Accurate loco-regional staging is essential in the management of esophageal cancer, guiding decisions regarding surgical resection, neoadjuvant therapy, and endoscopic interventions. Endoscopic ultrasound (EUS) is widely used for evaluating tumor depth (T stage) and regional lymph node involvement (N stage), but reported diagnostic performance varies across studies. This systematic review and meta-analysis aimed to synthesize evidence on the accuracy of EUS for staging esophageal cancer.

A comprehensive literature search was performed in MEDLINE, Embase and Cochrane Library until May 27, 2025. We identified primary studies reporting the diagnostic performance of conventional EUS (linear or radial) for esophageal cancer staging compared with histopathology as the reference standard. We excluded studies using miniprobe or non-conventional EUS techniques, as well as patients who received neoadjuvant radiochemotherapy.  Pooled sensitivity, specificity, PPV, NPV, accuracy, overstaging and understaging for T and N staging were calculated using a bivariate random-effects model. Heterogeneity was assessed with the I² statistic.

Thirteen studies comprising 1,232 patients were included for T-stage evaluation, and seven studies comprising 575 patients for N-stage evaluation. Of three retrospective and nine prospective studies, most used a radial probe (n=11) with only two using a linear probe. All studies included esophageal adenocarcinoma, with nine also looking at squamous cell carcinoma.  Overall accurate T staging rate was 0.79, with over- and understaging rates of 0.10 and 0.08, respectively. EUS demonstrated high sensitivity and specificity for T1 and T3 disease with diagnostic accuracy ranging from 0.90 to 0.93. Both sensitivity and specificity were high for diagnosing early esophageal cancer (T1) at 0.88 [95% CI 0.62-1.00] and 0.86 [95% CI 0.64, 0.99], respectively. Overstaging was most common in T2 disease (0.24). For nodal staging, EUS demonstrated moderate sensitivity (0.80; 95% CI 0.71–0.87) and specificity (0.72; 95% CI 0.62–0.83), with an overall accuracy of 0.76 (95% CI 0.72–0.80), and similar rates of over- and understaging (0.12 and 0.11)

Conventional EUS provides a strong diagnostic performance for T staging in esophageal cancer with high diagnostic accuracy across all T stages, although there is a risk of overstaging of T2 disease. Nodal staging performance remains modest and supports complementary staging, such as fine-needle aspiration/biopsy or other imaging modalities, to improve diagnostic accuracy.