Early squamous neoplasia of the esophagus: The endoscopic approach to diagnosis and management

Abstract

Considerable focus has been placed on esophageal adenocarcinoma in the last 10 years because of its rising incidence in the West. However, squamous cell cancer (SCC) continues to be the most common type of esophageal cancer in the rest of the world. The detection of esophageal SCC (ESCC) in its early stages can lead to early endoscopic resection and cure. The increased incidence of ESCC in high-risk groups, such as patients with head and neck squamous cancers, highlights the need for screening programs. Lugol's iodine chromoendoscopy remains the gold standard technique in detecting early ESCC, however, safer techniques such as electronic enhancement or virtual chromoendoscopy would be ideal. In addition to early detection, these new "push-button" technological advancements can help characterize early ESCC, thereby further aiding the diagnostic accuracy and facilitating resection. Endoscopic resection (ER) of early ESCC with negligible risk of lymph node metastases has been widely accepted as an effective therapeutic strategy because it offers similar success rates when compared to esophagectomy, but carries lesser morbidity and mortality. Endoscopic submucosal dissection (ESD) is the preferred technique of ER in lesions larger than 15 mm because it provides higher rates of en bloc resections and lower local recurrence rates when compared to endoscopic mucosal resection (EMR).

Figure 1

Early esophageal squamous cell neoplasia seen on standard white light endoscopy

Figure 2

(a) 0-Ia esophageal squamous cell neoplastic lesion is clearly seen on white light endoscopy. (b) The addition of Lugol dye reveals multiple Lugol voiding areas indicating further areas of squamous neoplasia

Figure 3

(a) NBI with DualFocus demonstrating type V2 intrapapillary capillary loop pattern. (b) BLI with zoom demonstrating Type V3 intrapapillary capillary loop pattern