Update on the diagnosis and management of early oesophageal squamous neoplasia
Vivek C Goodoory et al.
KEY MESSAGES
-
Oesophageal squamous cell cancer remains one of the commonest causes of death due to malignancy in the world.
-
Pathophysiology and outcomes of oesophageal squamous dysplasia differ significantly from oesophageal adenocarcinoma.
-
Early diagnosis at endoscopy is key to successful outcomes.
-
Accurate endoscopic staging is important in determining the best therapeutic modality.
-
Endoscopic submucosal dissection is preferred over endoscopic mucosal resections in cases selected for endoscopic resection (type B1 and B2 intrapapillary capillary loops).
-
Multidisciplinary team approach must be standard of care for these patients.
Abstract
Oesophageal squamous neoplasia consists of dysplasia and squamous cell cancer, the most common subtype of oesophageal cancer. Despite medical advances, outcomes in oesophageal cancer remain suboptimal partly because of late-stage diagnosis. This review will discuss the epidemiology and risk factors for oesophageal neoplasia. It focuses on early endoscopic recognition and diagnosis of oesophageal squamous neoplasia including endoscopic classification to guide management. The histological classifications of oesophageal dysplasia and carcinoma are also reviewed followed by discussion about endoscopic management. Finally, the guidelines for management of squamous neoplasia from major gastroenterology societies are reviewed.
Figure 1
(A) Endoscopic appearance of an inconspicuous reddish patch of oesophageal squamous dysplasia at 3 to 5 o’clock under white light imaging. (B) On virtual chromoendoscopy, two patches of oesophageal squamous dysplasia become more apparent. (C) Following Lugol iodine 1.5% staining, two Lugol void patches are confirmed.
Table 1
Summary of guideline recommendations, including level of evidence, from major gastroenterology societies
| WEO66 | JES60 61 72 | ESGE68 | ASGE67 | |
| Screening | In countries with a high incidence of oesophageal SCC, population-based screening based on age and other demographic criteria may be considered. | Beyond the scope of JES guideline | Beyond the scope of ESGE guideline | Beyond the scope of ASGE guideline |
| Diagnosis | Recommends the use of narrow band imaging magnifying endoscopy or Lugol chromoendoscopy for lesion detection and assessment. Recommends the use of validated classification systems (eg, JES classification) to estimate depth of invasion of superficial oesophageal squamous lesion. Recommends clinical staging based on endoscopic assessment, CT, EUS and PET-CT, where appropriate. |
Recommends the use of narrow band imaging magnifying endoscopy for lesion detection and assessment. Recommends the use of the JES classification to estimate depth of invasion of superficial oesophageal squamous lesion. Recommends clinical staging based on endoscopic assessment, CT and PET-CT. |
Recommends the use of virtual chromoendoscopy (preferred option) or Lugol chromoendoscopy for lesion detection. Recommends the use of the JES classification to estimate depth of invasion of oesophageal squamous lesion. |
Beyond the scope of ASGE guideline |
| Treatment | Recommends en bloc endoscopic resection (EMR for lesions ≤10 mm, EMR or ESD for lesions 10–20 mm and ESD for lesions >20 mm) for squamous dysplasia or early SCC. For those with clinical staging T1a or T1b-SM1, recommend en bloc endoscopic resection for curative or accurate pathological staging. For those with pathological pT1a with vascular invasion or pT1b lesions, recommends CRT or surgery |
For those with clinical staging T1a, recommends the use of an estimation of the depth of invasion, circumferential involvement and length of oesophageal lesion to guide initial treatment of endoscopic resection, CRT or surgery. Where endoscopic treatment was performed, further treatment is guided by pathological evaluation. For those with pathological staging pT1b or pT1a with vascular invasion, recommends CRT or surgery. |
For oesophageal squamous dysplasia or SCC with:
|
For oesophageal squamous dysplasia or early, well-differentiated nonulcerated SCC,
Following non-curative resection, for MDT discussion to consider surgery, chemoradiotherapy or endoscopic and imaging surveillance. |
| Surveillance | Recommends endoscopic surveillance or intervention for those with positive lateral margin involvement after endoscopic resection. Recommends annual endoscopic surveillance after endoscopic resection of early SCC. |
For pT1a lesions without vascular invasion, recommends surveillance. No specific guidance on follow-up interval or modality. | For curative resection (en bloc R0 pT1a-m2 or less), which carries a very low risk of LNM, recommends OGD at 3–6 months and then annually. For low-risk curative resection (en bloc R0 pT1a-m3), which carries a low risk of LNM, recommends discussion in MDT if further therapy required prior to surveillance. For local-risk resection (pEMR pT1a), recommends complete staging prior to endoscopic surveillance 3–6 months with biopsies until no recurrence confirmed. |
Following curative resection,
|
