Superficial Esophageal Neoplasia Research Articles

Long-term results of an endoscopic screening program for superficial esophageal cancer in patients with head and neck squamous cell carcinoma.

Background and study aims Patients with head and neck squamous cell carcinoma (HNSCC) are at risk of a second primary tumor in the gastrointestinal tract, most commonly in the esophagus. Screening these patients for esophageal carcinoma may help detect asymptomatic dysplasia and early cancer, thus allowing curative treatment and more prolonged survival, but the impact of endoscopic screening remains uncertain. Here we aimed to describe the long-term results of an esophageal SCC screening program in patients with head and neck cancer in terms of prevalence, associated risk factors, and survival. Patients and methods We performed an observational study of a prospectively collected database including patients with HNSCC who had undergone high-definition endoscopy with chromoscopy between 2010 and 2018 at a Brazilian tertiary academic center. Results The study included 1,888 patients. The esophageal SCC prevalence was 7.9 %, with the majority (77.8 %) being superficial lesions. Significant risk factors for esophageal high-grade dysplasia (HGD) and invasive cancer included tumors of the oral cavity and oropharynx and the presence of low-grade dysplasia (LGD). Overall survival (OS) was significantly shorter among patients in whom esophageal cancer was diagnosed at an advanced stage ( P < .001). OS did not significantly differ between patients with HGD and early esophageal cancer versus those without esophageal cancer ( P = .210) Conclusions Endoscopic screening for superficial esophageal neoplasia in patients with HNSCC improves esophageal cancer detection. Screening could potentially benefit patients with primary cancer located at the oropharynx or oral cavity. In addition, the detection of esophageal LGD indicates a need for endoscopic surveillance.

Usefulness of argon plasma coagulation for superficial esophageal squamous cell neoplasia in patients at high risk or with limited endoscopic resectability.

Endoscopic resection is the standard treatment for superficial esophageal squamous-cell neoplasia (SESCN). However, we encounter patients in whom endoscopic resection is difficult to perform. We retrospectively studied the usefulness of argon plasma coagulation (APC) in patients with SESCN. The study comprised 45 patients with SESCN (81 lesions) who underwent APC in our hospital from March 1999 through August 2016. Clinicopathological characteristics, treatment time, the presence or absence of metastasis and recurrence, adverse events, and outcomes were studied. The median follow-up was 40 months. The median age was 70 years. The tumor diameter was 10 mm or longer in 48 lesions and less than 10 mm in 33 lesions. The median treatment time was 22 minutes. The reasons for selecting APC were as follows: technical difficulty caused by the presence of metachronous multiple lesions in the radiation field after chemoradiotherapy or close proximity to the ulcer scar remaining after endoscopic treatment in 49 lesions (60.4%), and the presence of underlying diseases in 26 lesions (32.0%). Adverse events occurred in 2 patients (4.4%) who had hypoxemia due to over-sedation. Two lesions (2.5%) recurred locally but could be locally controlled by additional APC. No patient had metastasis or recurrence or died of esophageal neoplasia. The 3-year overall survival rate was 87.0%, and the 3-year recurrence-free survival rate was 97.2%. APC can be a useful treatment option for SESCN in patients with a limited life expectancy, poor performance status, or technical difficulty in resection of superficial neoplasms.

Radiofrequency Ablation for Early Superficial Flat Esophageal Squamous Cell Neoplasia: A Comprehensive Review.

Esophageal squamous cell carcinoma comprises the majority of esophageal carcinoma in the Eastern Asia. The need of early detection of precancerous neoplastic lesions and cancer has been necessitated due to the probability of progression to the advanced stage and its poor prognosis. In recent times, many endoscopic modalities have come into practice for early detection and treatment. Endoscopic radiofrequency ablation (RFA) has been recommended as an efficient therapy in treating the dysplastic mucosa in Barrett's esophagus (BE). Its potential in reversing neoplastic lesions in squamous epithelium has been gradually explored. This article is aimed at reviewing the current evidence regarding the use of RFA on esophageal squamous cell neoplasia.

