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Probe-Based Confocal Laser Endomicroscopy to Guide Real-Time Endoscopic Therapy in Barrett's Esophagus with Dysplasia.

Johnson EA, De Lee R, Agni R, Pfau P, Reichelderfer M, Gopal DV - Case Rep Gastroenterol (2012)

Bottom Line: All four patients had pCLE showing features of HGD.Another case had a normal-appearing esophagus, but pCLE found features of BE in discrete areas and targeted biopsies were performed, which confirmed BE.This patient subsequently underwent RFA therapy of the residual areas of BE.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisc., USA.

ABSTRACT
Probe-based confocal laser endomicroscopy (pCLE) is a novel imaging technique which utilizes a low-power laser light passed through a fiber-optic bundle, within a miniprobe that is advanced into the working channel, to obtain microscopic images of the mucosa. This allows the endoscopist to evaluate the microarchitecture of the gastrointestinal epithelium in real time. At this time pCLE cannot replace histopathology, but it can provide diagnostic information as well as guide therapeutic management in patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD). We describe a retrospective case series in which four patients with BE and biopsy-proven HGD underwent endoscopy with pCLE to direct real-time endoscopic ablation therapy and/or endoscopic mucosal resection (EMR), which was performed in conjunction with pCLE. All four patients had pCLE showing features of HGD. After either EMR or radiofrequency ablation (RFA), pCLE was again used to evaluate the margins after therapy to assure accuracy. In one case, pCLE had features of dysplasia at the margin and further repeat EMR was immediately performed. Another case had a normal-appearing esophagus, but pCLE found features of BE in discrete areas and targeted biopsies were performed, which confirmed BE. This patient subsequently underwent RFA therapy of the residual areas of BE. In conclusion, in patients with BE and dysplasia, pCLE is an effective tool used to target biopsies, guide endoscopic therapy and assess the accuracy of EMR or RFA.

No MeSH data available.


Related in: MedlinePlus

a Segment of BE with one region of nodularity (arrow). b Endomicroscopy image after EMR showing gland irregularity and cellular disorganization, representing residual dysplasia present at the resection margin. c Histology showing features of HGD including back-to-back glands, piled up nuclei, and loss of polarity (circle). The arrow shows BE without dysplasia. Magnification: ×20. d pCLE probe being used alongside the HALO-90 catheter to confirm eradication of dysplasia at margins after ablative therapy.
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Figure 1: a Segment of BE with one region of nodularity (arrow). b Endomicroscopy image after EMR showing gland irregularity and cellular disorganization, representing residual dysplasia present at the resection margin. c Histology showing features of HGD including back-to-back glands, piled up nuclei, and loss of polarity (circle). The arrow shows BE without dysplasia. Magnification: ×20. d pCLE probe being used alongside the HALO-90 catheter to confirm eradication of dysplasia at margins after ablative therapy.

Mentions: A 71-year-old male patient was referred with a 4 cm segment of BE with biopsy-proven LGD demonstrated 1 year earlier. A repeat 6 month surveillance endoscopy confirmed the diagnosis of BE with LGD. Subsequent follow-up endoscopy revealed two noncontiguous sub-centimeter regions of nodularity within the Barrett's segment. The nodularity was addressed with EMR via the Wilson-Cook Duette band ligation and snare system (Duette multiband mucosectomy, Cook Medical, Winston Salem, N.C., USA); three resections were performed. Pathology demonstrated HGD extending to the margins of the resected specimen. After careful discussion, the patient decided to proceed with endoscopic treatment. A repeat endoscopy again demonstrated a single sub-centimeter region of nodularity within the BE segment (fig. 1a). pCLE was then performed on the distal esophagus. The esophageal nodularity was evaluated by positioning the tip of the confocal miniprobe on the suspicious lesion and corresponding images demonstrated dysplasia embedded within intestinal metaplasia. EMR of the mucosal nodularity was performed. pCLE was again employed along the resection margins. Inspection demonstrated irregular glands and cellular disorganization consistent with dysplasia (fig. 1b). As further dysplasia was identified and there were concerns for residual mucosal nodularity at the margin, further EMR overlapping adjacent to the original dysplastic resection margin was performed, and follow-up pathology confirmed HGD (fig. 1c). pCLE was again used to evaluate the margins of the resection and demonstrated intestinal metaplasia without residual dysplasia. Endoscopically, there appeared to be complete mucosal resection of the nodular area. Following EMR, during the same endoscopic session HALO-90TM (Halo 360 and Halo 90, BARRX, Sunnyvale, Calif., USA) RFA was performed on the remaining Barrett's segment. After the ablation therapy was performed, pCLE was simultaneously employed in the esophagus alongside the HALO-90 RFA catheter confirming eradication of the Barrett's metaplasia in the treatment zones (fig. 1d). Of note, this technique was used to aid in the positioning of the HALO-RFA and to assess the efficacy of endoscopic therapy, but pCLE images were not acquired during active ablation therapy.


