Endoscopic ultrasonography is the best available method for the locoregional staging of esophageal carcinoma. Its main limitations are represented by a) tumor stenosis, b) distinguishing between malignant and benign lymph nodes, and c) distinguishing between mucosal and submucosal cancer. In untreated esophageal carcinoma, three main groups can be distinguished, based on clinical and morphological evaluation (endoscopy, abdominal ultrasound and CT). EUS is not useful when palliative treatment aiming to relieve dysphagia is the only treatment. In tumors with a superficial pattern at endoscopy, EUS is necessary to distinguish T1 from more invasive tumors, but endoscopic treatment (photodynamic therapy, strip biopsy) is indicated only in nonsurgical patients. In the last, and largest, group of tumors with no clear surgical contraindication, EUS is necessary when surgery is not the only treatment considered. EUS staging then improves patient management (surgery alone, surgery with preoperative treatment, or nonsurgical treatment; type of surgery). Moreover, it provides a good evaluation of the prognosis, and allows better follow-up after nonsurgical treatment.