Endoscopic diagnosis and treatment of early esophageal squamous neoplasia

Abstract

Esophageal cancer is one of the leading causes of cancer-related death and is associated with high morbidity and mortality. It carries a poor prognosis as more than half of patients present with advanced and unresectable disease. One contributing factor is the increased risk of lymph node metastases at early stages of disease. As such, it is essential to detect squamous cell neoplasia (SCN) at an early stage. In order to risk stratify lesions, endoscopists must be able to perform image enhanced endoscopy including magnification and Lugol’s chromoendoscopy. The assessment of both the horizontal extent and depth of any lesion is also of utmost importance prior to treatment. Endoscopic mucosal resection and submucosal dissection remain the standard of care with literature supportive their respective use. Radiofrequency ablation and other endoscopic treatments are currently available although should not be considered first line at this time. Our objective is to review the current options for the endoscopic diagnosis and treatment of esophageal SCN.

Accuracy and Pitfalls in the Assessment of Early Gastrointestinal Lesions

“…Intraepithelial carcinoma or lamina propria involvement has a negligible risk for nodal metastasis, whereas tumours involving the muscularis mucosa, superficial or deep submucosa and beyond have a metastatic frequency of 8-54% [19]. The highest risk for nodal metastases is seen in SCC [19].…”

“…In Asia, the most common histological type is SCC, while in Northern Europe and America adenocarcinoma predominates [17,19].…”

“…If the oesophageal carcinoma infiltrates the submucosa, it is classified as T2 class, which includes T2bsm 1, 2 or 3, depending on which segment of the submucosa is infiltrated [17]. Intraepithelial carcinoma or lamina propria involvement has a negligible risk for nodal metastasis, whereas tumours involving the muscularis mucosa, superficial or deep submucosa and beyond have a metastatic frequency of 8-54% [19]. The highest risk for nodal metastases is seen in SCC [19].…”

“…Using classic endoscopy methods, early oesophageal carcinoma can be identified by the appearance of mucosal nodularity, lost vascular patterns, the appearance of subtle white coating, and erythema [19]. Superficial oesophageal neoplasia is most often detected as discrete flat lesions [17].…”

“…During endoscopy, special attention must be paid to the right lateral wall, and to the cervical narrowing of the oesophagus [19]. Due to frequent synchronous lesions, in patients with oesophageal SCC, visualization of the oropharynx and hypopharynx is necessary [19].…”