Multimodal endoscopic therapy for multifocal intraepithelial neoplasia and superficial esophageal squamous cell carcinoma

We recently reported a series of six consecutive patients receiving endoscopic therapy for superficial esophageal squamous cell carcinoma (SESCC) [1]. Local endoscopic resection and radiofrequency ablation (RFA) were combined in a multimodal approach. Complete tumor eradication was achieved during follow-up ranging from 10 to 28 months.

Since that report, continuous follow-up examinations including Lugol-based chromoendoscopy have been performed twice annually. It is of interest that in three out of the six treated patients, synchronous SESCCs have been detected after 20, 24, and 30 months. All the neoplastic areas were distant from the previous lesion. There was no local tumor recurrence. Because of unchanged patient preferences, lesions were again treated, successfully, with the previously mentioned multimodal endoscopic approach.

In contrast to Barrett’s esophagus, where metaplastic epithelium is also ablated as it is the basis for neoplasia, we suspect that for squamous epithelium oncogenetic abnormalities persist after ablation (in addition to the patient risk factors). Our experience stands in agreement with published data reporting synchronous SESCC in up to 30 % of patients treated previously by endoscopic resection [2]. In contrast, data on neoplastic Barrett’s esophagus show complete eradication after either endoscopic resection or endoscopic resection followed by RFA in only one of 50 patients after 24 months [3].

In our opinion, RFA-based therapy of SESCC is still an option because further sessions can be successfully performed in patients with recurrent lesions. However, our limited data including patients with longer follow-up intervals demonstrate that the risk of metachronuous lesions is relatively high and close endoscopic follow-up examinations including Lugol staining, at 6-month intervals, appear mandatory.

• References

• 1 Becker V, Bajbouj M, Schmid RM et al. Multimodal endoscopic therapy for multifocal intraepithelial neoplasia and superficial esophageal squamous cell carcinoma – a case series. Endoscopy 2011; 43: 360-364 Epub 2011 Mar 31
• 2 Altorki NK, Lee PC, Liss Y et al. Multifocal neoplasia and nodal metastases in T1 esophageal carcinoma: implications for endoscopic treatment. Ann Surg 2008; 247: 434-439
• 3 van Vilsteren FG, Pouw RE, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773 Epub 2011 Jan 5