Endoscopic resection is the criterion standard of treatment for patients with early squamous cell neoplasia of the esophagus
2012; Elsevier BV; Volume: 76; Issue: 2 Linguagem: Inglês
10.1016/j.gie.2012.02.007
ISSN1097-6779
AutoresYuichi Shimizu, Masakazu Takahashi, Takeshi Yoshida, Shoko Ono, Katsuhiro Mabe, Mototsugu Kato, Masahiro Asaka,
Tópico(s)Gastric Cancer Management and Outcomes
ResumoWe have read with great interest the article by Bergman et al1Bergman J.J. Zhang Y.M. Wang G.Q. et al.Outcomes from a prospective trial of endoscopic radiofrequency ablation of early squamous cell neoplasia of the esophagus.Gastrointest Endosc. 2011; 74: 1181-1190Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar on the utility of endoscopic radiofrequency ablation (RFA) for the treatment for early squamous cell neoplasia of the esophagus (ESCN). They performed RFA for 29 patients with early ESCN and reported that RFA was associated with a high rate of histologic complete response (97% of the patients).We consider that the biggest problem of RFA is that no histopathologic diagnosis of the whole lesion, especially for high-grade intraepithelial neoplasia (HGIN) and squamous cell carcinoma (SCC), can be obtained. The authors stated that patients with findings of T1m3 were excluded from the study. However, diagnosis whether the lesion is T1m2 or T1m3 is quite difficult, even for flat lesions (Figure 1, Figure 2) . Diagnosis of the depth of invasion by biopsy specimen is inaccurate.Figure 2Endoscopic image with Lugol stain showing a demarcated flat lesion unstained by Lugol in the same area as that shown in Figure 1.View Large Image Figure ViewerDownload Hi-res image Download (PPT)We previously reported histologic results of endoscopic resection for esophageal lesions diagnosed as HGIN by endoscopic biopsy.2Shimizu Y. Kato M. Asaka M. et al.Histologic results of EMR for esophageal lesions diagnosed as high-grade intraepithelial squamous neoplasia by endoscopic biopsy.Gastrointest Endosc. 2006; 63: 16-21Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Fifty-one patients without EUS findings of submucosal tumor invasion were enrolled in that study. Histologic examination of totally resected specimens revealed that 12 (23.5%) of the 51 patients had tumor invasion of T1m2 and that 4 (7.8%) had tumor invasion of T1m3. The invasive focus in all lesions of invasive SCC was surrounded by HGIN (Fig. 3) . Inasmuch as lymph node metastasis occurs in about 10% of patients with T1m3 invasion,3Kodama M. Kakegawa T. Treatment of superficial cancer of the esophagus: a summary of the responses to a questionnaire on superficial cancer of the esophagus in Japan.Surgery. 1998; 123: 432-439Abstract Full Text Full Text PDF PubMed Scopus (379) Google Scholar such patients should undergo additional treatment such as chemoradiotherapy or close long-term follow-up to facilitate early detection of lymph node metastasis.4Shimizu Y. Kato M. Asaka M. et al.EMR combined with chemoradiotherapy: a novel treatment for superficial esophageal squamous-cell carcinoma.Gastrointest Endosc. 2004; 59: 199-204Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar We are afraid that a lesion with T1m3 invasion may be overlooked by complete destruction with RFA.Figure 3Photomicrograph of resected specimen showing squamous cell carcinoma invading the muscularis mucosae. The invasive focus is surrounded by high-grade intraepithelial squamous neoplasia (H&E, orig. mag. ×100).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Certainly, ESD is a more difficult technique than endoscopic RFA. However, owing to progress in the development of devices and the establishment of training systems,5Tsuji Y. Ohata K. Koike K. et al.An effective training system for endoscopic submucosal dissection of gastric neoplasm.Endoscopy. 2011; 43: 1033-1038Crossref PubMed Scopus (46) Google Scholar ESD is no longer a special technique in Japan. We consider that endoscopists must make great efforts for not only local complete remission but also accurate histopathologic assessment.The authors of Bergman et al were given the opportunity to reply but did not. We have read with great interest the article by Bergman et al1Bergman J.J. Zhang Y.M. Wang G.Q. et al.Outcomes from a prospective trial of endoscopic radiofrequency ablation of early squamous cell neoplasia of the esophagus.Gastrointest Endosc. 2011; 74: 1181-1190Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar on the utility of endoscopic radiofrequency ablation (RFA) for the treatment for early squamous cell neoplasia of the esophagus (ESCN). They performed RFA for 29 patients with early ESCN and reported that RFA was associated with a high rate of histologic complete response (97% of the patients). We consider that the biggest problem of RFA is that no histopathologic diagnosis of the whole lesion, especially for high-grade intraepithelial neoplasia (HGIN) and squamous cell carcinoma (SCC), can be obtained. The authors stated that patients with findings of T1m3 were excluded from the study. However, diagnosis whether the lesion is T1m2 or T1m3 is quite difficult, even for flat lesions (Figure 1, Figure 2) . Diagnosis of the depth of invasion by biopsy specimen is inaccurate. We previously reported histologic results of endoscopic resection for esophageal lesions diagnosed as HGIN by endoscopic biopsy.2Shimizu Y. Kato M. Asaka M. et al.Histologic results of EMR for esophageal lesions diagnosed as high-grade intraepithelial squamous neoplasia by endoscopic biopsy.Gastrointest Endosc. 2006; 63: 16-21Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Fifty-one patients without EUS findings of submucosal tumor invasion were enrolled in that study. Histologic examination of totally resected specimens revealed that 12 (23.5%) of the 51 patients had tumor invasion of T1m2 and that 4 (7.8%) had tumor invasion of T1m3. The invasive focus in all lesions of invasive SCC was surrounded by HGIN (Fig. 3) . Inasmuch as lymph node metastasis occurs in about 10% of patients with T1m3 invasion,3Kodama M. Kakegawa T. Treatment of superficial cancer of the esophagus: a summary of the responses to a questionnaire on superficial cancer of the esophagus in Japan.Surgery. 1998; 123: 432-439Abstract Full Text Full Text PDF PubMed Scopus (379) Google Scholar such patients should undergo additional treatment such as chemoradiotherapy or close long-term follow-up to facilitate early detection of lymph node metastasis.4Shimizu Y. Kato M. Asaka M. et al.EMR combined with chemoradiotherapy: a novel treatment for superficial esophageal squamous-cell carcinoma.Gastrointest Endosc. 2004; 59: 199-204Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar We are afraid that a lesion with T1m3 invasion may be overlooked by complete destruction with RFA. Certainly, ESD is a more difficult technique than endoscopic RFA. However, owing to progress in the development of devices and the establishment of training systems,5Tsuji Y. Ohata K. Koike K. et al.An effective training system for endoscopic submucosal dissection of gastric neoplasm.Endoscopy. 2011; 43: 1033-1038Crossref PubMed Scopus (46) Google Scholar ESD is no longer a special technique in Japan. We consider that endoscopists must make great efforts for not only local complete remission but also accurate histopathologic assessment. The authors of Bergman et al were given the opportunity to reply but did not. Outcomes from a prospective trial of endoscopic radiofrequency ablation of early squamous cell neoplasia of the esophagusGastrointestinal EndoscopyVol. 74Issue 6PreviewRadiofrequency ablation (RFA) is safe and effective for eradicating neoplasia in Barrett's esophagus. Full-Text PDF
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