| BackgroundThe patients of early esophageal cancer (EEC) and precancerous lesions have no typical symptoms or symptomless, so their diagnostic rates and the detection rates are low. Endoscopic examination and identification of morphological characteristic of EEC and precancerous lesions are important in improving the detection rates, so endoscopy is the important method in detecting and diagnosing EEC and precancerous lesions. Endoscopic approachs in diagnosing EEC and precancerous lesions of researchers at abroad include chromoendoscopy,endoscopic ultrasonography,magnifying endoscope,narrow-band imaging and confocal laser endoscopy. They select reasonable endoscopic therapy or surgical resection, according to lesion characteristics of intramucosal cancer and submucosal cancer in endoscopy and metastasis with the lymph node and the vessel or not. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are popular technology in treating EEC in Japan. Studies show that the effects of endoscopic therapy or surgical resection for intramucosal cancer are no obvious difference. In our country, endoscopic therapy is starting stage and surgical resection is the main method in EEC.Clinical data of 101 EEC patients from January 2003 to October 2008 in our hospital were retrospectively analyzed. Preoperative endoscopic diagnosis and postoperative pathology were compared to explore the clinical value of double staining of Lugol's solution and methylene blue in diagnosing EEC and precancerous lesions, and the lesions infiltrative depth was assessed by miniprobe sonography (MPS), and intramucosal cancer and submucosal cancer were differentiated by endoscopic classification, and therapic result between endoscopic therapy and surgical resection was compared to explore the therapic value of EMR and ESD in early esophageal cancer. There are four parts in this study, they are:1. Double staining of Lugol's solution and methylene blue to diagnose early esophageal cancer and precancerous lesionsObjective To explore the value of double staining of Lugol's solution and methylene blue in diagnosing EEC and precancerous lesions. Method 101 EEC and 197 non-cancer (precancerous lesions and non-precancerous lesions) patients from January 2003 to October 2008 in our hospital were examined by double staining of Lugol's solution and methylene blue. During endoscopic examination, 3% Lugol's solution was sprayed on the esophageal lesions first, followed by 0.5% methylene blue. The degree and range of the lesions of staining of Lugol's solution and double staining were observed respectively, and staining and biopsy result were compared. To compare the value of double staining and staining of Lugol's solution in diagnosing EEC and precancerous lesions. Results The sensitivity and specificity of EEC and severe dysplasia by non-stained by Lugol's solution were 89.5%,96.0%, and that of EEC and severe dysplasia by deep stained by methylene blue but non-stained by Lugol's solution were 86.3%,99.4%. The sensitivity and specificity of moderate dysplasia by light stained by Lugol's solution was 90.7%,55.7%, and that of mild and moderate dysplasia by light stained by methylene blue and Lugol's solution was 81.5%,96.8%. The sensitivity and specificity of non-precancerous lesions by light stained by Lugol's solution was 97.9%,69.2%, and that of non-precancerous lesions by non-stained by methylene blue but light stained by Lugol's solution was 92.9%,100.0%. Conclusion 1. EEC and severe dysplasia show non-stained by Lugol's solution in majority, mild and moderate dysplasia show light stained by Lugol's solution in majority. EEC and severe dysplasia show deep stained by methylene blue but non-stained by Lugol's solution, mild and moderate dysplasia show light stained by methylene blue and Lugol's solution in majority. 2. Double staining and staining of Lugol's solution are similar in diagnosing EEC and severe dysplasia, but the specificity by double staining in diagnosing mild and moderate dysplasia and non-precancerous lesions is more high than that by staining of Lugol's solution. 3. Double staining is more superiority than staining of Lugol's solution in identifying precancerous lesions and non- precancerous lesions. 4. Double staining can show clear range in EEC and precancerous lesions, and provide accurate excisional range for endoscopic therapy. 