355 Endoscopic Submucosal Dissection vs. Endoscopic Mucosal Resection for Treatment of Barrett’s Related Superficial Esophageal Neoplasia

INTRODUCTION: The difference in long-term outcomes of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for Barrett’s related superficial neoplasia remains unclear. We aimed to compare the rates of local and metachronous recurrence of ESD and EMR in patients with clinically staged BE-associated high-grade dysplasia (HGD) and T1a esophageal adenocarcinoma (EAC). METHODS: Multicenter study at six academic hospitals in the U.S. including patients who underwent ESD for BE-HGD or T1a EAC. Primary outcome was a composite of metastasis and local recurrence rate. A time-to-event analysis was performed to evaluate recurrence. A Kaplan-Meier plot was constructed, and a log-rank test was used to compare the groups. A Cox hazard ratio regression analysis was performed to identify predictors of recurrence. RESULTS: A total of 241 patients were included. 154 underwent EMR, while 84 underwent ESD (Table 1). ESD had higher en bloc (96% vs 33%, P &lt; 0.0001), R0 (76% vs 54%, P = 0.0009) and curative resection rates (75% vs 32%, P &lt; .0001) when compared to EMR. The 24-month local recurrence rate for EMR and ESD was 43% and 11%, respectively (P = 0.0007) (Figure 1). Significantly more endoscopic resection procedures were required to treat recurrence after EMR compared to after ESD (Table 1). EMR, piecemeal resection, positive margins, and non-curative resection were identified as predictors of recurrence on univariate analysis. En bloc resection remained significant after multivariate analysis (Table 2). CONCLUSION: This multicenter study showed that ESD results in more definitive treatment of BE-associated early neoplasia than EMR, with significant lower recurrence rates and less need for repeat endoscopic therapeutic procedures than EMR.

Inadequate steroid injection after esophageal ESD might cause mural necrosis

Background and study aims Locoregional triamcinolone acetonide (TAC) injection is increasingly used for prevention of stricture after extensive endoscopic submucosal dissection (ESD) for superficial esophageal neoplasia. However, the safety of intramural TAC injection has not been elucidated. The aim of this study was to assess the clinical courses and histopathological changes after TAC injection into the muscle layer in a porcine model. Methods Three pigs were subjected to ESD under general anesthesia. Two artificial 30-mm lesions were created at the oral and anal ends of the esophagus in each pig. TAC was injected into the muscle layer of the artificial oral ulcers (TAC group) and saline was injected into the muscle layer of the artificial anal ulcers (control group). Endoscopic, macroscopic, and histopathological evaluations were performed. Results The artificial ulcers remained open at sacrifice on day 28 post-ESD in the three ulcers injected with TAC. Esophageal wall perforation and abscess spreading to the mediastinum were observed in two of the three ulcers in the TAC group. The abscesses involved the lungs, bronchi, and aortic adventitia. Severe inflammatory cell infiltration in the muscularis propria layer and significant muscularis propria degradation were observed in all three ulcers in the TAC group. Conclusions This study suggests that TAC may cause deep mural damage when it is injected into the muscularis propria. Care should be taken not to inject TAC into the muscle layer when it is used to prevent post-ESD stricture formation.

Predictive factors of submucosal fibrosis before endoscopic submucosal dissection for superficial squamous esophageal neoplasia.

41 Background: Endoscopic submucosal dissection (ESD) is an effective treatment modality for superficial squamous esophageal neoplasia (SSEN). However, submucosal fibrosis is an important obstacle to successful ESD. The aim of this study was to determine the ESD outcome in relationship to the degree of submucosal fibrosis of SSEN and to identify factors for predicting submucosal fibrosis. Methods: We retrospectively analyzed endoscopic and pathologic factors related to submucosal fibrosis in 41 patients with SSEN who underwent ESD. Also, en bloc resection, complication rate, and procedure time according to the degree of submucosal fibrosis were evaluated. Masson’s trichrome staining was used to evaluate histologic submucosal fibrosis. Results: A depressed type tumor (vs. nondepressed type tumor, P= 0.002), longer diameter of tumor greater than 20 mm (vs. longer diameter of tumor ≤ 20mm, P= 0.036), and delayed ESD after initial diagnosis (vs. immediate ESD after initial diagnosis, P= 0.005) were independent factors predictive of submucosal fibrosis. The severity of submucosal fibrosis was significantly associated with a higher complication rate such as bleeding and perforation. Also, as the severity of the submucosal fibrosis increased, the amount of time required for the ESD procedure increased. Conclusions: Longer diameter of tumor greater than 20 mm and macroscopic depression are endoscopic predictive factors of submucosal fibrosis in SSEN. Moreover, to avoid submucosal fibrosis, ESD should be attempted immediately after biopsy for the diagnosis of SSEN.

