Study Of Endoscopic Techniques For Early Esophageal Squamous Cell Carcinoma And Precancerous Lesions

Part ?:Endoscopic resection(ER)techniques for squamous premalignant lesions and early carcinoma of the esophagus:ER-Cap,MBM and ESD,how do we choose?Multi-centers experience.Background and aims:In recent years,endoscopic resection cap technique(ER-Cap),Endoscopic submucosal dissection(ESD)and a newly developed multi-band mucosectomy(MBM)were widely applied in the treatment of squamous premalignant lesion and early carcinoma of the esophagus.However,little data was available to help make a clinical choice of these methods.The aim of the study was to compare the feasibility,safety,effectiveness and the costs of the three techniques.Methods:A retrospective analysis of 672 patients with 733 lesions during the period of January 2009 to December 2015 at multi-centers in China,including Cancer Hospital Chinese Academy of Medical Sciences,Dongping Peoples Hospital,Feicheng Peoples Hospital,Yanting Cancer Hospital,Changzhi Peoples Hospital was performed.The patients underwent endoscopic resection using one of the three methods and then were followed by periodic endoscopy for mean 44.37 months.Mean operation time,mean hospitalization cost,R0 resection rate,complication rate,local recurrence and metastasis were recorded for all the patients.Results:The operation time was significantly shorter for ER-Cap(29.26±16.73,mins,p?0.001)group,and the hospitalization cost was significantly lower in the MBM group(20942.0318435.56Y,p=0.003).The resection sample size of ESD was significantly larger(4.4011.20,cm,p?0.001)and en-bloc resection rate of ESD was significantly higher(p<0.001)than that of the other two groups.There was no significant difference among the three groups regarding the site of tumor location and sub-mucosal average invasion depth(p>0.05).The frequencies of perforation,bleeding and cicatricial stenosis were significantly lower in the MBM group(p?0.001,p=0.011,p=0.009).Three local recurrences were observed in ER-Cap group,while no recurrence in MBM and ESD group.Three and two metastatic patients were observed respectively in MBM and ESD group.Conclusions:ER-Cap,MBM and ESD are all minimally invasive,safe and effective methods in the treatment of early esophageal squamous cell carcinoma.ESD is suitable for a large lesion and could achieve a high en-bloc resection rate.While MBM offers a safe,simple and effective procedure with low local recurrence and similar metastatic rate to ESD.MBM would be a good alternative when performed by less-experienced endoscopists in a high-risk ESCC area with limited resources.Part ?:Durability of Radiofrequency Ablation for Treatment of Esophageal Squamous Cell Neoplasia:5 Year Follow-Up of a Treated Cohort in ChinaBackground and aims:Radiofrequency ablation(RFA)has been accepted as one of treatment methods for flat Barrett's neoplasia.Less is known about RFA for esophageal squamous-cell neoplasia(ESCN).Our group has reported several prospective studies of RFA for ESCN in China with promising results through 12 months of follow-up.In the current study,we aimed to evaluate longer-term outcomes after RFA for ESCN.Methods:Patients with flat unstained lesions(USLs)on Lugol's endoscopy containing moderate/high grade intra-epithelial neoplasia(MGIN/HGIN)or mucosal cancer were treated with RFA every 3 months until complete remission(CR;no MGIN+).Patients with CR at 12 months(CR12)were included for follow-up and underwent annual Lugol's endoscopy with biopsies and re-RFA for flat USLs.The clinical course of patients with persistent ESCN at 12 month('treatment failures')is also reported.Results:Among the 78 CR12 patients,67(86%)had sustained CR during a median 48mo(IQR 48-48)of follow-up and 5 endoscopies(IQR 4-6).Recurrence occurred in 7/78(9%)patients(MGIN,6,HGIN,1);all were managed with RFA.Four other patients(5%)had progression(to HGIN,1;ESCC-sm,3).During follow-up,protocol violations occurred in 46/78 patients(59%).Of the 12 treatment failures,progression occurred in 6.Overall,two patients developed subepithelial disease that was not visible after Lugol's.Based on post-hoc analysis,the 'pink-color sign' at baseline(a pink color change after Lugol's)significantly predicted failure after RFA.Conclusion:RFA is relatively easy to apply and can efficiently treat large areas with ESCN.Despite protocol violations that may have interfered with the efficacy of RFA in 59%of patients,the great majority with CR12 had sustained CR during FU.Based on currently available data,we advise to restrict the use of RFA for flat MGIN and HGIN without the pink-color sign on Lugol's chromoendoscopy.Part ?:Clinical risk factors for complications after endoscopic resection techniques for squamous premalignant lesions and early carcinoma of the esophagusBackground:Endoscopic resection techniques are curative,standard therapy for early esophageal cancer.This study investigated the risk factors of complications after endoscopic resection and provided the basis to work out measure for preventing complications.Methods:A retrospective analysis of 459 patients during the period of January 2009 to December 2015 at Cancer Hospital Chinese Academy of Medical Sciences was performed.The patients were diagnosis as squamous premalignant lesions or early carcinoma of the esophagus and underwent endoscopic resection.The incidence rates of perforation,bleeding after procedure and cicatricial stenosis were recorded and analyzed for all the patients.Results:In 459 patients,bleeding after procedure,perforation and cicatricial stenosis occurred in 15(3.3%),16(3.5%)and 82(17.9%)cases respectively.Patients with bleeding and perforation underwent successful conservative treatments with no cases converted to surgery.Patients with cicatricial stenosis were all relieved by dilation.The size of lesion(OR=1.51,p=0.020),circumference of lesion(OR=1.24,p=0.037)and ER-Cap(MBM/EMR-CAP:OR=0.13,p=0.007)were significant risk factors of bleeding after proceture.Sex(Female/male:OR=4,55,p=0.008)and ESD(ESD/EMR-CAP:OR=15.38,p=0.013)were significant risk factors of perforation.Circumference of lesion(OR=0.12,p=0.003),cervical segment lesion(OR=0.12,p=0.003)and procedure time(OR=1.02,p=0.007)were significant risk factors of cicatricial stenosis.Conclusions:Endoscopic resection techniques for squamous premalignant lesions and early carcinoma of the esophagus have low rate of complications,and most of the complications can be successfully treated by endoscopic therapy or internal medicine procedures.Patients with long and large circumference of lesion or treated with ER-Cap have high risk of bleeding after procedure.Female patients and ESD may lead to high rate of perforation.And cases with lesions in cervical segment,large circumference lesion or long procedure time have high rate of cicatricial stenosis.