Endoscopic ultrasound (EUS) has been proven to be the most accurate staging modality for esophageal cancer (EsoCa). However, the ability of EUS to predict outcomes or prognosis is unclear.We prospectively followed patients who had EUS for EsoCa staging to determine if EUS can predict survival in EsoCa. Methods: 204 consecutive patients undergoing EUS for EsoCa staging were studied over a 66 month (mo.) period. Survival data was determined in 196 patients. Median survival was calculated for each T-stage and N-stage as determined by EUS. Kaplan Meier survival curves were generated for each stage and Cox regression was used to test for statistically significant differences in survival adjusting for age, sex, and histology (adeno CA vs. squamous cell CA). The differences in survival in T stage and N stage were adjusted for N stage and T stage respectively. Results: The incidence of each T and N stage was Tis (7), T1 (24), T2 (47), T3 (93), T4(28), Tx (5) and N0 (53), N1 (145), Nx (6). Median follow-up after EUS exam was 35.4 mos. ranging from 12 to 66 mos. Median survival in mos. for each stage was Tis (26.7), T1 (21.6), T2 (19.5), T3 (15.6), T4 (6.5) and N0 (25.0), N1 (13.5). Overall there was a significant difference in the ability of EUS determined T stage to predict survival (p=0.001), with patients having higher EUS T stages succumbing sooner. This difference remained significant after adjusting for age, sex, and histology (P=.035). Patients with local disease (Tis, T1, T2) determined by EUS live significantly longer when compared with patients with advanced disease (T3, T4) (HR=2.0, 95%CI 1.34-2.95). Patients with EUS N stage 0 had significantly longer survival than patients with EUS N stage 1 [25.0 mos. vs. 13.5 mos.] (p<0.001, HR=3.9, 95% CI 2.2-6.8), which was unchanged when adjusted for age, sex, and histology (p<0.001). Differences in survival based on T stage adjusted for N stage showed T stage not to be a predictor of survival (p=.417). When differences in survival based on N stage were adjusted for T stage N stage remained a significant predictor of survival (p=.0005). Conclusions: (1) EUS can predict long-term survival in EsoCa based on initial T staging and the presence of lymphadenopathy on pre-treatment EUS. (2) Esophageal cancer patients with advanced disease as determined by EUS will have significantly shorter survival. (3) Patient's age, sex, and histology of the tumor does not significantly alter the ability of EUS T and N stage to predict survival. (4) The presence of lymphadenopathy at EUS is the most important predictor of survival. (5) EUS should be performed in all EsoCa patients to not only stage patients prior to therapy but also as a prognostic tool.