Tu1211 Endoscopic Submucosal Dissection for Superficial Proximal Esophageal Neoplasia Is Highly Successful

Tu1211 Endoscopic Submucosal Dissection for Superficial Proximal Esophageal Neoplasia Is Highly Successful

Single Locoregional Triamcinolone Injection Immediately After Esophageal Endoscopic Submucosal Dissection Prevents Stricture Formation.

Objectives:Although endoscopic submucosal dissection (ESD) is an efficient treatment for superficial esophageal cancer, it is associated with stricture formation after wide-circumference resection that leads to a low quality of life. Although locoregional steroid injections prevent stricture formation, a randomized comparative study did not report any advantages associated with steroid injection. We evaluated the prophylactic efficacy of a single locoregional triamcinolone injection for stricture formation after esophageal ESD.Methods:This was a retrospective matched case-control study using propensity score matching (PSM). Between April 2006 and July 2015, a total of 602 patients with superficial esophageal neoplasia underwent ESD. Among them, 189 patients with mucosal defects that spanned more than 2/3 of the esophageal circumference were included. After exclusion, 150 patients were enrolled. Triamcinolone acetonide (80 mg) was injected into the residual submucosal layer of the resected region immediately after ESD. PSM was performed to reduce the effects of selection bias for steroid injection. The primary outcome was the incidence of stricture formation. The secondary outcome was the number of balloon dilatation procedures required to resolve the stricture formation.Results:Thirty-seven patients, with and without triamcinolone injection each, were matched after PSM. The incidence of stricture formation decreased from 45.9% (17/37) without triamcinolone injection to 18.9% (7/37) with triamcinolone injection (p=0.016). After matching, the mean number of balloon dilatation procedures required also decreased from 2.8±4.6 to 0.6±1.5 times (P<0.01).Conclusions:A single locoregional triamcinolone injection efficiently prevented stricture formation after esophageal ESD.

Prevention of esophageal stricture after endoscopic submucosal dissection: a systematic review and meta-analysis.

Endoscopic submucosal dissection (ESD) of extensive superficial cancers of the esophagus may progress with high rates of postoperative stenosis, resulting in significantly decreased quality of life. Several therapies are performed to prevent this, but have not yet been compared in a systematic review. A systematic review of the literature and meta-analysis were performed using the MEDLINE, Embase, Cochrane, LILACS, Scopus, and CINAHL databases. Clinical trials and observational studies were searched from March 2014 to February 2015. Search terms included: endoscopy, ESD, esophageal stenosis, and esophageal stricture. Three retrospective and four prospective (three randomized) cohort studies were selected and involved 249 patients with superficial esophageal neoplasia who underwent ESD, at least two-thirds of the circumference. We grouped trials comparing different techniques to prevent esophagus stenosis post-ESD. We conducted different meta-analyses on randomized clinical trials (RCT), non-RCT, and global analysis. In RCT (three studies, n=85), the preventive therapy decreased the risk of stenosis (risk difference=-0.36, 95% CI -0.55 to -0.18, P=0.0001). Two studies (one randomized and one non-randomized, n=55) showed that preventative therapy lowered the average number of endoscopy dilatations (mean difference=-8.57, 95% CI -13.88 to -3.25, P<0.002). There were no significant differences in the three RCT studies (n=85) in complication rates between patients with preventative therapy and those without (risk difference=0.02, 95% CI -0.09 to 0.14, P=0.68). The use of preventive therapy after extensive ESD of the esophagus reduces the risk of stenosis and the number of endoscopic dilatations for resolution of stenosis without increasing the number of complications.

Effect of endoscopic submucosal dissection for superficial esophageal neoplasms and risk factors for postoperative stricture.

