Diagnosis and treatment of early esophageal cancer

Increasing numbers of early esophageal neoplasias (especially Barrett's cancer) are being detected in Western countries, so that endoscopic therapy with a curative intent plays an increasing role.

Technological advances in endoscope development and auxiliary techniques such as chromoendoscopy increase the detection rate of early esophageal neoplasias. In all localizable lesions (high-grade intraepithelial neoplasia and mucosal cancers), the treatment of choice is endoscopic resection, which allows histological assessment. Photodynamic therapy with 5-aminolevulinic acid is suitable mainly in nonlocalizable neoplasias. Intensive photodynamic therapy with porfimer sodium should not be used, due to the high complication rate. The rationale for endoscopic therapy is that there is a very low risk of lymph-node metastasis in mucosal carcinomas, lower than the mortality risk with surgery. Surveillance of these endoscopically treated patients is absolutely necessary to detect recurrent or metachronous lesions, which can again be treated endoscopically.

Careful staging is indispensable before curative endoscopic therapy, as is consistent and careful follow-up. Endoscopic therapy is safe and effective, and endoscopic resection is the treatment of choice. Endoscopic therapy can replace radical esophageal resection in early mucosal esophageal carcinoma (at least in lesions with good to moderate differentiation and no lymph-node invasion).