Endoscopic Management of Early Adenocarcinoma and Squamous Cell Carcinoma of the Esophagus: Screening, Diagnosis, and Therapy

Abstract

Because the esophagus is easily accessible with endoscopy, early diagnosis and curative treatment of esophageal cancer is possible. However, diagnosis is often delayed because symptoms are not specific during early stages of tumor development. The onset of dysphagia is associated with advanced disease, which has a survival at 5 years lower than 15%. Population screening by endoscopy is not cost-effective, but a number of alternative imaging and cell analysis technologies are under investigation. The ideal screening test should be inexpensive, well tolerated, and applicable to primary care. Over the past 10 years, significant progress has been made in endoscopic diagnosis and treatment of dysplasia (squamous and Barrett's), and early esophageal cancer using resection and ablation technologies supported by evidence from randomized controlled trials. We review the state-of-the-art technologies for early diagnosis and minimally invasive treatment, which together could reduce the burden of disease.

Keywords: Barrett’s Esophagus; Endoscopy; Esophageal Cancer; Screening.

Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. Advanced imaging techniques available in clinical practice to enhance detection of early esophageal neoplasia.

A-B. Examples of loss of acetowhitening after topic application of 2.5% acetic acid (AA). C-D. Magnification endoscopy in combination with AA allows identification of irregular mucosal pit for lesion delineation (area in C represents magnified view from B). E. Example of early flat esophageal squamous cell carcinoma (ESCC) difficult to delineate on WLE. F. Same case as E after topic application of 2.5% iodine (Lugol), which demonstrates voiding area and precisely delineates the lesion. G. Early ESCC appears on NBI as brownish discolouration of the mucosa. H. Same case as in G, where NBI magnification demonstrates Type V1 or B1 IPCLs in keeping with mucosal cancer. I. Example of flat early esophageal adenocarcinoma (EA) difficult to delineate on WLE. J. Same case as in I, where AFI demonstrate a clear positive area at the 3o’clock position extending for 25% of the circumference. K. Example of early EA well delineated by non-magnified NBI. L. Same case as in K; magnification NBI allows interrogation of mucosal pit and superficial vasculature to define the demarcation line (arrows). M. pCLE view of non-dysplastic Barrett’s esophagus (BE) with regular cells, regular glandular margins (arrows) and clearly visible goblet cells (arrowheads). N. Example of HGD on pCLE analysis with irregular glands (arrows), pleomorphic cells (arrowheads) and loss of goblet cells. O-P. Example of AFI directed pCLE on inconspicuous BE. pCLE shows irregular cells (arrowheads) and glands (arrows), suspicious for dysplasia. Histology confirmed low-grade dysplasia.

Figure 2. Endoscopic techniques for eradication of oesophageal early neoplasia.

A Band endoscopic mucosal resection (EMR) involves suction and ligation (banding) of a target lesion, with or without prior submucosal injection, followed resection using snare polypectomy technique. Endoscopic photo shows the endoscopic view of the submucosa through the banding device after complete resection of well-differentiated adenocarcinoma. B. Argon plasma coagulation (APC) involves conduction of heat energy with argon gas to the mucosa (arrow). Endoscopic image shows the APC catheter and white coagulation necrosis of treated BE mucosa (arrow). C. RFA involves the application of a preset amount of heat energy (12 Joules) through electrodes on a circumferential (Halo 360) ablation catheter (arrow) inflated to make contact with the esophageal mucosa. Endoscopic image of post-RFA necrosis. D. Liquid nitrogen spray cryotherapy involves release of liquid nitrogen that expands to gas and freezes large areas of tissue to -196 degrees Celsius. The dosing of liquid nitrogen cryogen has varied from 15-20 seconds of ice, followed by a timed minimum 45 seconds of thaw and repeated for 3 cycles. Endoscopic image of a hemi-circumferential patch of ice on the esophageal mucosa. E. The cryoballoon ablation system includes a portable hand-held reusable controller that delivers nitrous oxide gas into a low pressure compliant 30 mm long oval shaped balloon at the end of a disposable balloon catheter passed through the endoscope channel. The balloon at the end of the catheter is inflated and simultaneously cooled by the gas expansion. The cryogen is directed towards a specific location by rotation of the diffuser. Endoscopic image shows the endoscopic view through the cryoballoon with a focal ice patch and thawed treated mucosa with post cryotherapy red color change (arrow).