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Endoscopic resection is the criterion standard of treatment for patients with early squamous cell neoplasia of the esophagus
LETTERS TO THE EDITOR
Endoscopic resection is the criterion standard of treatment for patients with early squamous cell neoplasia of the esophagus To the Editor: We have read with great interest the article by Bergman et al1 on the utility of endoscopic radiofrequency ablation (RFA) for the treatment for early squamous cell neoplasia of the esophagus (ESCN). They performed RFA for 29 patients with early ESCN and reported that RFA was associated with a high rate of histologic complete response (97% of the patients). We consider that the biggest problem of RFA is that no histopathologic diagnosis of the whole lesion, especially for high-grade intraepithelial neoplasia (HGIN) and squamous cell carcinoma (SCC), can be obtained. The authors stated that patients with findings of T1m3 were excluded from the study. However, diagnosis whether the lesion is T1m2 or T1m3 is quite difficult, even for flat lesions (Figs. 1 and 2). Diagnosis of the depth of invasion by biopsy specimen is inaccurate. We previously reported histologic results of endoscopic resection for esophageal lesions diagnosed as HGIN by endoscopic biopsy.2 Fifty-one patients without EUS findings of submucosal tumor invasion were enrolled in that study. Histologic examination of totally resected specimens revealed that 12 (23.5%) of the 51 patients had tumor invasion of T1m2 and that 4 (7.8%) had tumor invasion of T1m3. The invasive focus in all lesions of invasive SCC was surrounded by HGIN (Fig. 3). Inasmuch as lymph node metastasis occurs in about
Figure 1. Endoscopic image showing an obscure erythematous flat lesion in the lower esophagus in a 70-year-old man.
464 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 2 : 2012
Figure 2. Endoscopic image with Lugol stain showing a demarcated flat lesion unstained by Lugol in the same area as that shown in Figure 1.
Figure 3. Photomicrograph of resected specimen showing squamous cell carcinoma invading the muscularis mucosae. The invasive focus is surrounded by high-grade intraepithelial squamous neoplasia (H&E, orig. mag. ⫻100).
10% of patients with T1m3 invasion,3 such patients should undergo additional treatment such as chemoradiotherapy or close long-term follow-up to facilitate early detection of lymph node metastasis.4 We are afraid that a lesion with T1m3 invasion may be overlooked by complete destruction with RFA. Certainly, ESD is a more difficult technique than endoscopic RFA. However, owing to progress in the development of devices and the establishment of training systems,5 ESD is no longer a special technique in Japan. We consider that endoscopists must make great efforts for not only local complete remission but also accurate histopathologic assessment. www.giejournal.org
Letters to the Editor
The authors of Bergman et al were given the opportunity to reply but did not. Yuichi Shimizu, MD Masakazu Takahashi, MD Takeshi Yoshida, MD Third Department of Internal Medicine Shouko Ono, MD Katsuhiro Mabe, MD Mototsugu Kato, MD Division of Endoscopy Masahiro Asaka, MD Department of Cancer Preventive Medicine Hokkaido Graduate School of Medicine Sapporo, Japan
REFERENCES 1. Bergman JJ, Zhang YM, Wang GQ, et al. Outcomes from a prospective trial of endoscopic radiofrequency ablation of early squamous cell neoplasia of the esophagus. Gastrointest Endosc 2011;74:1181-90. 2. Shimizu Y, Kato M, Asaka M, et al. Histologic results of EMR for esophageal lesions diagnosed as high-grade intraepithelial squamous neoplasia by endoscopic biopsy. Gastrointest Endosc 2006;63:16-21. 3. Kodama M, Kakegawa T. Treatment of superficial cancer of the esophagus: a summary of the responses to a questionnaire on superficial cancer of the esophagus in Japan. Surgery 1998;123:432-9. 4. Shimizu Y, Kato M, Asaka M, et al. EMR combined with chemoradiotherapy: a novel treatment for superficial esophageal squamous-cell carcinoma. Gastrointest Endosc 2004;59:199-204.
5. Tsuji Y, Ohata K, Koike K, et al. An effective training system for endoscopic submucosal dissection of gastric neoplasm. Endoscopy 2011;43:1033-8. doi:10.1016/j.gie.2012.02.007
Submucosal gland tumor spreading in mucosal squamous cell carcinoma: a concern for radiofrequency ablation? To the Editor: Radiofrequency ablation (RFA) has been recently proposed as an efficacious alternative for resection of superficial esophageal squamous cell carcinoma (SCC).1,2 We report here the case of an 89-year-old woman with a flat hemicircumferential, mucosal-limited (EUS assessment) lower esophageal SCC who underwent endoscopic submucosal dissection with en bloc complete resection of the lesion, without any complications. Microscopically, it was described as a complete resected pT1m1 SCC with spreading to submucosal glands through the muscularis mucosae (Fig. 1). To date, after 8 months of follow-up, there has been no evidence of recurrence or metastasis. This case illustrates the advantages of en bloc resection of SCC that allowed precise staging of a pT1m1 SCC with the uncommon description of tumor spreading in the submucosal glands without extension to the chorion, inasmuch as no invasion through the basal margin of the glands could be observed. Submucosal glands, generally located in the lower part of the esophagus,3 lie in straight
Figure 1. A, Esophageal squamous cell carcinoma with spreading in the submucosal gland ducts (red arrows) through the muscularis mucosae (green arrows) and limited to the inside part of the glands without extension to the surrounding chorion (H&E, orig. mag. ⫻5). B, Actin immunohistochemistry: the muscularis mucosae is marked in brown (green arrows) and presents an appearance of isolated or irregularly arranged muscle bundles rather than forming a continuous sheet. The neoplastic glands are marked by red arrows.