Endoscopic submucosal dissection (ESD) enables wider tumor resection compared with endoscopic mucosal resection and en bloc resection of superficial esophageal neoplasms. However, ESD may cause difficult-to-treat stricture of the esophagus, and therefore, prediction of and measures against postoperative esophageal stricture are critical. The aim of this study was to evaluate the effect of ESD on superficial esophageal neoplasms and identify risk factors associated with esophageal stricture after ESD.This study included 165 lesions in 120 patients with superficial esophageal neoplasms, including cancer and neoplasia, who underwent ESD from 2009 to 2013.The complete resection rate of superficial esophageal neoplasms by ESD was 90.9%. After ESD, 22 subjects (18.3%) had symptomatic esophageal stricture, 12 (10.0%) had aspiration pneumonia of grade 2, and 7 (5.8%) had mediastinal emphysema of grade 2. Comparison of the 22 subjects with stricture with the 98 subjects without stricture showed significant differences in the rate of resection of >75% of the esophageal circumference, rate of whole circumference resection, and the required time for resection. The tumor size and the size of the resected tissue sample also differed between the 2 groups. The groups did not differ in age, sex, alcohol intake, and smoking; location, macroscopic, and histological tumor findings; chest pain; or use of anticoagulants for comorbidities. In multivariate analysis, tumor size and whole circumference resection were independent risk factors for stricture. Furthermore, in 45 subjects with resection of >75% of the esophageal circumference, whole resection of the esophagus was the only independent risk factor for stricture.This study suggests that ESD has a strong therapeutic effect on superficial esophageal neoplasms; however, a greater extent of resection of the esophagus increases the risk of postoperative esophageal stricture. Preventive measures against development of postoperative stricture require further study.

Efficacy and safety of endoscopic submucosal dissection for superficial squamous esophageal neoplasia: A systematic review and meta-analysis of the literature.

127 Background: The number of ESD candidates with esophageal neoplasia has increased with the recent development of endoscopy. Increasing number of studies has recently reported the application of endoscopic submucosal dissection (ESD) for treatment of esophageal lesions. However, most of these series were retrospective and single center studies that included only a relatively small number of cases. The aim of this systematic review and meta-analysis was to assess the efficacy and safety of ESD for esophageal lesions. Methods: Comprehensive literature searches were performed on studies that reported ESD for the removal of esophageal dysplasia or esophageal squamous cell carcinoma. MEDLINE, EMBASE and the Cochrane Library were searched using the primary keywords “endoscopic submucosal dissection”, “esophagus” and “esophageal”. Statistical analyses were executed by the aid of Comprehensive Meta-analysis software version 2. Results: A total of 17 studies were identified. Meta-analysis revealed pooled estimates of complete cure en bloc resection as 89.7% (95%CI 85%-93%; I2 =54.6%) and pooled estimates of en bloc resection as 96% (95%CI;93%-98%; I2=21.2). The pooled estimates of complications of ESD such as bleeding, perforation and stenosis were 2%, 5%, 12%, respectively. Subgroup analysis was performed by grouping studies into two groups. Complete cure en bloc resection was 92.4% for studies from Japan and 81.6% for studies from other countries than Japan. Conclusions: ESD appeared to be an extremely effective technique to achieve complete cure en bloc resection of superficial squamous esophageal neoplasia. The very low rate of complications also shows the potential safety of this approach. However, the resection rates were statistically different for studies from Japan and for studies from other countries. Standardization of techniques and equipment may be needed before ESD can be widely accepted for treatment of superficial squamous esophageal neoplasms.

Histological features responsible for brownish epithelium in squamous neoplasia of the esophagus by narrow band imaging

Esophageal squamous neoplasias usually appear brown under narrow band imaging as a result of microvascular proliferation, and brownish color changes in the areas between vessels, referred to as brownish epithelium. However, the reasons for the development of this brownish epithelium and its clinical implications have not been fully investigated. Patients with superficial esophageal neoplasias treated by endoscopic resection were included in the study. Areas of mucosa with brownish and non-brownish epithelia were evaluated histologically. A total of 68 superficial esophageal neoplasias in 58 patients were included in the analysis. Of the 68 lesions, 32 were classified in the brownish epithelium group, and 36 in the non-brownish epithelium group. Brownish epithelium was significantly associated with a diagnosis of high-grade intraepithelial neoplasia or invasive cancer (P < 0.0001). Thinning of the keratinous layer, thinning of the epithelium, and cellular atypia were significantly associated with brownish epithelium by univariate analysis, and thinning of the keratinous layer and thinning of the epithelium were confirmed to be independent factors by multivariate analysis. The odds ratios were 9.6 (95% confidence interval: 2.0-46.3) for thinning of the keratinous layer, and 4.6 (95% confidence interval: 1.1-19.4) for thinning of the epithelium. Brownish epithelium is an important finding in the diagnosis of esophageal squamous neoplasia, and may be related to thinning of the keratinous layer, caused by neoplastic cell proliferation, and thinning of the epithelium.

