Endoscopic Resection and Radiofrequency Ablation for Early Esophageal Neoplasia

Abstract

Background: In the last few decades, endoscopic treatment of early neoplastic lesions in the esophagus has established itself as a valid and less invasive alternative to surgical resection. Endoscopic resection (ER) is the cornerstone of endoscopic therapy. Next to the curative potential of ER, by removing neoplastic lesions, ER may also serve as a diagnostic tool. The relatively large tissue specimens obtained with ER enable accurate histological staging of a lesion, allowing for optimal decision-making for further patient management. ER was pioneered in Japan, mainly for the resection of gastric lesions and squamous esophageal neoplasia, and also Western countries have been increasingly implementing ER in the treatment of early gastroesophageal neoplasia, mostly associated with Barrett's esophagus (BE). In BE, however, there is still a risk of metachronous lesions in the remainder of the Barrett's after focal ER. Additional treatment of all Barrett's mucosa is therefore advised. Currently, the most effective method for this is by using radiofrequency ablation (RFA). This review will provide an overview of indications for ER and RFA. Key Messages and Conclusions: Endoscopic management of early esophageal neoplasia is a safe and valid alternative to surgery and is nowadays the treatment of choice. ER is the mainstay of endoscopic management of early esophageal neoplasia since it allows for removal of neoplastic lesions and provides a large tissue specimen for histological evaluation. In case of early neoplasia in BE, focal ER should be complemented by eradication of the remaining Barrett's mucosa. RFA has proven to be a safe and effective modality to achieve complete eradication of Barrett's mucosa.

Radiofrequency Ablation for Early Superficial Flat Esophageal Squamous Cell Neoplasia: A Comprehensive Review

“…Moreover, the endoscopic ultrasound (EUS) is required to exclude submucosal invasion and lymphadenopathy, and computed tomography (CT) of the chest and upper abdomen is required to exclude the metastasis and lymphadenopathy. The rationales of the threshold of m 2 lie in the following: first, the maximum ablation depth of RFA at 12 J/cm 2 is up to the muscularis mucosae and 1000 μm on the esophagus [10][11][12][13]. Theoretically, only lesions restricted to m 3 are most likely to be completely eradicated.…”

Barrett’s esophagus: best practices for treatment and post-treatment surveillance

“…RFA uses a bipolar electrode array and a generator to generate a thermal injury of limited depth (500-1,000 µm) (45). Different sized ablation devices are designed for circumferential (360 degrees) or focal (90 or 60 degrees) RFA.…”

Prospective development and validation of a volumetric laser endomicroscopy computer algorithm for detection of Barrett’s neoplasia

“…Patients with Barrett's esophagus (BE) are at risk of developing esophageal adenocarcinoma and require endoscopic surveillance for detection and treatment of early neoplasia, including high-grade dysplasia and intramucosal adenocarcinoma. 1,2 However, current BE surveillance practices are suboptimal because early neoplasia can be missed due to its subtle endoscopic appearance and sampling error of random biopsies. 3,4 Volumetric laser endomicroscopy (VLE) has the potential to identify and mark areas suspicious for early BE neoplasia not appreciated under high-definition white-light endoscopy.…”