Upper gastrointestinal tumors

Outcomes from a prospective trial of endoscopic radiofrequency ablation of early squamous cell neoplasia of the esophagus (Bergman et al., Gastrointest Endosc 2011 [1])

Nearly half of the worldwide esophageal squamous cell carcinoma (ESCC) cases occur in China [2]. In China, early esophageal squamous cell neoplasia (ESCN) is graded according to the proportion of the epithelial thickness containing neoplasia: 1/3 (low grade intraepithelial neoplasia [LGIN], mild dysplasia), 2/3 (moderate-grade [MGIN], moderate dysplasia), or 3/3 (high-grade [HGIN], severe dysplasia) [3]. The rate of progression to invasive ESCC varies according to the baseline grade of neoplasia: LGIN (5 % incident ESCC within 3.5 years, 24 % incident ESCC within 13.5 years), MGIN (27 % and 50 %, respectively), and HGIN (65 % and 74 %, respectively) [4] [5].

Endoscopic radiofrequency ablation (RFA) has been shown to be safe and effective for eradicating early neoplasia in Barrett’s esophagus [6]. This evidence suggests that RFA may also have utility for eradicating early ESCC. Bergman et al. [1] evaluated the efficacy and safety of this ablation technique in early ESCC at the Cancer Institute and Hospital of the Chinese Academy of Medical Sciences in Beijing. Patients with flat lesions (type 0-IIb) that were shorter than 12 cm and non-staining with Lugol’s chromoendosocpy, and with a consensus diagnosis of MGIN, HGIN, or ESCC by two expert gastrointestinal pathologists, were included. A total of 29 patients (14 male; mean age 60.3 years) with non-staining lesions confirmed as MGIN (n = 18), HGIN (n = 10) or ESCC (n = 1) were treated with circumferential RFA, creating a continuous treatment area that included all lesions. The mean length of the non-staining lesions was 6.2 cm with a continuous treatment area of 8.2 cm. At 3 months after one RFA session, 25 /29 patients (86 %) showed a complete response, defined as absence of MGIN, HGIN or ESCC; at 12 months 28/29 patients (97 %) showed a complete response. Four strictures developed following RFA, which were all dilated successfully.

Compared with alternative treatment modalities, including endoscopic resection, endoscopic submucosal dissection (ESD), and even esophagectomy, RFA is easy to employ with an acceptable adverse event profile. Moreover, ESD for extensive lesions, as were treated in this study, is technically demanding and is associated with high local recurrence and stricture rates. Although further dosimetry work is needed, it was suggested that squamous epithelium was more sensitive to RFA than Barrett’s epithelium.

The preliminary data from this study are important, especially for populations with a high incidence of ESCC. Nonetheless, for RFA of early ESCN to be effective, an endoscopic screening program in high risk areas is needed. The high costs of such a program, combined with the relatively high costs of the currently available RFA system, will for now hinder large scale introduction. Cheaper screening systems, such as ingestible esophageal sampling devices (Cytosponge) [7] or disposable transnasal esophagoscopes [8], but also cheaper ablation methods, could bring this closer to realization.

