Diagnosis of esophageal cancer

Diagnosis is the process of finding out the cause of a health problem. Diagnosing esophageal cancer usually begins with a visit to your family doctor. Your doctor will ask you about any symptoms you have and may do a physical exam. Based on this information, your doctor may refer you to a specialist or order tests to check for esophageal cancer or other health problems.

The process of diagnosis may seem long and frustrating. It's normal to worry, but try to remember that other health conditions can cause similar symptoms as esophageal cancer. It's important for the healthcare team to rule out other reasons for a health problem before making a diagnosis of esophageal cancer.

The following tests are usually used to rule out or diagnose esophageal cancer. Many of the same tests used to diagnose cancer are used to find out the stage (how far the cancer has progressed). Your doctor may also order other tests to check your general health and to help plan your treatment.

Your health history is a record of your symptoms, risk factors and all the medical events and problems you have had in the past. Your doctor will ask questions about your history of:

• symptoms that suggest esophageal cancer, such as problems swallowing
• gastroesophageal reflux disease (GERD)
• Barrett's esophagus
• smoking and alcohol use
• weight loss

Your doctor may also ask about a family history of:

• esophageal cancer
• risk factors for esophageal cancer
• other cancers

A physical exam allows your doctor to look for any signs of esophageal cancer. During a physical exam, your doctor may:

• check if your voice is hoarse
• feel the lymph nodes above the collarbone and in the neck to check for swelling
• feel the abdomen for enlarged organs or a buildup of fluid in the abdomen (called ascites)
• check the spine for any pain in the bones of the spine

Find out more about physical exam.

An upper (GI) series uses special liquids that coat the inside of organs and shows their outline clearly on an x-ray. During an upper GI series, you swallow the liquid and then a technician takes x-rays of the upper gastrointestinal tract, including the esophagus, stomach and upper small intestine.

An upper GI series is often the first diagnostic test used to check for esophageal cancer. It can show:

• a break in the surface of the esophagus (called ulceration)
• narrowing of the esophagus (called a stricture)
• the location and general size of a tumour in the esophagus
• an abnormal opening from the esophagus into the trachea (called tracheoesophageal fistula)
• how well you can swallow
• if the cancer has spread to the stomach

Find out more about upper GI series.

An upper GI endoscopy is done to examine the upper gastrointestinal tract, including the esophagus, stomach and the first part of the small intestine (called the duodenum). It uses an endoscope, which is a flexible tube with a light and lens on the end. The doctor passes the endoscope through your mouth and down your throat into the esophagus. Before the procedure, a local anesthetic is sprayed onto the back of your throat to numb it. You may be given intravenous (IV) medication as well to help you stay relaxed and calm during the test.

An upper GI endoscopy is done to:

• check the esophagus, stomach and duodenum for bleeding, ulcers, tumours, inflammation or narrowing
• take samples of tissue to be tested in the lab (biopsy)
• widen, or dilate, the esophagus if there is narrowing
• put a narrow tube called a stent in the esophagus if it is blocked with a tumour

Find out more about endoscopies.

Ultrasound uses high-frequency sound waves to make images of structures in the body. EUS uses an endoscope with an ultrasound probe. It can provide detailed information about the location, size and depth of the tumour. It can also show doctors if the cancer has spread to surrounding lymph nodes or tissues.

EUS is often done at the same time as an upper GI endoscopy.

Find out more about ultrasounds.

During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab. The report from the lab will confirm whether or not cancer cells are present in the sample.

An endoscopic biopsy removes tissue from the esophagus through an endoscope during an upper GI endoscopy or endoscopic ultrasound (EUS).

A fine needle aspiration (FNA) biopsy may be done through the wall of the esophagus to check for cancer in surrounding lymph nodes.

A brush biopsy uses a needle or brush is to remove cells from an abnormal-looking or suspicious area.

Find out more about biopsies.

A computed tomography (CT) scan uses special x-ray equipment to make 3D and cross-sectional images of organs, tissues, bones and blood vessels inside the body. A computer turns the images into detailed pictures.

A CT scan is used to look at the chest and abdomen to find out the size and location to help stage an esophageal tumour. It is also used to look for cancer that has spread to the nearby lymph nodes, liver, lungs or adrenal glands. CT scan may also be used to guide a biopsy needle to remove tissue samples from abnormal or suspicious lymph nodes.

A CT scan is better at staging advanced esophageal cancer than finding small, early stage esophageal tumours.

Find out more about CT scans.

A positron emission tomography (PET) scan uses radioactive materials called radiopharmaceuticals to look for changes in the metabolic activity of body tissues. A computer analyzes the radioactive patterns and makes 3D colour images of the area being scanned.

A PET scan is used to look for very small tumours in the chest or abdomen that may have spread from an esophageal cancer. It is also used to see how well an esophageal cancer responds to chemotherapy or radiation therapy.

A PET scan can be combined with a CT scan (called PET/CT). Newer machines can do a PET and CT scan at the same time. PET/CT provides more detailed information about structures in the body that are sometimes hard to see with PET alone.

Find out more about PET scans.

A laparoscopy is a procedure that uses an endoscope (a thin, tube-like instrument with a light and lens) to examine or treat organs inside the abdomen and pelvis. It allows doctors to examine and remove internal organs through several small incisions, or cuts. Doctors may also take biopsy samples during a laparoscopy (called laparoscopic biopsy).

A laparoscopy is used to accurately stage esophageal cancer so doctors can plan treatment. It may find cancer that has spread to other parts of the abdomen that wasn't seen on a PET or CT scan.

A CBC measures the number and quality of white blood cells, red blood cells and platelets. A CBC is done to check for anemia from long-term, or chronic, bleeding. A CBC may also be done to set a baseline to compare with blood tests done during and after treatment to check the effects of therapies that can lower blood cell counts.

Find out more about a complete blood count (CBC).

Blood chemistry tests measure certain chemicals in the blood. They show how well certain organs are functioning and can help find abnormalities.

Liver function tests may be done to stage esophageal cancer. These tests measure lactic dehydrogenase (LDH), alanine aminotransferase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP) and bilirubin to check how well the liver is working. Higher levels of these enzymes may mean the cancer has spread to the liver. Higher levels of ALP may also mean the cancer has spread to the bone.

Find out more about blood chemistry tests.

ERBB2 is more commonly known as HER2 (or HER2/neu). HER2 stands for human epidermal growth factor receptor 2. It is a gene that has changed (mutated) so it helps a tumour grow (called an oncogene). Testing is done on cells to find out if they are making more HER2 protein than normal (called overexpression).

HER2 status testing is done on esophageal tumours found where the esophagus and stomach join (called the gastroesophageal, or GE, junction). This information will help your healthcare team decide which treatments will work best for you.

Find out more about HER2 status testing.

To make the decisions that are right for you, ask your healthcare team questions to ask about diagnosis.