Targeting neoplasia using volumetric laser endomicroscopy with laser marking

Volumetric laser endomicroscopy (VLE) is a recent advanced imaging technology that allows high resolution microstructure imaging of the esophagus and gastric cardia; it has been increasingly used in Europe and the USA [1] [2] [3]. The system has been recently upgraded to include a laser marking device that places cautery marks on the mucosa to provide targets for histology. We report a case of an incidental finding of focal high grade dysplasia targeted using this new technology.

A 69-year-old man was referred for advanced imaging and removal of a gastroesophageal junction polyp. The polyp was visualized, using high definition resolution white-light endoscopy (HDR-WLE), on the cardia side of the gastroesophageal junction ([Fig. 1]; [Video 1]). It was a mobile pedunculated polyp with its base at the gastric cardia (Paris classification 0 – 1 p).

Fig. 1 Endoscopic view using high definition resolution white-light endoscopy showing the polyp at the gastroesophageal junction and adjacent normal-looking areas.

Video 1: Video showing volumetric laser endomicroscopy (VLE) with laser marking to target an area of dysplasia adjacent to a polyp at the gastroesophageal junction.

It is our practice to use VLE for high resolution imaging of mucosal pathology in the esophagus and gastroesophageal junction. We used a 20-mm balloon containing the VLE probe ([Fig. 2]). VLE showed that the polyp of interest did not contain any of the VLE characteristics that have been associated with neoplasia [4] [5]. No atypical glands or abnormal signal intensity were seen. There was however an area at the gastroesophageal junction just proximal to the polyp that contained a cluster of atypical glands that were suspicious for neoplasia ([Fig. 3]). This area appeared normal on HDR-WLE and narrow-band imaging (NBI) so laser marks were placed at the site to mark it for targeting ([Fig. 4]). Endoscopic mucosal resection of the polyp and the VLE-targeted area was performed. Histology of the polyp showed an inflammatory polyp and the VLE-targeted area was consistent with focal high grade dysplasia ([Fig. 5]; [Video 1]).

Fig. 2 The balloon containing the volumetric laser endomicroscopy (VLE) probe scanning the gastroesophageal junction and distal esophagus.

Fig. 3 Volumetric laser endomicroscopy (VLE) of the area proximal to the polyp showing: a on 360-degree image, an area that was suspicious for neoplasia (arrow); b a magnified snapshot of the suspicious area with an atypical cluster of glands (arrow).

Fig. 4 Endoscopic view showing laser marks placed at the area of suspected neoplasia using the volumetric laser endomicroscopy (VLE) laser marking system to help target the area for resection (arrows).

Fig. 5 Histology of the endoscopic mucosal resection specimen of the volumetric laser endomicroscopy (VLE)-targeted area. Columnar epithelium with loss of surface maturation, architecture complexity and high-grade nuclear atypia (HE × 400 magnification).

This case demonstrates the capability of VLE to obtain high resolution microstructure imaging of the esophagus and gastroesophageal junction that can aid in the diagnosis of neoplasia.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AC

Competing interests

None

• References

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