Magnified Endoscopy Combined with Narrow Band Imaging of Minimal Superficial Esophageal Neoplasia—Indicators to Differentiate Intraepithelial Neoplasias

PurposeClinical application of narrow band imaging facilitates diagnosis of esophageal neoplasia. However, no previous investigation has been conducted on magnifying endoscopy combined with narrow band imaging in detection of minimal superficial esophageal neoplasia, which is defined as neoplasia <10 mm in diameter. The aim of this retrospective study was to evaluate the usefulness of this combined technique in the differential diagnosis of minimal superficial esophageal neoplasia.MethodsBetween January 2005 and November 2011, 53 minimal superficial esophageal neoplasias in 40 patients were diagnosed by screening upper gastrointestinal endoscopy with narrow band imaging at our hospital. We investigated findings including brownish dots, brownish epithelium, and demarcation line of minimal superficial esophageal neoplasia diagnosed histopathologically as low-grade intraepithelial neoplasia, high-grade intraepithelial neoplasia, and squamous cell carcinoma.ResultsSignificantly more brownish dots (P < 0.05) and brownish epithelium (P < 0.005) were observed in intraepithelial papillary capillary loops in high-grade neoplasia compared with low-grade neoplasia. When minimal superficial esophageal neoplasia was diagnosed as high-grade intraepithelial neoplasia or squamous cell carcinoma, sensitivity, specificity, positive predictive value, and negative predictive value were 88.9, 42.9, 44.4, and 88.2 %, respectively, for brownish dots; 94.4, 51.4, 50.0, and 94.7 %, respectively, for brownish epithelium; and 66.7, 62.9, 48.0, and 78.6 %, respectively, for demarcation line.ConclusionsThe combined technique was useful in the differential diagnosis of minimal superficial esophageal neoplasia.

Effects of Carbon Dioxide Insufflation in Esophageal Endoscopic Submucosal Dissection

Although carbon dioxide (CO2) insufflation has successfully replaced air insufflation in a variety of procedures, the effects of CO2-insufflation in esophageal endoscopic submucosal dissection (ESD) have not been adequately investigated. This study was designed to evaluate the effects of CO2 insufflation in esophageal ESD. From January 2009 to January 2011, 57 superficial esophageal neoplasias in 54 patients (51 men and 3 women) were treated under conscious sedation with midazolam and pethidine hydrochloride, using ESD technique with a combination of small-caliber-tip transparent hood and flex knife. They were divided into air-insufflation (39 lesions, 37 patients) and CO2-insufflation (18 lesions, 17 patients) groups and therapeutic efficacy and complications were retrospectively evaluated in each group. The rate of en bloc resection was 100% and there were no complications in each group. No significant differences were seen in procedural time, the amount of pethidine hydrochloride required, body temperature and white blood cell count on post-procedure day 1, and length of hospital stay after ESD. A difference in the amount of midazolam required between the air-insufflation group and the CO2-insufflation group was noted (6mg vs. 4mg, p=0.0017). CO2-insufflation could be considered useful for reducing patients' discomfort in esophageal ESD.

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for superficial esophageal neoplasia. Is it safe for elderly patients?

