After a diagnosis, your oncologist will determine if esophageal cancer has grown outside of its point of origin. If it has, they will find out how far the cancer has spread. The stage of cancer determines the best form of treatment which varies based on whether it has spread. Remember, if esophageal cancer spreads to other areas of the body it will still be treated as esophageal cancer. Spreading to other organs such as the stomach or colon does not mean you have stomach or colon cancer. 

If you were recently diagnosed with esophageal cancer, talk with your GI oncologists about your treatment options.

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Determining the Esophageal Cancer Stage

The American Joint Committee on Cancer (AJCC) TNM system is the staging system most often used for esophageal cancer. In regards to staging, TNM refers to:

  • Tumor size and extent of tumors (T)
  • Lymph node involvement (N)
  • Presence or absence of distant metastasis or spread to other areas of the body (M)

Staging can be done in a few different ways:

  • Clinical stage: If surgery is not the first approach or will be done after another treatment, the clinical stage is determined based on the physical exam, biopsy, and imaging tests. This information is used to recommend a treatment plan. However, it may not be able to describe prognosis as accurately as the pathologic stage as sometimes the cancer has spread further than estimated in the clinical stage.
  • Pathological staging (also known as surgical stage): If surgery is the first line of treatment, oncologists determine the pathological stage by examining tissue removed during surgery. This system is the most commonly used.
  • Postneoadjuvant stage: If radiation therapy or chemotherapy is given before surgery (neoadjuvant therapy), a postneoadjuvant stage will be determined after surgery.

Tumor Grade

In addition to the T, N, and M staging system, each tumor is assigned a grade. The grade indicates how closely the cancer resembles normal tissue when viewed under a microscope.

Tumor grades for esophageal cancer are as follows:

  • GX: The grade is unknown because it cannot be evaluated.
  • Grade 1 (G1): The cancer cells appear more similar to normal esophageal cells and are categorized as well-differentiated or low-grade.
  • Grades 2 (G2): The cells are moderately differentiated, falling between Grade 1 and Grade 3.
  • Grade 3 (G3): The cancer cells look very abnormal and are classified as poorly differentiated or high-grade.

Low-grade cancers tend to grow and spread more slowly than high-grade cancers, which means the prognosis is typically better for low-grade cancers than for high-grade cancers of the same stage.

Esophageal Stage Descriptions

Your cancer can be stage 0, I, II, III, or IV. The lower the number, the less the cancer has spread. A higher number, like stage IV, means a more serious cancer that has spread from where it started. Below are the details of each class for the two main types of esophageal cancer: squamous cell carcinoma and adenocarcinoma.

Esophageal Squamous Cell Carcinoma Stages

Stage 0 Squamous Cell Carcinoma of the Esophagus

Abnormal cells are present but only in the inner layer of the esophageal wall. They have not spread to nearby tissue. This stage is known as high-grade dysplasia, and the grade does not apply.

Stage I Squamous Cell Carcinoma of the Esophagus

The cancer has not spread to lymph nodes or distant parts of the body. This stage is divided into two subgroups:

  • Stage IA - Cancer has spread from the inner layer of cells into the mucosa or thin muscle layer of the esophageal wall. The cancer cells are either grade 1 or the grade is unknown.
  • Stage IB - The cancer has penetrated deeper into the mucosa, thin muscle, or submucosa layers of the esophageal wall. The grade may be GX, G1, or G2.

Stage II Squamous Cell Carcinoma of the Esophagus

The cancer has not spread to distant parts of the body and is divided into two groups:

  • Stage IIA - The cancer has invaded the esophagus thick muscle layer (muscularis propria) or into the esophagus's outer layer (the adventitia) without spreading to nearby lymph nodes. It may be any grade if located in the lower esophagus or grade 1 if located in the upper or middle esophagus.
  • Stage IIB - The cancer is any grade and meets one of the following criteria:
    • It has spread from the inner cell layer to the next three layers of the esophagus and to one or two nearby lymph nodes.
    • It has reached the outer layer of the esophagus but has not spread to local lymph nodes.

Stage III Squamous Cell Carcinoma of the Esophagus

Cancer is present but has not spread to distant parts of the body. It can be any grade and is divided into two groups:

  • Stage IIIA - The cancer is confined to the muscle layer (muscularis propria) of the esophagus and has not spread to more than six nearby lymph nodes.
  • Stage IIIB - One of the following is true:
    • The cancer has grown through the outer layer of the esophagus and spread to no more than six nearby lymph nodes.
    • The cancer has expanded through the muscularis propria and has spread to no more than six lymph nodes.
    • The cancer is invading the tissue that covers the lungs (pleura), the sac around the heart (pericardium), or the diaphragm, possibly affecting no more than two nearby lymph nodes.

