Images of Early Cancer: Esophageal Squamous-Cell Carcinoma

Abstract

IntroductionDespite the widespread use of upper gastrointestinal endoscopy, the proportion of superficial esophageal squamous-cell carcinomas (SCCs) detected in Western countries is poor [1]. In a European enquiry, 51 such cases were found among 902 207 upper digestive endoscopy procedures. According to the registry in Burgundy, T1 cancer represents 4 % of the total number of esophageal SCCs, and T1 cancer limited to the mucosa only makes up 0.8 % of cases in France. By contrast, the rate of T1 esophageal SCC is five times higher in Japanese reports. The rates of T1 and T1 mucosal cancer reported by the National Cancer Center in Tokyo are 42 % and 18 %, respectively. These differences between Japan and Western countries may be explained by differences in histological interpretation, but it is likely that Japanese authors are more aware of the diagnosis of superficial cancer and pay more attention to it in general, and especially during endoscopy procedures. The failure of endoscopy to provide an early diagnosis of SCC in Western countries, despite a higher incidence of the condition than in Japan, shows that there is insufficient knowledge in the West of the macroscopic patterns of early carcinoma and that there is a tendency to carry out a cursory examination of the esophagus and to use chromoendoscopy to only a very limited extent.Adequate examination of the esophagus involves slow and complete analysis of the mucosa in order to detect any raised areas and ± more importantly ± any abnormalities in color, as alterations in color can reflect differences in the vascular pattern between tumor tissue and normal tissue. The superficial lesions frequently have an erythroplastic appearance if they are flat, or whitish if they are slightly elevated. The examiner also needs to focus on peristalsis transmission along the esophagus; a fixed area may be explained by the presence of a flat but already invasive carcinoma.Chromoendoscopy with vital staining is carried out between the initial precise examination and the taking of biopsies. In Europe, chromoendoscopy is not a widely used procedure, as it is regarded as being of little interest, difficult to perform, and above all, time-consuming and expensive. It must be emphasized that chromoscopy is mandatory in relation to esophageal squamouscell carcinoma; in certain circumstances, not performing it must be regarded as an error.The first expert approach section published in Endoscopy, in 2001, was concerned with Lugol staining [2]. The cases presented in the picture gallery here illustrate the high sensitivity and specificity of this method for diagnosing SCC. Toluidine blue is also capable of revealing occult dysplasia or unsuspected SCC in conventional esophagoscopy, but the technique required is more difficult and prolonged than Lugol staining, and it has a higher rate of false-negative results. Of all the chromoendoscopy methods available, Lugol staining at least should be recommended in Europe.Which patients should undergo Lugol staining? There are several theoretical g...

Chromoendoscopy to Detect Early Synchronous Second Primary Esophageal Carcinoma in Patients with Squamous Cell Carcinomas of the Head and Neck?

“…Lugol's staining patterns correlate well with the degree of glycogen within squamous epithelium, and dysplastic epithelium can be visualized as LVLs [1, 5, 8, 17, 33]. Chromoendoscopy is inexpensive and can be performed easily by a gastroenterologist; no special tools or light sources are necessary [1].…”

“…Therefore, the identification of early esophageal lesions localized and limited only to the mucosa and submucosa may enhance the cure rate for patients with HNSCC [1, 7–11]. Moreover, these esophageal lesions can potentially be completely removed by endoscopic mucosal resection [7, 8, 10, 12]. …”

Endoscopic characteristics of short‐segment Barrett's esophagus, focusing on squamous islands and mucosal folds

“…Narrow band imaging is a recent optical technique that enhances the diagnostic capability of endoscopic examination by characterizing tissues using narrow‐bandwidth filters in a video system 13,14 . Although chromoendoscopy with iodine solution is the gold standard technique for the diagnosis of squamous cell carcinoma of the esophagus, 25,26 iodine solution can lead to a transient dysphagia related to esophagospasm, and cause nausea, epigastric discomfort, and allergic reactions 27,28 . In the present study, NBI could detect squamous islands in 71 (94.7%) of 75 SSBE cases in which squamous islands were found by iodine chromoendoscopy.…”

Relationships between Micro-Vascular and Iodine-Staining Patterns in the Vicinity of the Tumor Front of Superficial Esophageal Squamous Carcinoma

“…However, it has not been easy to diagnose early-stage ESCC using conventional endoscopy [ 1 ]. Chromoendoscopy using iodine-staining is a very sensitive screening technique, and has markedly improved the rate of early detection of ESCC [ 2 ],[ 3 ]. However, iodine-staining has certain drawbacks: it prolongs the time required for screening, some patients may have iodine allergy, and it can elicit certain side effects such as chest discomfort or coughing[ 2 ],[ 4 ].…”

“…Some groups have reported that image-enhanced magnifying endoscopy is able to detect the border of cancer clearly by visualizing the so-called “brownish area” [ 8 ], and have considered that this is advantageous in comparison with iodine-staining, and its various unfavorable aspects [ 2 ],[ 4 ],[ 9 ]. However, the relationship between changes in micro-vascular morphology and the iodine-unstained area of mucosal cancer has not been investigated.…”