Esophageal Cancer Workup and Staging (NCCN 2024)

Algorithm Steps

1. ▶

   Start

   Biopsy-Proven Esophageal Cancer

   Adenocarcinoma or SCC

   1. ●

      Action

      Staging Workup

      CT, PET-CT, EUS

      • CT C/A with contrast
      • PET-CT (especially SCC)
      • EUS for T/N staging
      1. ●

         Action

         Biomarker Testing

         HER2, PD-L1, MSI

         • HER2 (adenocarcinoma)
         • PD-L1 CPS score
         • MSI/dMMR status
         1. ◆

            Decision

            Clinical Stage

            • Superficial (Tis-T1a)
            • Locoregional (T1b-T4a)
            • Locally advanced (T4b)
            • Metastatic (M1)
            1. ●

               Action

               Superficial

               Tis-T1a, mucosa only

               1. ●

                  Action

                  Endoscopic Therapy

                  EMR/ESD for Tis-T1a

                  • Curative if no LVI, clear margins
                  • Surveillance + Barrett's ablation
                  1. ■

                     End

                     Surveillance & Support

                     EGD q3-6mo x2yr, nutrition, follow-up imaging

               2. ●

                  Action

                  Esophagectomy

                  Ivor Lewis, transhiatal, or McKeown

                  • MIE preferred
                  • R0 resection goal
                  • Appropriate for T1b-T4a post-neoadjuvant
            2. ●

               Action

               Locoregional

               T1b-T4a, resectable

               1. ●

                  Action

                  Neoadjuvant Therapy

                  CROSS chemoRT or FLOT

                  • Carboplatin/paclitaxel + 41.4 Gy
                  • FLOT for GEJ extension
            3. ●

               Action

               Locally Advanced/T4b

               Unresectable or SCC organ preservation

               1. ●

                  Action

                  Definitive ChemoRT

                  50-50.4 Gy concurrent chemo

                  • Organ preservation for SCC
                  • Salvage esophagectomy option
            4. ●

               Action

               Metastatic

               M1 disease

               1. ●

                  Action

                  Systemic Therapy

                  Chemo + immunotherapy

                  • FOLFOX/CAPOX + pembrolizumab
                  • Trastuzumab if HER2+
                  • Palliative stent for dysphagia