The Comparative Study Of Endoscopic Tenique For Early Esophageal Squamous Cell Carcinoma And Precancerous Lesions

[Background and Purpose]Piecemeal endoscopic resection (ER) for esophageal high-grade intraepithelial neoplasia (HGIN) or early squamous cell carcinoma (ESCC) is usually performed with the ER-cap technique. This requires submucosal lifting and multiple snares. Multiband mucosectomy (MBM) uses a modified variceal-band ligator without submucosal lifting. MBM might be a better applicable ER-technique. The aim is to compare MBM to ER-cap for piecemeal ER of esophageal ESCC.Endoscopic radiofrequency ablation (RFA) is an established therapy for Barrett’s esophagus. Preliminary reports, limited by low patient numbers, suggest a possible role for RFA for early esophageal squamous cell neoplasia (ESCN), as well. The aim is to enlarge the patient numbers to value its efficiency and safety.[Patients and Methods]1. MBM vs EMR-Cap study:Patients with mucosal HGIN/ESCC (≥2≤6 cm, max 2/3 of circumference) were included. Lesions were delineated after 1.25% Lugol staining, followed by randomisation to MBM or ER-cap and piecemeal resection. Endpoints: procedure-time, procedure-costs, complete endoscopic resection, adverse events, absence of HGIN/ESCC at 3 and 12 months follow-up.2. RFA:All patients had≥ flat (type 0-Ⅱb) unstained lesion (USL) on Lugol’s chromoendoscopy and consensus diagnosis of MGIN, HGIN, or early ESCC. Exclusions: prior endoscopic resection or ablation, stricture, non-flat mucosa. RFA was used at baseline to treat all USLs, then biopsy (and focal RFA if USL(s) persisted) every 3 months until all biopsies were negative for MGIN, HGIN and ESCC. Main outcome measurements:Complete response (CR) at 3 and 12 months (absence of MGIN, HGIN, and ESCC), neoplastic progression, adverse events.3. RFA combined with ER:Patients with early non-flat type ESCC and precancerous lesions (≥3cm<12cm). RFA is used, then non-flat lesion is resected with MBM. To observe the proportion of patients with histological complete response (CR) at 3months, 12 months to 5 years and adverse events.[Results]1. MBM vs. EMR-Cap study:In 84 patients (59 male, mean age 60 yrs) ER was performed with MBM (n=42) or ER-cap (n=42). There was no difference in baseline characteristics. Endoscopic complete resection was achieved in all lesions. Procedure time was significantly shorter with MBM (11 vs.22 minutes, p<0.0001). One perforation was seen after ER-cap and treated conservatively. Total costs of disposables was less for MBM (p=0.04).At 3 and 12 months follow-up none of the patients demonstrated HGIN/ESCC at the resection site.2. RFA study:96 patients participated (MGIN 45, HGIN 42, early ESCC 9). At 3 and 12 months, respectively,74%(70/94) and 87%(81/93) were CR. Two patients (2%) progressed (MGIN to HGIN; HGIN to T1m2 ESCC); both were treated endoscopically and achieved CR. Stricture occurred in 20 patients (21%), all after circumferential RFA. Lugol’s+RFA 12 J/cm2 (single application, no cleaning) was the optimal baseline circumferential technique (82% 12-month CR,6% stricture).3. RFA combined with ER study:In 4 patients, totally male, mean age 62 years with ESSCC (2), HGIN (1), MGIN (1) participated. USL length was 6-12 (mean 8.5) cm. Total treatment time is 42-105 (mean 66.8) min, RFA time 3-12 (mean 8.25) min, ER time 6-20(10.25) min. Average hospitalization day was 3days. There were 2 cases with sever strictures, all dilated to resolution.3 cases were CR at 3-months, 1year till to 5 year. 1 case was found HGIN at 3month and MGIN at lyear and 3year follow up, CR after treated with HALO system.[Conclusions]Piecemeal ER of esophageal ESCC with MBM is faster and cheaper compared to EMR-cap. Both techniques are highly effective and safe. MBM may have significant advantages over the ER-cap technique, especially in countries where ESCC is extremely common but endoscopic expertise and resources are limited.In patients with early ESCN, RFA is associated with a high CR rate and acceptable safety profile.RFA combined with ER is effective, safe and less technique demanded in treating with patients diagnosed as early non-flat esophageal squamous cell carcinoma and precancerous lesions, thus enlarged the indications of endoscopic treatment.