• References

• 1 Bergman JJ, Zhang YM, He S et al. Outcomes from a prospective trial of endoscopic radiofrequency ablation of early squamous cell neoplasia of the esophagus. Gastrointest Endosc 2011; 74: 1181-1190
• 2 Lu XJ, Chen ZF, Guo CL et al. Endoscopic survey of esophageal cancer in a high-risk area of China. World J Gastroenterol 2004; 10: 2931-2935
• 3 Dawsey SM, Lewin KJ, Liu FS et al. Esophageal morphology from Linxian, China. Squamous histologic findings in 754 patients. Cancer 1994; 73: 2027-2037
• 4 Dawsey SM, Lewin KJ, Wang G-Q et al. Squamous esophageal histology and subsequent risk of squamous cell carcinoma of the esophagus. A prospective follow-up study from Linxian, China. Cancer 1994; 74: 1686-1692
• 5 Wang GQ, Abnet CC, Shen Q et al. Histological precursors of oesophageal squamous cell carcinoma: results from a 13 year prospective follow up study in a high risk population. Gut 2005; 54: 187-192
• 6 Shaheen NJ, Sharma P, Overholt BF et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 2009; 360: 2277-2288
• 7 Kadri SR, Lao-Sirieix P, O’Donovan M et al. Acceptability and accuracy of a non-endoscopic screening test for Barrett’s oesophagus in primary care: cohort study. BMJ 2010; 341: c4372
• 8 Chung JW, Park S, Chung MJ et al. A novel disposable, transnasal esophagoscope: a pilot trial of feasibility, safety, and tolerance. Endoscopy 2012; 44: 206-209
• 9 Rupinski M, Zagorowicz E, Regula J et al. Randomized comparison of three palliative regimens including brachytherapy, photodynamic therapy, and APC in patients with malignant dysphagia (CONSORT 1a) (Revised II). Am J Gastroenterol 2011; 106: 1612-1620
• 10 de Wijkerslooth LR, Vleggaar FP, Siersema PD. Endoscopic management of difficult or recurrent esophageal strictures. Am J Gastroenterol 2011; 106: 2080-2089
• 11 Hirdes MM, Vleggaar FP, Siersema PD. Stent placement for esophageal strictures: an update. Expert Rev Med Devices 2011; 8: 733-755
• 12 Siersema PD, Vleggaar FP. Esophageal strictures, tumors and fistulae – Alternative techniques for palliating primary esophageal cancer. Tech Gastrointest Endosc 2011; 12: 203-209
• 13 Homs MYV, Steyerberg EW, Eijkenboom WMH et al. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer, multicenter, randomised trial. Lancet 2004; 364: 1497-1504
• 14 Jeon SR, Cho WY, Jin SY et al. Optical biopsies by confocal endomicroscopy prevent additive endoscopic biopsies before endoscopic submucosal dissection in gastric epithelial neoplasias: a prospective, comparative study. Gastrointest Endosc 2011; 74: 772-780
• 15 Hisao THN. Recent advances in electronic endoscopes: image-enhanced endoscopy. Japan Medical Association Journal 2008; 51: 199-203
• 16 Gotoda T. Endoscopic resection of early gastric cancer. Gastric Cancer 2007; 10: 1-11
• 17 Yokoi CST, Kusano C. Long-term outcome of EMR/ESD for undifferentiated adenocarcinoma of the stomach. Stomach Intestine 2009; 44: 71-81
• 18 Namieno T, Koito K, Higashi T et al. Assessing the suitability of gastric carcinoma for limited resection: histologic differentiation of endoscopic biopsy. World J Surg 1998; 22: 865-868
• 19 Inoue H, Cho JY, Satodate H et al. Development of virtual histology and virtual biopsy using laser-scanning confocal microscopy. Scand J Gastroenterol Suppl 2003; 237: 37-39
• 20 Li WB, Zuo XL, Zuo F et al. Characterization and identification of gastric hyperplastic polyps and adenomas by confocal laser endomicroscopy. Surg Endosc 2010; 24: 517-524
• 21 Cho WY, Kim YJ, Cho JY et al. Hybrid natural orifice transluminal endoscopic surgery: endoscopic full-thickness resection of early gastric cancer and laparoscopic regional lymph node dissection – 14 human cases. Endoscopy 2011; 43: 134-139
• 22 Seto Y, Shimoyama S, Kitayama J et al. Lymph node metastasis and preoperative diagnosis of depth of invasion in early gastric cancer. Gastric Cancer 2001; 4: 34-38
• 23 Mendelsohn RB, Gerdes H, Markowitz AJ et al. Carcinomatosis is not a contraindication to enteral stenting in selected patients with malignant gastric outlet obstruction. Gastrointest Endosc 2011; 73: 1135-1140
• 24 Jeurnink SM, Steyerberg EW, van Hooft JE et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc 2010; 71: 490-499
• 25 Baron TH, Harewood GC. Enteral self-expandable metal stents. Gastrointest Endosc 2003; 58: 421-433
• 26 Jeurnink SM, van Eijck CH, Steyerberg EW et al. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol 2007; 7: 18