Endoscopic Resection of Malignancies in the Upper GI Tract: A Clinical Algorithm

Abstract

Background: Malignancies in the upper gastrointestinal tract are amenable to endoscopic resection at an early stage. Achieving a curative resection is the most stringent quality criterion, but post-resection risk assessment and aftercare are also part of a comprehensive quality program.

Summary: Various factors influence the achievement of curative resection. These include endoscopic assessment prior to resection using chromoendoscopy and HD technology. If resectability is possible, it is particularly important to delineate the lateral resection margins as precisely as possible before resection. Furthermore, the correct choice of resection technique depending on the lesion must be taken into account. Endoscopic submucosal dissection is the standard for esophageal squamous cell carcinoma and gastric carcinoma. In Western countries, it is becoming increasingly popular to treat Barrett's neoplasia over 2 cm in size and/or with suspected submucosal infiltration with en bloc resection instead of piece meal resection. After resection, risk assessment based on the histopathological resection determines the patient's individual risk of lymph node metastases, particularly in the case of high-risk lesions. This is categorized according to the current literature.

Key messages: This review presents clinical algorithms for endoscopic resection of esophageal SCC, Barrett's neoplasia, and gastric neoplasia. The algorithms include the pre-resection assessment of the lesion and the resection margins, the adequate resection technique for the respective lesion, as well as the post-resection risk assessment with an evidence-based recommendation for follow-up therapy and surveillance.

Keywords: Barrett’s neoplasia; Endoscopic submucosal dissection; Gastric neoplasia; Risk classification; Surveillance.

Fig. 1.

Clinical algorithm for endoscopic resection of esophageal squamous cell cancer: preparation, resection, risk assessment, and follow-up.

Fig. 2.

a Circumscribed SCC of the esophagus, Paris classification 1 s. Examination and delineation of the resection margins with chromoendoscopy before ESD. Histology revealed pT1a (m³) G2 LV0 R0. b More extensive esophageal SCC, Paris classification II a+c. Determination of the resection margins using chromoendoscopy. Large-area ESD over half the circumference revealed a T1b (sm²) G2 L0V0 carcinoma resected R0. The patient underwent surgery in accordance with the guidelines (esophagectomy and lymphadenectomy).

Fig. 3.

Clinical algorithm for endoscopic resection of Barrett’s neoplasia: preparation, resection, risk assessment, and follow-up.

Fig. 4.

a Discolored area on examination with chromoendoscopy plus acetic staining resulting in a Barrett’s HG-IN lesion. Complete targeted removal using the cap EMR technique. b Barrett’s carcinoma, Paris classification IIa, definition of the resection margins with chromoendoscopy. ESD extending over half of the circumference from the squamous epithelium to the cardia. Final histology: PT1a (m³) G1 L0V0 R0. c Barrett’s carcinoma, Paris classification IIa+c. Wide-area resection with ESD achieved the following histology: PT1b (sm¹) G1L0V0 R0. d Barrett’s carcinoma, Paris classification Is. According to ESD, the histological tumor stage is PT1b (sm³) G1 L0 V0 R0. The patient underwent surgery in accordance with the guidelines.

Fig. 5.

Clinical algorithm for endoscopic resection of gastric neoplasia: preparation, resection, risk assessment, and follow-up.

Fig. 6.

a Three cases of early gastric carcinomas, predominantly Paris classification IIa or IIb, all endoscopically removed R0 with ESD. Histology revealed low risk cancer. b A small prepyloric carcinoma in the antrum: Paris classification IIa with small ulcer. Surrounding biopsies were performed in the preliminary examination for resection planning. The final histology revealed a 0.9-cm PT1a(m²) G1 L0V0 R0-resected low-risk cancer. c Small prepyloric G3 carcinoma, Paris classification IIa without ulcer. Surrounding biopsies were also taken during the preliminary examination for resection planning. The final histology revealed a 3.3-cm G3 T1a (m³) L0V0, R0-resected high-risk cancer. The patient refused a gastrectomy and is undergoing surveillance currently in year 3 without recurrence. d Flat early gastric carcinoma less than 2 cm with irregular bleeding tumor vessels. Histology according to ESD revealed pT1b (sm²) G3, L0 V0 R0. A gastrectomy with lymphadenectomy was performed in accordance with the guidelines. e Gastric adenoma removed with the ESD technique. Histological findings were HG-IN (previously LG-IN on biopsy) and surprisingly a transition to a focal mucosal carcinoma.