Endoscopic Therapy of Esophageal Premalignancy and Early Malignancy

Abstract

Esophageal adenocarcinoma (EAC) is an often deadly cancer with a rising incidence in Western countries. Chronic gastroesophageal reflux disease is associated with the metaplastic transformation of normal squamous epithelium to premalignant specialized intestinal metaplasia within the esophagus (Barrett's esophagus). Barrett's esophagus may progress to low-grade dysplasia (LGD), high-grade dysplasia (HGD), or even EAC. Although nondysplastic Barrett's esophagus progresses to EAC at a rate of 0.5% per year, rates of progression for true LGD and HGD are significantly higher. Treatment is mandatory for HGD and may be appropriate in select patients with nondysplastic Barrett's esophagus and many with LGD. Thus, accurate pathologic assessment is necessary before considering endoscopic therapy. Previously, only esophagectomy was offered to patients with HGD or EAC. However, esophagectomy has significant morbidity and mortality, and therefore endoscopic therapies have been advocated for early Barrett's neoplasia. These methods include endoscopic mucosal resection (EMR) and ablative techniques. Ablation techniques include argon plasma coagulation, multipolar electrocoagulation, laser therapy, photodynamic therapy, radiofrequency ablation, and cryotherapy. Of these, radiofrequency ablation has experienced the greatest adoption for the treatment of dysplastic Barrett's esophagus because of excellent published outcomes. The use of EMR to resect suspicious areas or raised lesions is mandatory to provide histology. In contrast, ablation techniques such as radiofrequency ablation have been shown to effectively eradicate large areas of dysplastic tissue with relative ease but do not allow for histologic assessment of the treated area. Combination EMR with radiofrequency ablation is thus advocated to resect visible lesions via EMR (providing histology) and ablate the remainder of the Barrett's esophagus. As always, the appropriate treatment is best determined after careful discussion with patients in a multidisciplinary environment. However, endoscopic therapy offers an attractive alternative to esophagectomy for early Barrett's neoplasia.

Barrett’s esophagus and esophageal cancer: An overview

“…The strongest evidence for the effectiveness of photodynamic therapy derives from a prospective, randomized study in which, after a five years' follow-up, a significant difference was shown between a group of patients treated with photodynamic therapy plus omeprazole vs. a group treated with omeprazole alone. In this study, the percentage of ablation in high grade dysplasia was 77% vs. 39% (p=0.004), whereas the recurrence of neoplasia was 15% vs. 29% (p=0.027) (75). The occurrence of esophageal stenosis is a relatively frequent adverse event of photodynamic therapy (27-34% of cases), which typically develops within one month (76).…”

“…The introduction of new endoscopic treatments characterized by a lower incidence of complications, including the risk of lymphatic or hematogenous dissemination, has reduced the indications of surgery to patients with high grade dysplasia or early AC (74,75). The endoscopic procedures, either by resection or by ablation of the inner lining of the esophagus, usually result in regenerated squamous epithelium.…”

Diagnosis and Endoscopic Management of Barrett’s Esophagus: an Italian Experts’ Opinion based document

“…The discussion led to the following shared statement [34][35][36][37]: Consensus Statement 10: The Working Group recommends that patients with BE with a diagnosis of HGD/IMC (confirmed by a pathologist) are treated, in the absence of visible lesions, with targeted EMR in the area where the HGD/IMC is suspected based on the mapping biopsy, plus RFA; alternatively only with RFA.…”

Development and Validation of a Gene-panel-based Nomogram for Prediction of Lymph Node Metastasis in Esophageal Squamous Cell Carcinoma

“…Over the decades, esophagectomy with lymph node (LN) dissection has remained the most effective treatment modality for patients with early-stage ESCC (6,7). Adequate lymph nodes harvested, esophagectomy might increase postoperative morbidity and mortality which is probably unsuitable for patients with suspected T1N0M0 disease (8)(9)(10). In recent years, endoscopic resection (ER), however, exhibits great potential in treating small-sized T1 disease, which might be alternative to conventional esophagectomy (11).…”