Diagnosis and treatment of superficial esophageal cancer

Abstract

Endoscopy allows for the screening, early diagnosis, treatment and follow up of superficial esophageal cancer. Endoscopic submucosal dissection has become the gold standard for the resection of superficial squamous cell neoplasia. Combinations of endoscopic mucosal resection and radiofrequency ablation are the mainstay of the management of Barrett's associated neoplasia. However, protruded, non-lifting or large lesions may be better managed by endoscopic submucosal dissection. Novel ablation tools, such as argon plasma coagulation with submucosal lifting and cryoablation balloons, are being developed for the treatment of residual Barrett's esophagus, since iatrogenic strictures still hamper the development of extensive circumferential resections in the esophagus. Optimal surveillance modalities after endoscopic resection are still to be determined. The assessment of the risk of lymph-node metastases, as well as of the need for additional treatments based on qualitative and quantitative histological criteria, balanced to the patient's condition, requires a dedicated multidisciplinary team decision process. The need for trained endoscopists, expert pathologists and surgeons, and specialized multidisciplinary meetings underlines the role of expert centers in the management of superficial esophageal cancer.

Keywords: Barrett’s esophagus; Superficial esophageal neoplasm; early adenocarcinoma; endoscopic resection; endoscopic submucosal dissection; radiofrequency ablation; squamous cell carcinoma.

Figure 1

Endoscopic submucosal dissection of an early squamous cell carcinoma (T1am2). (A) High-definition white-light endoscopy visualization of a Paris 0-IIb lesion of the mid esophagus. (B) Narrow-band imaging and (C) Lugol coloration showing the limits of the lesion. (D) Narrow-band imaging with magnification showing the type V-2 intrapapillary capillary loops suggesting m², resectable lesion. (E) Circular markings before endoscopic submucosal dissection. (F) Distal incision. (G) Submucosal dissection using the tunnel technique under the lesion. (H) Resection wound after en bloc endoscopic submucosal dissection. (I, J, K) Three-month follow-up endoscopy showing a clean esophageal, Lugol-negative scar, without evidence for recurrence or residual neoplasia

Figure 2

Endoscopic treatment of early Barrett's neoplasia (T1am1). (A) High-definition white-light endoscopy showing a visible abnormality with nodularity and irregular nodularity and irregular pit pattern on a short Barrett's tongue. (B and C) Narrow-band imaging of the lesion in direct and retroflex view. (D) Band ligation of the lesion without submucosal lifting, before (E) placement of the snare below the band, and (F) resection wound after multiband mucosectomy. (G) Radiofrequency ablation using a focal probe to ablate residual Barrett's esophagus, 3 months after endoscopic mucosal resection. (H and I) Follow-up endoscopy 3 months later, showing a normal-appearing neo-Z line under white-light endoscopy (H) and narrow-band imaging (I)