Lymph node metastases identified with mediastinoscopy in a patient with superficial carcinoma of the esophagus

The new era of staging as a key for an appropriate treatment for esophageal cancer

Fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) have become the gold standard for staging of esophageal cancer by detecting distant metastases, but metastatic lymph nodes are often difficult to diagnose from the size and standardized uptake value (SUV). If we compare the diagnostic performance of endoscopic ultrasonography (EUS), CT, and FDG-PET in staging of esophageal cancer, EUS is the most sensitive method to identify the detection of regional lymph node metastases, whereas CT and FDG-PET are more specific tests. Combination study with CT, EUS and PETCT cannot make a precise diagnosis after neoadjuvant therapy (NAT). A precise staging might be determined by the fine needle aspiration biopsy (FNAB) under EUS and US screening in the neck and the abdomen even after NAT. Indication of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for superficial cancer is sensitive because of difficulty in T1b cancer diagnosis. Detailed examination about vessel invasion and the possibility of residual tumor with dissected specimen will offer an appropriate additional therapy. New strategy like sentinel lymph node (SLN) navigation could supply more information about lymphatic routes and metastatic nodes. SLN navigation with ESD might become a new less invasive strategy for superficial esophageal cancer.