Stage IV Squamous Cell Carcinoma of the Esophagus

The cancer has spread to distant parts of the body and is divided into two subgroups:

  • Stage IVA - The cancer has spread to any layer of the esophagus. It has affected seven or more nearby lymph nodes, or it has reached the pleura, pericardium, or diaphragm while affecting no more than six lymph nodes, or it has spread to vital structures such as the trachea, aorta, spine, or other key organs without involving more than six surrounding lymph nodes.
  • Stage IVB - The cancer has spread to other parts of the body, such as distant lymph nodes, liver, or lungs. It can be any grade.

Esophageal Adenocarcinoma Stages

Stage 0 Adenocarcinoma of the Esophagus

Abnormal cells are present but only in the inner layer of the esophageal wall (epithelium). The cells have not spread to nearby tissue, lymph nodes, or distant organs. This stage is known as high-grade dysplasia. The grade does not apply.

Stage I Adenocarcinoma of the Esophagus

 The cancer has not spread to lymph nodes or distant parts of the body. This stage is divided into three groups depending on where the cancer has spread:

  • Stage IA - The cancer has spread from the inner esophageal layer to the next two layers. The grade is GX or G1.
  • Stage IB - The cancer has penetrated deeper into the mucosa, thin muscle, or submucosa layers of the esophageal wall. The grade may be GX, G1, or G2.
  • Stage IC - The cancer has penetrated deeper into the mucosa layer, thin muscle layer, submucosa layer, and possibly into the thick muscle layer of the esophagus wall.  The grade may be GX, G1, G2, or G3.

Stage II Adenocarcinoma of the Esophagus

The cancer has not spread to distant parts of the body. The stage is divided into two groups depending on where the cancer has spread: 

  • Stage IIA - The cancer has spread into the thick muscle layer of the esophageal wall but not to nearby lymph nodes. The grade is GX or G3. 
  • Stage IIB - The cancer is any grade and meets one of the following criteria: 
    • The cancer is growing into the mucosa layer, thin muscle layer, or submucosa layer of the esophageal wall and has spread to 1 or 2 nearby lymph nodes.
    • The cancer is growing into the outer layer of the esophagus (adventitia) but has not spread to nearby lymph nodes.

Stage III Adenocarcinoma of the Esophagus

Cancer has not spread to distant parts of the body, can be any grade, and is divided into two groups: 

  • Stage IIIA - The cancer is growing into the lamina propria, muscularis mucosa (the tissue under the epithelium), submucosa, or the thick muscle layer (muscularis propria). It has spread to no more than six nearby lymph nodes.
  • Stage IIIB - The cancer has spread to: 
    • The thick muscle layer (muscularis propria) and to no more than six nearby lymph nodes.
    • The outer layer of the esophagus (the adventitia) and to no more than six nearby lymph nodes.
    • The pleura (the thin layer of tissue covering the lungs), the pericardium (the thin sac surrounding the heart), or the diaphragm (the muscle below the lungs that separates the chest from the abdomen) and spread to no more than two nearby lymph nodes.

Stage IV Adenocarcinoma of the Esophagus

The cancer can be any grade and is divided into two groups: 

  • Stage IVA - The cancer has not spread to distant organs. Stage IVA cancer has spread to: 
    • The pleura (the thin layer of tissue covering the lungs), the pericardium (the thin sac surrounding the heart), or the diaphragm (the muscle below the lungs that separates the chest from the abdomen) and involves no more than six nearby lymph nodes.
    • The trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures, with no more than six nearby lymph nodes being involved.
    • Any layers of the esophagus and seven or more nearby lymph nodes.
  • Stage IVB - The cancer has spread to distant lymph nodes and/or other organs, such as the liver and lungs.

Resectable Versus Unresectable Esophageal Cancer and How It Impacts Treatment Options

Understanding the stage of your esophageal cancer helps the oncologist determine the most effective treatment plan. Another factor considered is whether the cancer can be completely removed through surgery (resected). Most of the time Stages 0, I, and II are considered potentially resectable. This means there’s a good chance surgery can be performed to remove all of the cancer. Cancer that has spread too far to be fully removed is classified as unresectable. When surgery is not recommended other treatments for metastatic cancer are used.

Learn more about esophageal treatment options.