In the West, adenocarcinoma of the lower esophagus and gastric cardia has surpassed squamous cell cancer as the predominant cell type, believed to be related to gastroesophageal reflux disease, obesity, and Barrett’s esophagus, which are uncommon in Asian populations. When found, squamous cell cancers tend to locate in the midesophagus; they can be multicentric, and have the propensity for submucosal spread. Both are reasons prompting the use of special stains like Lugol’s iodine to look for unsuspected lesions in the rest of the esophagus. A panendoscopy is also a necessity to examine the tracheobronchial tree for involvement by the esophageal tumor. This is of particular importance for tumors that are located in the upper or midesophagus because of the close proximity to the airway. Tumor involvement of the tracheobronchial tree contraindicates resection. The rest of the upper aerodigestive tract is also screened for synchronous tumors because of the phenomenon of field cancerization.

Accurate staging of esophageal cancer has gained more importance because of stage-directed therapy. The sensitivity and specificity of a conventional CT scan for local tumor infiltration and local-regional lymph node are suboptimal. PET with 18-F-fluoro-deoxy-D-glucose (FDG) is increasingly used, and is of particular use in identifying distant nodal or systemic metastases. Sensitivity, specificity, and accuracy rates for the detection of distant metastases of 88%, 93%, and 91%, respectively, have been reported, but local-regional staging of N1 disease seems much inferior to EUS. On EUS, lymph nodes that are typically identified as harboring metastatic disease usually are larger than 5 mm in size and oval in shape, with an echo-poor pattern and smooth borders. The accuracy of determining T stage ranges between 85% and 90%, while nodal staging accuracy approximates 70% to 90%. When EUS-guided fine-needle aspiration cytology (EUS-FNA) is used, the diagnostic accuracy extends beyond 90%.