimes biopsies rule out cancer. Other times, a cancer diagnosis is confirmed. Precancerous cells or conditions like Barrett’s esophagus that increase the risk of cancer may also be detected.

In addition to diagnosing cancer, tests on biopsy samples provide additional information about a cancer that may help determine which treatment options are most appropriate. Possible findings may include the following.

The type of esophageal cancer: Cancers are classified by the type of cell from which they grow. Most esophageal cancers are either adenocarcinoma or squamous cell carcinoma types.

The grade of the cancer (1 to 3): Grading compares the degree of abnormality in a cancer cell to a similar, noncancerous one. A higher grade indicates a tumor that is more likely to spread.

Specific DNA biomarkers (mutations): A patient’s tumor cells may be checked for the presence of DNA biomarkers known to respond to specific cancer treatment regimens. This approach helps identify which treatments a patient’s particular cancer is likely to respond to. Common esophageal cancer biomarkers include proteins and genes, such as HER2, PD-L1, MMR and MSI.

Imaging Scans

Multiple types of imaging scans may be used to detect esophageal cancer.

Computed tomography (CT): CT scans use X-rays to create 3D images to help locate, measure and assess tumors. They are also able to look for abnormalities in lymph nodes and organs that may indicate a cancer has spread. A patient may need to swallow a contrast liquid before the test.

Magnetic resonance imaging (MRI): These scans use strong magnets and radio waves and may help to detect higher stage cancers. It may also be helpful in assessing treatment response and nearby spread.

Positron emissions tomography (PET): This nuclear scan requires injection of a slightly radioactive sugar called fludeoxyglucose (FDG). If cancer is present, FDG will be quickly absorbed by rapidly dividing cancer cells, and these sites will show up as bright spots on the scan.

PET/MRI scan: A detailed combined scan helps detect the spread of cancer to distant sites.

Cancer cells may travel through blood and the lymphatic system, so imaging scans may be used to help look for signs of cancer over a wider area, farther from the initial cancer. In some cases, imaging may also help guide biopsies to locations that are harder to reach.

Esophageal Cancer Staging

Once a diagnosis is made, the staging process measures how large the tumor is and the extent to which the cancer may have spread from the initial site to other parts of the body. Classifying cancers by stage helps the care team develop a personalized treatment plan appropriate for the patient’s cancer. Staging is also used to provide a forecast of how the disease may progress (prognosis).

A system called TNM is used to help with staging cancers, including esophageal cancer. TNM stands for the following characteristics of cancer.

Tumor: The tumor size and location are considered.

Node(s): The number of cancerous lymph nodes detected are counted.

Metastasis: The level of cancer spread to other parts of the body is assessed.

In addition to TNM, information from the pathology report — which describes the type of cancer cells and tumor grade — is factored in to categorize a patient’s cancer using a letter-and-number scale. Grade describes how abnormal the cells look. Higher numbers indicate more advanced cancers.

GX: Grade is unknown.

Grade 1: Cancer cells resemble normal esophagus cells.

Grade 2: Cancer cells fall between Grade 1 and 3 in appearance.

Grade 3: Cancer cells have a very abnormal appearance.

Esophageal cancer is staged differently from other cancers due to multiple staging steps for some patients. For example:

• Clinical staging occurs before surgery and is based on unique factors such as how the tumor looks on imaging.
• Standard pathological staging is based on the tumor characteristics determined from the biopsy before surgery.
• The care team may also perform post-treatment pathologic staging, which is the pathologic stage after patients have received chemotherapy and sometimes radiation therapy.

One reason esophageal cancer may be restaged after treatment is that small differences in the tumor characteristics may occur during treatment, which may impact overall survival. However, the care team can’t predict how any particular patient will respond to initial treatment, so the stage will be determined prior to treatment, and then it may be reassessed afterward.

In many esophageal cancer patients, survival is often based on the T stage after treatment. That’s why it’s important to know the T, N and M stages the care team assigns both before treatment and afterward.

Physicians use a different staging system for adenocarcinoma of the esophagus than they do for squamous cell carcinoma of the esophagus.

Esophageal Adenocarcinoma Stages

Adenocarcinoma of the esophagus goes through clinical and pathological staging processes prior to surgery. This chart breaks down the clinical stages of esophageal adenocarcinoma:

Below are the esophageal adenocarcinoma pathological stages.

Following are the post-treatment pathological stages for both esophageal adenocarcinoma and squamous cell carcinoma:

Squamous Cell Carcinoma of the Esophagus Stages

Squamous cell carcinoma of the esophagus goes through clinical and pathological staging processes before surgery. The chart below outlines the clinical stages of esophageal squamous cell carcinoma:

Below are the squamous cell carcinoma pathological stages.

Talk to the care team for information on the patient’s specific stage before treatment, as well as afterward.