Post written by Wen-Lun Wang, MD, PhD, and Ching-Tai Lee, MD, from the Department of Gastroenterology and Hepatology, E-Da Hospital, Kaohsiung, Taiwan.

Metachronous recurrence frequently develops in patients with superficial esophageal squamous cell carcinomas (ESCCs) after curative endoscopic submucosal dissection (ESD), especially in those with multiple (>10) small Lugol-voiding lesions (LVLs) over the esophageal background mucosa (ie, speckled pattern).

We conducted a randomized controlled trial to investigate whether endoscopic radiofrequency ablation (RFA) for esophageal background mucosal resurfacing (EBMR) can decrease the rate of metachronous neoplasia. Of 112 patients screened, 30 were randomized to receive EBMR (n = 15) or surveillance (n = 15). EBMR reduced the risk of metachronous recurrence (0% in the EBMR group vs 53% in the control group, P = .001), with the number needed to treat 1.9. The mean procedure time of EBMR was 30.7 minutes (range, 25-40). One patient developed post-RFA stenosis, which resolved after 3 sessions of endoscopic dilation. Reversal of the Lugol staining speckled pattern to only a few LVLs occurred in all patients and persisted for at least 5 years in the ablation group.

To the best of our knowledge, this study is the first randomized controlled trial to investigate whether endoscopic RFA for EBMR can decrease the rate of metachronous neoplasia. Our data suggest that endoscopic ablation over the entire esophageal background mucosa is a superior management strategy to endoscopic surveillance in patients with Lugol speckled background mucosa. EBMR is an innovative secondary method to prevent the metachronous recurrence of ESCC after complete ESD.

High rates of metachronous recurrence or cancer progression from Lugol speckled background mucosa have been reported. No effective chemoprevention agent exists, and the mechanism of the speckled pattern is unclear. In our trial, we demonstrated that EBMR is durable, its effects may persist for at least 5 years, and no case progressed to high-grade dysplasia or squamous cell carcinoma within the follow-up period.

Although endoscopic surveillance every 6 to 12 months after complete ESD is the standard treatment strategy, the surveillance interval should be shortened for patients with multiple small LVLs. Given the high rate of malignant transformation in the control group, the low number needed to treat to prevent metachronous recurrence, and the acceptable safety profile, a shift to earlier endoscopic intervention in this patient population needs consideration.

In this trial, we expanded the indication of RFA to prevent metachronous recurrence easily and safely in patients with multiple small LVLs in the esophageal background after complete ESD. Further verification is expected through multicenter prospective studies. Whether EBMR is feasible as the primary prevention of ESCC in patients with speckled background mucosa warrants further research.

Representative case of endoscopic background mucosal resurfacing (EBMR) with balloon-based endoscopic radiofrequency ablation. A-C, Before EBMR, Lugol chromoendoscopy showed multiple small Lugol-voiding lesions (LVLs) over the entire endoscopic background mucosa. D, EBMR was performed to ablate the entire esophageal mucosa from the upper to lower esophagus. E, After a single ablation, we attached a transparent hood at the end of endoscope to remove coagulum and confirm the efficacy of ablation. F, The coagulum of the entire esophageal epithelium was removed. G-I, Three months after EBMR, Lugol chromoendoscopy showed no residual LVLs over the endoscopic background.

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