Endoscopic management of dysplasia and early oesophageal cancer S.S. Zeki a, * , J.J. Bergman b , J.M. Dunn a a Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom b Dep. of Gastroenterology, Academic Medical Center, Amsterdam, Netherlands article info Article history: Received 5 November 2018 Accepted 19 November 2018 Keywords: Barrett's oesophagus High-grade dysplasia Low-grade dysplasia Early adenocarcinoma Endoscopic resection Radiofrequency ablation abstract In the past decade there have been technological advances in Endoscopic Eradication Therapy (EET) for the management of patients with oesophageal neoplasia and early cancer. Multiple endoscopic tech- niques now exist for both squamous and Barrett's oesophagus associated neoplasia or early cancer. A fundamental aspect of endotherapy is removal of the target lesion by endoscopic mucosal resection, or endosopic submucosal dissection. Residual tissue is subsequently ablated to remove the risk of recur- rence. The most validated technique for Barrett's oesophagus is radiofrequency ablation, but other techniques such as hybrid-APC and cryotherapy also show good results. This chapter will discuss the evolution of EET, and which patients are most likely to benefit. It will also explore the evidence behind the success of different techniques and provide practical advice on how to carry out the endoscopic techniques with a focus on radiofrequency ablation and endoscopic mucosal resection in particular. Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved. Introduction The aim of endoscopic eradication therapy (EET) for early ma- lignancy is both curative and preventative. In addition, endoscopic resection aims to provide accurate staging and confirmation of early malignancy. The aim of this chapter is to both describe the techniques of EET in the two most common oesophageal malignancies - squamous cell cancer (SCC) and oesophageal adenocarcinoma (OAC). Impor- tantly, how to recognize and choose the lesions most likely to be successfully cured with EET will also be addressed. OAC arises from glandular tissue in the upper GI tract. The progression to OAC is thought to be linear from non-dysplastic tissue to low, then high-grade dysplasia (LGD and HGD respec- tively), intra-mucosal cancer (IMC) and then invasive cancer. Bar- rett's oesophagus (BE), characterized by a columnar lined mucosa (with or without intestinal metaplasia depending on the guidelines being assessed) is the most common predisposing lesion associated with OAC although in most new diagnoses of OAC, no Barrett's is detected [19e21]. There are four histopathological diagnoses of premalignant Barrett's oesophagus: non-dysplastic Barrett's oesophagus (NDBE), indefinite for neoplasia/dysplasia (IFD), LGD and HGD. Because dysplasia is characterized by often subjective cellular criteria, there can be a wide inter-observer variability between the pathological grades for non-GI experts, as has been historically demonstrated for LGD [22]. BE is also described according to its length. A composite score known as the Prague classification describes the circumferential length above the top of the gastric folds (C) as well as any exten- sions above this margin-known as the maximum extent (M). The risk of dysplasia development is thought to be related to the length of the Barrett's segment [23]. SCC also develops along a dysplasia pathway but because of the basal origin of the dysplastic cells the lesions of squamous dysplasia and cancer are fundamentally different with regards to aetiology, demographic and oesophageal distribution. Premalignant squa- mous lesions are classified as low-grade intraepithelial neoplasia (LGIN) or high-grade intraepithelial neoplasia (HGIN). Indications for endoscopic treatment EET depends on correct patient selection. This is determined by balancing the chance of curative success versus the risk of morbidity and mortality from a surgical resection. Curative success is defined by a complete resection without recurrence either local or regional. This in turn is defined largely by the lymph node * Corresponding author. Dept. of Gastroenterology and Hepatology, St Thoma- s’Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom. E-mail address: Sebastian.zeki@gstt.nhs.uk (S.S. Zeki). Contents lists available at ScienceDirect Best Practice & Research Clinical Gastroenterology journal homepage: https://ees.elsevier.com/ybega/default.asp https://doi.org/10.1016/j.bpg.2018.11.003 1521-6918/Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved. Best Practice & Research Clinical Gastroenterology xxx (xxxx) xxx Please cite this article as: Zeki SS et al., Endoscopic management of dysplasia and early oesophageal cancer, Best Practice & Research Clinical Gastroenterology, https://doi.org/10.1016/j.bpg.2018.11.003