Probe-Based Confocal Laser Endomicroscopy to Guide Real-Time Endoscopic Therapy in Barrett's Esophagus with Dysplasia.

Johnson EA, De Lee R, Agni R, Pfau P, Reichelderfer M, Gopal DV - Case Rep Gastroenterol (2012)

a Segment of BE with one region of nodularity (arrow). b Endomicroscopy image after EMR showing gland irregularity and cellular disorganization, representing residual dysplasia present at the resection margin. c Histology showing features of HGD including back-to-back glands, piled up nuclei, and loss of polarity (circle). The arrow shows BE without dysplasia. Magnification: ×20. d pCLE probe being used alongside the HALO-90 catheter to confirm eradication of dysplasia at margins after ablative therapy.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC3376345&req=5

Figure 1: a Segment of BE with one region of nodularity (arrow). b Endomicroscopy image after EMR showing gland irregularity and cellular disorganization, representing residual dysplasia present at the resection margin. c Histology showing features of HGD including back-to-back glands, piled up nuclei, and loss of polarity (circle). The arrow shows BE without dysplasia. Magnification: ×20. d pCLE probe being used alongside the HALO-90 catheter to confirm eradication of dysplasia at margins after ablative therapy.
Mentions: A 71-year-old male patient was referred with a 4 cm segment of BE with biopsy-proven LGD demonstrated 1 year earlier. A repeat 6 month surveillance endoscopy confirmed the diagnosis of BE with LGD. Subsequent follow-up endoscopy revealed two noncontiguous sub-centimeter regions of nodularity within the Barrett's segment. The nodularity was addressed with EMR via the Wilson-Cook Duette band ligation and snare system (Duette multiband mucosectomy, Cook Medical, Winston Salem, N.C., USA); three resections were performed. Pathology demonstrated HGD extending to the margins of the resected specimen. After careful discussion, the patient decided to proceed with endoscopic treatment. A repeat endoscopy again demonstrated a single sub-centimeter region of nodularity within the BE segment (fig. 1a). pCLE was then performed on the distal esophagus. The esophageal nodularity was evaluated by positioning the tip of the confocal miniprobe on the suspicious lesion and corresponding images demonstrated dysplasia embedded within intestinal metaplasia. EMR of the mucosal nodularity was performed. pCLE was again employed along the resection margins. Inspection demonstrated irregular glands and cellular disorganization consistent with dysplasia (fig. 1b). As further dysplasia was identified and there were concerns for residual mucosal nodularity at the margin, further EMR overlapping adjacent to the original dysplastic resection margin was performed, and follow-up pathology confirmed HGD (fig. 1c). pCLE was again used to evaluate the margins of the resection and demonstrated intestinal metaplasia without residual dysplasia. Endoscopically, there appeared to be complete mucosal resection of the nodular area. Following EMR, during the same endoscopic session HALO-90TM (Halo 360 and Halo 90, BARRX, Sunnyvale, Calif., USA) RFA was performed on the remaining Barrett's segment. After the ablation therapy was performed, pCLE was simultaneously employed in the esophagus alongside the HALO-90 RFA catheter confirming eradication of the Barrett's metaplasia in the treatment zones (fig. 1d). Of note, this technique was used to aid in the positioning of the HALO-RFA and to assess the efficacy of endoscopic therapy, but pCLE images were not acquired during active ablation therapy.

Bottom Line: All four patients had pCLE showing features of HGD.Another case had a normal-appearing esophagus, but pCLE found features of BE in discrete areas and targeted biopsies were performed, which confirmed BE.This patient subsequently underwent RFA therapy of the residual areas of BE.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisc., USA.

ABSTRACT
Probe-based confocal laser endomicroscopy (pCLE) is a novel imaging technique which utilizes a low-power laser light passed through a fiber-optic bundle, within a miniprobe that is advanced into the working channel, to obtain microscopic images of the mucosa. This allows the endoscopist to evaluate the microarchitecture of the gastrointestinal epithelium in real time. At this time pCLE cannot replace histopathology, but it can provide diagnostic information as well as guide therapeutic management in patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD). We describe a retrospective case series in which four patients with BE and biopsy-proven HGD underwent endoscopy with pCLE to direct real-time endoscopic ablation therapy and/or endoscopic mucosal resection (EMR), which was performed in conjunction with pCLE. All four patients had pCLE showing features of HGD. After either EMR or radiofrequency ablation (RFA), pCLE was again used to evaluate the margins after therapy to assure accuracy. In one case, pCLE had features of dysplasia at the margin and further repeat EMR was immediately performed. Another case had a normal-appearing esophagus, but pCLE found features of BE in discrete areas and targeted biopsies were performed, which confirmed BE. This patient subsequently underwent RFA therapy of the residual areas of BE. In conclusion, in patients with BE and dysplasia, pCLE is an effective tool used to target biopsies, guide endoscopic therapy and assess the accuracy of EMR or RFA.

No MeSH data available.


Related in: MedlinePlus