2. Miniprobe sonography judge the infiltrative depth in early esophageal cancerObjective To explore the clinical value of MPS in identifying intraepithelial cancer, muscularis mucosae cancer, and submucosal cancer. Method 101 EEC patients from January 2003 to October 2008 in our hospital were examined by MPS before operation. Ultrasonographic image of intraepithelial cancer and muscularis mucosae cancer and submucosal cancer was analyzed, and ultrasound result and postoperative pathology were compared to explore the value of MPS in differentiating intramucosal cancer from submucosal cancer. Results MPS show intraepithelial cancer 28 cases and muscularis mucosae cancer 29 cases and submucosal cancer 42 cases and muscularis propria cancer 2 cases. Postoperative pathology show intraepithelial cancer 27 cases and muscularis mucosae cancer 33 cases and submucosal cancer 41 cases. The specificity and sensitivity and positive predictive value and negative predictive value of the esophagus intramucosal cancer by MPS were 89.7%,88.3%,93.0%,83.3%, and that of submucosal cancer were 88.3%,85.4%,83.3%,89.8%, and the diagnostic accuracy in differentiating intramucosal cancer from submucosal cancer by MPS was 87.1%, and MPS show that deep staging was 9 cases and superficial staging was 4 cases and the metastasis rate of lymph node was 50.0%. Conclusion 1. MPS can exactly identify esophageal intramucosal cancer and submucosal cancer, but there is deep or superficial staging. 2. There is circumscribed in diagnosing the metastasis of lymph node and vessel infiltration by MPS. 3. MPS can provide reasonable therapy method, including endoscopic therapy or surgical resection.3. Endoscopic classification to identify early esophageal intramucosal cancer and submucosal cancerObjective To explore the endoscopic classification value in identifying early esophageal intramucosal cancer and submucosal cancer. Method 101 EEC patients from January 2003 to October 2008 in our hospital were analyzed. According to the growth pattern, height and cup depth under common endoscopy or endoscopic ultrasonography, 101 early esophageal cancer lesions were classified into surface diffusion growth and intra-lumen growth and intra-wall growth and bi-direction growth and mixed growth. Infiltration depth of early cancers was contrasted by endoscopic classification and postoperative pathology. Results With the criteria of intramucosal cancer as surface diffusion growth and intra-lumen growth<5mm and bi-direction growth<2mm and intra-wall growth < 0.5mm, With the criteria of submucosal cancer as intra-lumen growth≥5mm and bi-direction growth≥2mm and intra-wall growth≥0.5mm and mixed growth. The specificity and sensitivity and positive predictive value and negative predictive value of intramucosal cancer were 78.0%,91.7%,85.9%,86.5%, and that of submucosal cancer were 91.7%,78.0%,86.5%,85.9%, the diagnostic accuracy rate in differentiating intramucosal cancer from submucosal cancer by endoscopic classification was 86.1%. Conclusion 1. Endoscopic classification is effective in differentiating esophageal intramucosal cancer from submucosal cancer. 2. Endoscopic classification is significance in directing to chose the reasonable therapy method and to distinguish endoscopic therapy group or surgical resection group for EEC.4. The preliminary comparative study between endoscopic therapy and surgical resection for early esophageal cancerObjective To compare the therapic result of endoscopic therapy and surgical resection for early esophageal cancer, to explore the value of EMR and ESD for EEC. Method 101 EEC patients from January 2003 to October 2008 in our hospital were analyzed, EMR 30 cases including 32 lesions, ESD 4 cases, surgery 67 cases including 68 lesions. To compare the result of endoscopic therapy and surgical resection for EEC. Results Postoperative pathology in EMR shows that intraepithelial cancer was 12 lesions and muscularis mucosae cancer was 19 lesions and submucosal cancer was 1 lesion, pathological diagnosis accordance rate by resection and biopsy specimen was 96.9%, 31 lesions were resected and the resection rate was 96.9%. Postoperative pathology in ESD shows that intraepithelial cancer was 2 cases and muscularis mucosae cancer was 2 cases, the overall resection rate was 100.0%, and the bleeding rate was 0.0%. The death patients were 2 cases in endoscopic therapy group, the general and 3,4 year survival rate were respectively 94.1%,93.8%,84.6% in our follow-up period. The death patients were 3 cases in surgical resection group, the general and 3,4 year survival rate were respectively 95.5%,96.6%,87.5% in our follow-up period. The two groups general and 3,4 year survival rate were not difference in statistics. But because the follow-up patients were not many, the 5 year survival rate needed research furtherly. Conclusion 1. EMR is safe and effective, but it has residual and recurrence. 2. ESD can not only resect completely the lesions, but also provide complete pathologic diagnosis, but it has the bleeding and perforation risk. 3. The patients have much dominance such as slight wound and better quality of life after EMR and ESD. 4. The endoscopic therapy and surgical resection groups general and Survival rate for 3,4 year are not difference in our follow-up period, and the therapic result is similar. But the Survival rate for 5 year need research furtherly.
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