www.giejournal.org
Volume 76, No. 2 : 2012 GASTROINTESTINAL ENDOSCOPY 465
Endoscopic resection is the criterion standard of treatment for patients with early squamous cell neoplasia of the esophagus To the Editor: We have read with great interest the article by Bergman et al1 on the utility of endoscopic radiofrequency ablation (RFA) for the treatment for early squamous cell neoplasia of the esophagus (ESCN). They performed RFA for 29 patients with early ESCN and reported that RFA was associated with a high rate of histologic complete response (97% of the patients). We consider that the biggest problem of RFA is that no histopathologic diagnosis of the whole lesion, especially for high-grade intraepithelial neoplasia (HGIN) and squamous cell carcinoma (SCC), can be obtained. The authors stated that patients with findings of T1m3 were excluded from the study. However, diagnosis whether the lesion is T1m2 or T1m3 is quite difficult, even for flat lesions (Figs. 1 and 2). Diagnosis of the depth of invasion by biopsy specimen is inaccurate. We previously reported histologic results of endoscopic resection for esophageal lesions diagnosed as HGIN by endoscopic biopsy.2 Fifty-one patients without EUS findings of submucosal tumor invasion were enrolled in that study. Histologic examination of totally resected specimens revealed that 12 (23.5%) of the 51 patients had tumor invasion of T1m2 and that 4 (7.8%) had tumor invasion of T1m3. The invasive focus in all lesions of invasive SCC was surrounded by HGIN (Fig. 3). Inasmuch as lymph node metastasis occurs in about
Figure 1. Endoscopic image showing an obscure erythematous flat lesion in the lower esophagus in a 70-year-old man.
464 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 2 : 2012
Figure 2. Endoscopic image with Lugol stain showing a demarcated flat lesion unstained by Lugol in the same area as that shown in Figure 1.
Figure 3. Photomicrograph of resected specimen showing squamous cell carcinoma invading the muscularis mucosae. The invasive focus is surrounded by high-grade intraepithelial squamous neoplasia (H&E, orig. mag. ⫻100).
10% of patients with T1m3 invasion,3 such patients should undergo additional treatment such as chemoradiotherapy or close long-term follow-up to facilitate early detection of lymph node metastasis.4 We are afraid that a lesion with T1m3 invasion may be overlooked by complete destruction with RFA. Certainly, ESD is a more difficult technique than endoscopic RFA. However, owing to progress in the development of devices and the establishment of training systems,5 ESD is no longer a special technique in Japan. We consider that endoscopists must make great efforts for not only local complete remission but also accurate histopathologic assessment. www.giejournal.org
Letters to the Editor
The authors of Bergman et al were given the opportunity to reply but did not. Yuichi Shimizu, MD Masakazu Takahashi, MD Takeshi Yoshida, MD Third Department of Internal Medicine Shouko Ono, MD Katsuhiro Mabe, MD Mototsugu Kato, MD Division of Endoscopy Masahiro Asaka, MD Department of Cancer Preventive Medicine Hokkaido Graduate School of Medicine Sapporo, Japan
REFERENCES 1. Bergman JJ, Zhang YM, Wang GQ, et al. Outcomes from a prospective trial of endoscopic radiofrequency ablation of early squamous cell neoplasia of the esophagus. Gastrointest Endosc 2011;74:1181-90. 2. Shimizu Y, Kato M, Asaka M, et al. Histologic results of EMR for esophageal lesions diagnosed as high-grade intraepithelial squamous neoplasia by endoscopic biopsy. Gastrointest Endosc 2006;63:16-21. 3. Kodama M, Kakegawa T. Treatment of superficial cancer of the esophagus: a summary of the responses to a questionnaire on superficial cancer of the esophagus in Japan. Surgery 1998;123:432-9. 4. Shimizu Y, Kato M, Asaka M, et al. EMR combined with chemoradiotherapy: a novel treatment for superficial esophageal squamous-cell carcinoma. Gastrointest Endosc 2004;59:199-204.
5. Tsuji Y, Ohata K, Koike K, et al. An effective training system for endoscopic submucosal dissection of gastric neoplasm. Endoscopy 2011;43:1033-8. doi:10.1016/j.gie.2012.02.007
Submucosal gland tumor spreading in mucosal squamous cell carcinoma: a concern for radiofrequency ablation? To the Editor: Radiofrequency ablation (RFA) has been recently proposed as an efficacious alternative for resection of superficial esophageal squamous cell carcinoma (SCC).1,2 We report here the case of an 89-year-old woman with a flat hemicircumferential, mucosal-limited (EUS assessment) lower esophageal SCC who underwent endoscopic submucosal dissection with en bloc complete resection of the lesion, without any complications. Microscopically, it was described as a complete resected pT1m1 SCC with spreading to submucosal glands through the muscularis mucosae (Fig. 1). To date, after 8 months of follow-up, there has been no evidence of recurrence or metastasis. This case illustrates the advantages of en bloc resection of SCC that allowed precise staging of a pT1m1 SCC with the uncommon description of tumor spreading in the submucosal glands without extension to the chorion, inasmuch as no invasion through the basal margin of the glands could be observed. Submucosal glands, generally located in the lower part of the esophagus,3 lie in straight
Figure 1. A, Esophageal squamous cell carcinoma with spreading in the submucosal gland ducts (red arrows) through the muscularis mucosae (green arrows) and limited to the inside part of the glands without extension to the surrounding chorion (H&E, orig. mag. ⫻5). B, Actin immunohistochemistry: the muscularis mucosae is marked in brown (green arrows) and presents an appearance of isolated or irregularly arranged muscle bundles rather than forming a continuous sheet. The neoplastic glands are marked by red arrows.
www.giejournal.org
Volume 76, No. 2 : 2012 GASTROINTESTINAL ENDOSCOPY 465