Is it justified to ablate flat-type esophageal squamous cancer? An analysis of endoscopic submucosal dissection specimens of lesions meeting the selection criteria of radiofrequency studies - 01/06/16

Doi : 10.1016/j.gie.2014.09.004

Marnix Jansen, MD, PhD ^1,^{^{∗
Drs Jansen and Schölvinck share first authorship.}}, Dirk W. Schölvinck, MD ^2,^3,^{^{∗
Drs Jansen and Schölvinck share first authorship.}}, Ryoji Kushima, MD, PhD ⁴, Shigeki Sekine, MD, PhD ⁴, Bas L.A.M. Weusten, MD, PhD ³, Guiqi Q. Wang, MD, PhD ⁶, David E. Fleischer, MD ⁷, Shigetaka Yoshinaga, MD, PhD ⁵, Sanford M. Dawsey, MD ⁸, Sybren L. Meijer, MD, PhD ¹, Jacques J.G.H.M. Bergman, MD, PhD ^2,^⁎,^{^{†
Drs Bergman and Oda share senior authorship.}}, Ichiro Oda, MD ^5,^{^{†
Drs Bergman and Oda share senior authorship.}}
¹ Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
² Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
³ Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
⁴ Pathology Division, National Cancer Center Hospital, Tokyo, Japan
⁵ Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
⁶ Department of Endoscopy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
⁷ Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
⁸ Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA

^∗Reprint requests: Jacques J. Bergman, MD, PhD, Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.

Abstract

Background

Endoscopic radiofrequency ablation (RFA) appears to be a safe and effective treatment for flat-type noninvasive squamous neoplasia of the esophagus. However, if RFA is applied to lesions containing invasive cancer (esophageal squamous cell carcinoma [ESCC]), histological features associated with lymph node metastases may remain undetected. In addition, extension of neoplasia down the ducts of esophageal submucosal glands (SMGs) may create a sheltered “niche” beyond the reach of ablation.

Objective

To determine the RFA eligibility of flat-type ESCC.

Design

Retrospective analysis of prospectively collected data of ESCC patients.

Setting

National Cancer Center Hospital, Tokyo, Japan.

Patients

Patients with flat-type ESCC larger than 3 cm removed by endoscopic submucosal dissection (ESD).

Interventions

Three endoscopists involved in RFA studies in China reviewed endoscopic images to select lesions eligible for RFA. Corresponding ESD resection specimens were histologically examined.

Main Outcome Measurements

The presence of poor histological features (ie, invasion in m3 or deeper, poor tumor differentiation, or lymphovascular invasion) and the number of involved esophageal SMGs and ducts.

Results

Sixty-five lesions were included, 17 (26%) of which qualified as RFA eligible by RFA endoscopists. Interobserver agreement for this assessment was poor (κ = 0.09). Six of the 17 specimens (35%) showed relevant disease: 4 lesions invaded in the muscularis mucosae, 1 of which also showed lymphovascular invasion; 2 lesions showed extension of neoplasia into SMGs.

Limitations

Limited number of cases. RFA eligibility status was based on analysis of still images.

Conclusions

One third of flat-type ESCC, deemed eligible for RFA, demonstrated histological features that are considered (relative) contraindications to endoscopic treatment. Because it appears difficult for endoscopists to identify low-risk ESCC, conservative use of RFA for flat-type ESCC is advocated until long-term follow-up data are available.

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Abbreviations : ESCC, ESD, IQR, LNM, LVI, RFA, SMG, USL

Plan

Methods

Patient selection

Endoscopic resection and histology processing

Review of endoscopic images for the selection of RFA-eligible lesions

Selection of lesions eligible for ablative treatment

Histopathology in RFA-eligible lesions

Ductal extension

Discussion

DISCLOSURE: The following author disclosed a financial relationship relevant to this article: Dr Bergmann is a consultant for, on the Advisory Board of, and has received research support from Covidien. All other authors disclosed no financial relationships relevant to this article.