Synopsis
Select CT, PET-CT, endoscopic ultrasound and staging laparoscopy according to the management question, interpret their limits, and avoid redundant or hazardous staging.
- Whole-body CT is the initial anatomical staging survey after histologically confirmed oesophageal, junctional or gastric cancer, but it is not routine before resection merely to distinguish T1a from T1b in suspected early oesophageal adenocarcinoma.
- Offer FDG PET-CT before radical treatment of oesophageal or junctional cancer except T1a; investigate a solitary unexpected focus when it would remove a curative option.
- Use EUS only when local depth or nodal information will guide management; NICE says not to offer it solely to distinguish T2 from T3, and a stenosis must not be forcibly traversed.
Key red flags
A normal staging CT does not exclude small peritoneal gastric metastases, so potentially curable gastric cancer still needs staging laparoscopy.
EUS should be used when local depth or nodal information can alter a radical plan; forcing an echoendoscope through a tight tumour is unsafe and unnecessary.
Non-traversability limits EUS and raises perforation risk, requiring alternative staging.
Reasoning priorities
Establish gross local, regional and distant anatomical stage for an invasive-cancer pathway.
Look for organ invasion, nodes and distant disease. Do not insert CT merely before endoscopic resection of suspected T1N0 oesophageal adenocarcinoma or a gastric lesion already suitable for local resection.
Worked reasoning
A fit 62-year-old has biopsy-proven antral adenocarcinoma; contrast CT suggests cT3N1 disease without liver, lung or visible peritoneal metastasis.
- The specialist MDT confirms that curative treatment remains plausible on CT and offers staging laparoscopy before committing to the perioperative surgical pathway.
- Laparoscopy identifies a 4 mm nodule on the right hemidiaphragm that was not visible on CT; the surgeon biopsies it and obtains peritoneal washings.
- Histology confirms metastatic adenocarcinoma in the nodule, so the MDT cancels the proposed radical gastrectomy pathway and requests tumour biomarkers for systemic-treatment selection.
- Verify that the patient receives the revised stage and plan, that the avoided laparotomy is recorded, and that oncology and dietetic appointments are booked before discharge.