Background: High resolution imaging of the left hepatic lobe can be obtained via EUS, allowing for detection of unsuspected metastatic disease during cancer staging. This is a prospective study to determine the utility of dedicated left hepatic lobe evaluation during routine EUS staging of cancer of the esophagus and cardia. Methods: From 6/02 to 12/03, 98 patients underwent EUS staging for cancer of the esophagus and cardia. All exams were performed by an experienced endosonographer (KM). Dilation over a guide wire was performed if necessary to facilitate EUS staging. Cancers were first staged with the Olympus radial echoendoscope (GF-UM130), followed by examination using the Pentax curvilinear echoendoscope (FG 36 UA) with attention to the left hepatic lobe. A complete exam was defined as passage of both echoendoscopes to the antrum, including left hepatic lobe examination with the curvilinear scope. Results: Thirty two percent (31/98) of patients required dilation (median 14 mm, range 8-15 mm). With dilation, the radial scope and curvilinear scope successfully traversed 86% and 81% of the malignant strictures, respectively. Examination with the curvilinear echoendoscope was not attempted in 4 patients due to intolerance of the procedure. Of the complete examinations (81%), EUS staging results were as follows: Stage I 17%, Stage IIA 14%, Stage IIB 8%, Stage III 25%, Stage IVa 24% (celiac nodes in distal esophageal/cardia cancer) Stage IVb 12% (celiac nodes in mid/upper esophageal cancer or distant metastases in distal esophageal/cardia cancer). Lesions suspicious for left hepatic lobe metastases were found in 7% (5/76) of cases, all of which underwent EUS-guided FNA. All lesions were proven metastases: 4 true positive and 1 false negative cytologic result. There were no complications related to EUS staging. Conclusion: Curvilinear EUS examination of the left hepatic lobe in addition to standard radial EUS examination can be performed safely when staging cancer of the esophagus and cardia. Dedicated left hepatic lobe examination avoids unnecessary surgery in a subset of these patients by detection of unsuspected liver metastases