Safety and efficacy of endoscopic submucosal dissection (ESD) for esophageal neoplasias have not been adequately investigated in elderly patients. This study was designed to evaluate the safety and efficacy of ESD for esophageal neoplasias in elderly patients. Fifty-three superficial esophageal neoplasias treated with ESD using a combination of small-caliber-tip transparent hood and flex knife from May 2006 to June 2009 were divided into elderly group (aged 70 years or older: 25 lesions in 23 patients) and nonelderly group (younger than aged 70 years: 28 lesions in 25 patients). Therapeutic efficacy, complications, and follow-up results were evaluated retrospectively. The history of cerebral infarction or cardiopulmonary disease and the usage of antiplatelet agents or anticoagulants were significantly higher in elderly group (p 0.0050 and p 0.0013, respectively). Median procedural times in the elderly group and the nonelderly group were 93 ± 53 (range, 42-235) min and 95 ± 55 (range, 40-230) min (p 0.73), respectively. Median sizes of the neoplasias and the resected specimens were 14 ± 11 (range, 5-45) mm and 15 ± 17 (range, 5-83) mm (p 0.56), and 35 ± 12 (range, 18-60) mm and 38 ± 17 (range, 18-90) mm (p 0.38), respectively. En bloc resection rate was 100% in each group. Body temperature and white blood cell counts of the next day after ESD were significantly higher in the nonelderly group than in the elderly group (p 0.0087 and p 0.0043, respectively). There were no complications, such as postoperative bleeding or perforation, in each group. The median follow-up period of 23 ± 10 (range, 4-35) months in the elderly group revealed no local or distant metastasis. ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasia in elderly and nonelderly patients.

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias

Superficial esophageal neoplasias resected in piecemeal manner with endoscopic mucosal resection (EMR) sometimes recur locally, and additional treatments need to be developed. Efficacy and safety of endoscopic submucosal dissection (ESD) for esophageal neoplasias are not sufficiently demonstrated, so we conducted a retrospective study to evaluate the efficacy and safety of ESD for superficial esophageal neoplasias. Thirty-seven superficial esophageal neoplasias consisted of 34 squamous cell neoplasias and 3 columnar neoplasias in 35 patients were treated with ESD from May 2006 to July 2008. Patients were regularly followed up with endoscopy every 6 months, and with echoendoscope and computed tomography every year. Therapeutic efficacy, complications, and follow-up results were evaluated. The mean size of the resected neoplasias and that of the resected specimens were 22 mm (range 10-83 mm) and 41 mm (range 18-90 mm), respectively. The mean duration of the ESD procedures was 117 min (range 40-235 min). The overall rates of en bloc resection and of free margin resection were 100% (37/37) and 95% (35/37), respectively. The mean follow-up period of 19 months (range 7-32 months) revealed no local or distant recurrence. There were no complications such as bleeding or perforation in any case. In all nine cases, the strictures were successfully managed with prophylactic endoscopic balloon dilation. ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe endoscopic treatment for superficial esophageal neoplasias and enables large en bloc resection.

Narrow Band Imaging (NBI) Against Conventional Lugol Chromoendoscopy for Detection of Superficial Esophageal Neoplasia in High Risk Patients - A Prospective Comparative Study

Background: Esophageal cancer shared similar risk factor of development with head & neck cancer. 10 to 15% of patients with head and neck cancer harbored a second primary esophageal cancer. Conventionally, endoscopic surveillance is achieved in high risk patients with Lugol chromoendoscopy. Lugol chromoendoscopy, however, can induce significant esophageal spasm and chest pain. Recently, NBI is developed as one of the option to achieve optical chromoendoscopy. This study aimed to compared NBI. Method: We prospectively recruit patients with head and neck cancer or history of squamous esophageal cancer treated with definitive chemoradiotherapy (CRT) for surveillance endoscopy.

Endoscopic Therapy of Dysplasia and Early-Stage Cancers of the Esophagus

Endoscopic treatments have become a viable alternative for some patients with early-stage esophageal neoplasia. Although esophagectomy remains the standard of care for high-grade dysplasia and superficial cancers, surgical morbidity and mortality may deter patients who are medically unfit or reluctant to undergo surgery. Photodynamic therapy (PDT) and endoscopic mucosal resection (EMR) are the best-studied nonsurgical approaches at present. PDT has been reported to eradicate high-grade dysplasia (HGD) and early Barrett's cancers at rates ranging from 75% to 100% and 17% to 100%, respectively, and a recent randomized controlled trial confirmed that PDT may prevent progression of HGD to cancer. Complete remission rates greater than 90% have also been reported with EMR and other mucosa-ablating interventions, although recurrence rates necessitate close endoscopic surveillance and retreatment in some patients. In addition to PDT and EMR, several emerging endoscopic treatment options for superficial esophageal neoplasia may provide attractive alternatives to surgery.