A pilot study of the endomicroscopic assessment of tumor extension in Barrett’s esophagus–associated neoplasia before endoscopic resection

Werner Dolak; Ildiko Mesteri; Reza Asari; Matthias Preusser; Barbara Tribl; Friedrich Wrba; Sebastian F. Schoppmann; Michael Hejna; Michael Trauner; Michael Häfner; Andreas Püspök

doi:10.1055/s-0034-1377935

Endoscopy International Open, Table of Contents

Endosc Int Open 2015; 03(01): E19-E28
DOI: 10.1055/s-0034-1377935

Original article

A pilot study of the endomicroscopic assessment of tumor extension in Barrett’s esophagus–associated neoplasia before endoscopic resection

Werner Dolak

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Ildiko Mesteri

²Clinical Institute of Pathology, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Reza Asari

³Department of Surgery, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Matthias Preusser

⁴Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Barbara Tribl

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Friedrich Wrba

²Clinical Institute of Pathology, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Sebastian F. Schoppmann

³Department of Surgery, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Michael Hejna

⁴Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Michael Trauner

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Michael Häfner

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

,

Andreas Püspök

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, and Gastroesophageal Tumor Unit, Comprehensive Cancer Center, Vienna, Austria

› Author Affiliations

Abstract

Background and study aims: Barrett’s esophagus (BE) – associated neoplasia can be treated endoscopically, but accurate assessment before intervention is challenging. This study aimed to investigate the role of confocal laser endomicroscopy (CLE) as an adjunct in the endoscopic treatment of BE-associated neoplasia by assessing lateral tumor and subsquamous tumor (SST) extension.

Patients and methods: In the context of a prospective, single-arm pilot clinical trial, patients referred for endoscopic resection of BE-associated neoplasia (high grade dysplasia and esophageal adenocarcinoma) underwent high definition, white light endoscopy with narrow-band imaging (NBI). Then, CLE mapping of suspected neoplastic lesions was performed by another endoscopist, partially blinded to the previous findings, before the patients underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), depending on lesion size and anticipated histology.

Results: In 7 of 38 patients (18 %), CLE revealed additional neoplastic tissue compared with prior white light endoscopy and NBI: 2 concomitant lesions, 2 cases of lateral tumor extension within the Barrett’s epithelium, and 3 cases of previously undetected SST extension. Overall, en bloc resection (tumor-free lateral margin) was achieved in 28 of 34 neoplastic lesions (82 %), and complete resection (tumor-free lateral and basal margins) in 21 of 34 neoplastic lesions (62 %).

Conclusions: CLE-assisted endoscopic resection of BE-associated neoplasia was safe and effective in this study, as proved by a high additional diagnostic yield of CLE (including visualization of occult SST extension) and a favorable rate of en bloc resection. The clinical value of CLE for assisting endoscopic therapy of BE-associated neoplasia deserves further evaluation in randomized controlled trials.

Full Text

References

References
1 Blot WJ, Devesa SS, Kneller RW et al. Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA 1991; 265: 1287-1289
2 Brown LM, Devesa SS. Epidemiologic trends in esophageal and gastric cancer in the United States. Surg Oncol Clin N Am 2002; 11: 235-256
3 Murray L, Watson P, Johnston B. Risk of adenocarcinoma in Barrett's oesophagus: population based study. BMJ 2003; 327: 534-535
4 Hvid-Jensen F, Pedersen L, Drewes AM et al. Incidence of adenocarcinoma among patients with Barrett's esophagus. N Engl J Med 2011; 365: 1375-1383
5 Dolak W. The evil lies below the surface: subsquamous tumor extension in Barrett’s adenocarcinoma. Endosc Int Open 2014; 02: E41-E42
6 Anders M, Lucks Y, El-Masry MA et al. Subsquamous extension of intestinal metaplasia is detected in 98% of cases of neoplastic Barrett's esophagus. Clin Gastroenterol Hepatol 2014; 12: 405-410
7 Nagami Y, Machida H, Shiba M et al. Clinical efficacy of endoscopic submucosal dissection for adenocarcinomas of the esophagogastric junction. Endosc Int Open 2014; 02: E15-E20
8 Polglase AL, McLaren WJ, Skinner SA et al. A fluorescence confocal endomicroscope for in vivo microscopy of the upper- and the lower-GI tract. Gastrointest Endosc 2005; 62: 686-695
9 Kiesslich R, Gossner L, Goetz M et al. In vivo histology of Barrett's esophagus and associated neoplasia by confocal laser endomicroscopy. Clin Gastroenterol Hepatol 2006; 4: 979-987
10 Dunbar KB, Okolo 3rd P, Montgomery E. Confocal laser endomicroscopy in Barrett's esophagus and endoscopically inapparent Barrett's neoplasia: a prospective, randomized, double-blind, controlled, crossover trial. Gastrointest Endosc 2009; 70: 645-654
11 Levine DS, Blount PL, Rudolph RE et al. Safety of a systematic endoscopic biopsy protocol in patients with Barrett's esophagus. Am J Gastroenterol 2000; 95: 1152-1157
12 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-S43
13 Edge SB, Byrd DR, Compton CC et al., eds. American Joint Committee on Cancer Staging Manual. 7th. ed. New York, NY: Springer; 2010: 103
14 Sharma P, Dent J, Armstrong D et al. The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria. Gastroenterology 2006; 131: 1392-1399
15 Bajbouj M, Vieth M, Rösch T et al. Probe-based confocal laser endomicroscopy compared with standard four-quadrant biopsy for evaluation of neoplasia in Barrett's esophagus. Endoscopy 2010; 42: 435-440
16 Jayasekera C, Taylor AC, Desmond PV et al. Added value of narrow band imaging and confocal laser endomicroscopy in detecting Barrett's esophagus neoplasia. Endoscopy 2012; 44: 1089-1095
17 Yamagata T, Hirasawa D, Fujita N et al. Efficacy of acetic acid-spraying method in diagnosing extension of Barrett's cancer under the squamous epithelium. Dig Endosc 2012; 24: 309-314
18 Omae M, Fujisaki J, Shimizu T et al. Magnifying endoscopy with narrow-band imaging findings in the diagnosis of Barrett's esophageal adenocarcinoma spreading below squamous epithelium. Dig Endosc 2013; 25: 162-167
19 Vieth M, Ell C, Gossner L et al. Histological analysis of endoscopic resection specimens from 326 patients with Barrett's esophagus and early neoplasia. Endoscopy 2004; 36: 776-781
20 Neuhaus H, Terheggen G, Rutz EM et al. Endoscopic submucosal dissection plus radiofrequency ablation of neoplastic Barrett's esophagus. Endoscopy 2012; 44: 1105-1113
21 Nagami Y, Machida H, Shiba M et al. Clinical efficacy of endoscopic submucosal dissection for adenocarcinomas of the esophagogastric junction. Endosc Int Open 2014; 02: E15-E20
22 May A, Günter E, Roth F et al. Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: a comparative, prospective, and blinded trial. Gut 2004; 53: 634-640
23 Larghi A, Lightdale CJ, Memeo L. EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett's esophagus. Gastrointest Endosc 2005; 62: 16-23
24 Behrens A, May A, Gossner L et al. Curative treatment for high-grade intraepithelial neoplasia in Barrett's esophagus. Endoscopy 2005; 37: 999-1005