Post written by Robert Bechara, MD, from Hotel Dieu Hospital, Queens University, Kingston Health Sciences Center, Kingston, Ontario, Canada.

Chromoendoscopy with Lugol’s is a valuable technique for the detection of esophageal squamous cell carcinoma (ESCC). The sensitivity and specificity of a “pink color sign” for high-grade dysplasia or worse after Lugol’s staining is reported to be 88% and 95%, respectively. After detection, the macroscopic exam using the Paris classification revealed a IIa + IIc morphology. Approximately 50% of ESCC with IIa + IIc morphology has at least SM2 involvement.

The microscopic exam is completed by examining the intrapapillary capillary loops (IPCLs) using magnification, which allows the depth of invasion to be estimated according to the Japanese Esophageal Society classification. In our case, B2 vessels were seen in the area of depression.

B2 vessels are suggested to have 75% sensitivity and 96% specificity for M3 (carcinoma to the muscularis mucosa) to Sm-1 (submucosal invasion to 200µm) invasion, which would be a relative indication for ESD. There was also evidence suggestive of potentially deeper invasion by the demarcated depressed area and a larger area of B2 vessel involvement.

Additionally, poor differentiation is suggested by the reticular pattern of IPCLs. Nonetheless, because the ESD would provide definitive histology and the potential to avoid an esophagectomy, it was decided in discussion with the patient and at multidisciplinary tumor boards to proceed with ESD as the first step.

Systemically examining lesions macroscopically and microscopically allows for a thorough endoscopic examination to be completed efficiently. Image-enhanced endoscopy and optical diagnosis have been commonplace in Japan for decades, but appreciation of these aspects of endoscopy is still not widespread in North America. In addition, because of the relatively low incidence of esophageal squamous cell carcinoma in North America, the subtle findings in the optical diagnosis of ESCC often go unnoticed.

Careful and systematic macroscopic and microscopic examination of ESCC with image-enhanced endoscopy, Lugol’s, and magnification can provide vital information in the assessment of ESCC. The use of this information helps predict histology and allows for a more informed, comprehensive, and patient-centered treatment plan. This case also highlights the importance and utility of multidisciplinary discussion and close collaboration and communication among gastroenterology, surgery, pathology, and oncology.

Macroscopic findings of the squamous cell carcinoma. A, White light examination (WLE). B, Optical enhancement mode 2 (OE-2). C, Optical enhancement mode 1 (OE-1). Thirty seconds after 1.5% Lugol’s. D, WLE. E, OE-2. F, OE1. Three minutes after 1.5% of Lugol’s. G, WLE. H, OE-2. I, OE-1.

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