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Answer 3
  1. Referral for endoscopic ultrasonography. The patient does not have obvious metastatic cancer and may be a candidate for surgery. However, it is too early to determine if surgery would be appropriate because more information regarding the tumor should be obtained. Endoscopic ultrasonography will allow more complete locoregional staging (ie, T and N staging of the tumor, assess for depth of tumor invasion, and determine presence or absence of malignant lymph nodes). Endoscopic ultrasound can also be used to sample suspicious peritumoral lymph nodes via fine-needle aspiration. Patients found to have advanced local disease (deep tumor invasion into or through the esophageal wall) and/or malignant adenopathy are typically referred for neoadjuvant therapy in an effort to decrease tumor burden prior to operative therapy.

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