Endoscopic Mucosal Resection of Esophageal Lesions



Endoscopic Mucosal Resection of Esophageal Lesions


Sumit Singla, MD

Cyrus Piraka, MD



Endoscopic mucosal resection (EMR) typically refers to the removal of flat or sessile lesions of the upper GI tract, although it is often used to describe a type of endoscopic resection of the mucosal layer of any part of the bowel with the use of submucosal lifting and snare resection of tissue. EMR is a well-established diagnostic and therapeutic modality for the management of esophageal lesions. This review will assist in understanding the applicable disease states, technique, and safety of this procedure in the upper GI tract and specifically in the esophagus.


DISEASE STATE



  • 1. Barrett esophagus



    • a. Intramucosal adenocarcinoma


    • b. High-grade dysplasia


    • c. Low-grade dysplasia


  • 2. Squamous cell carcinoma


  • 3. Other differentiated or undifferentiated lesions in the superficial or deep mucosa or shallow submucosa


TECHNIQUE



  • 1. Careful examination



    • a. Understand the indication for the procedure and perform a high-quality examination. This should include the use of an attached clear plastic cap and high-definition white light. Evolving technologies, such as the use of chromoendoscopy, confocal endomicroscopy, optical coherence tomography, and magnification endoscopy (not currently available in the United States), may improve the fidelity of this examination. Chromoendoscopy with Lugol iodine may aid in defining the presence and extent of squamous cell cancer (where dysplastic tissue is unstained). Part of
      the rationale for performing a high-quality endoscopic examination is to exclude the presence of deeply invasive malignancy. This may also be performed in conjunction with endoscopic ultrasound (EUS) and other newer modalities to exclude malignancy.


    • b. The most common indication for EMR is removal of dysplastic/neoplastic lesions associated with Barrett esophagus. EUS is generally regarded as the gold standard for accurate staging of cancer associated with Barrett esophagus via TNM classification.1,2 However, distinguishing between high-grade dysplasia, cancer confined to the superficial and deep mucosa (T1a) and cancer invading into submucosa (T1b) can be challenging and may overstage or less likely understage the lesion.3,4 Clinical evidence and expert opinion have validated the central role of EMR in the removal of tissue and in providing the most accurate staging of early esophageal malignancy (see Fig. 10.1).


    • c. According to the Japanese Society for Gastroenterological Endoscopy criteria for EMR of early endoluminal cancers, early esophageal cancers are amenable to EMR if they meet the following criteria:



      • i. Are less than 2 cm


      • ii. Involve less than 1/3 of the esophageal wall


      • iii. Are confined to the esophageal mucosa (stage T1a)






        FIG. 10.1 Staging animation depicting depth of lesions amenable to endoscopic eradication therapy (EET), including endoscopic mucosal resection (EMR). HGT, high-grade dysplasia; LN, lymph node. (Adapted from Komanduri S, Muthsuswamy VR, Wani S. Controversies in endoscopic eradication therapy for Barrett’s esophagus. Gastroenterology. 2018;154(7):1861-1875. Copyright © 2018 American Gastroenterological Association. With permission.)







        FIG. 10.2 Paris classification of neoplastic lesions within the digestive tract. (From Schlemper RJ, Hirata I, Dixon MF. The macroscopic classification of early neoplasia of the digestive tract. Endoscopy. 2002;34(2):163-168. Copyright © 2002 Georg Thieme Verlag KG.)


  • 2. While European and American guidelines do not specifically address lesion size and circumference that would preclude resection, most expert centers currently attempt EMR even with larger lesions. The majority of studies demonstrating safety and efficacy do not specify a distinct size criteria at which resection should be deferred5,6


  • 3. Description of the lesion (Fig. 10.2)

Tags:
May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Endoscopic Mucosal Resection of Esophageal Lesions

Full access? Get Clinical Tree
Get Clinical Tree app for offline access