HD Endoscopy, EUS, and Microscopy - USCAP Knowledge …/102nd/pdf/companion21h05.pdf · The Rodger...
90
HD Endoscopy, EUS, and Microscopy Marcia Irene Canto, M.D., M.H.S. Professor of Medicine and Oncology Johns Hopkins Medical Institutions Baltimore, Maryland The Rodger C. Haggitt Memorial Lecture
HD Endoscopy, EUS, and Microscopy - USCAP Knowledge …/102nd/pdf/companion21h05.pdf · The Rodger C. Haggitt Memorial Lecture . Disclosures • Research support – Pentax, Olympus,
Marcia Irene Canto, M.D., M.H.S.Professor of Medicine and OncologyJohns Hopkins Medical Institutions
Baltimore, Maryland
The Rodger C. Haggitt Memorial Lecture
Disclosures
• Research support – Pentax, Olympus, Cook Medical
• Consulting – Covidien (Barrx)
Objective and Menu
• To highlight the added value of imaging to microscopic diagnosis–High definition endoscopy
•Chromoendoscopy•Digital enhancement
–Endoscopic Ultrasound (EUS)–Endomicroscopy
Endoscopic Imaging Today
Standard• Standard resolution• High resolution (HD)• Magnification• Red flag techniques
–Tissue stains, AA–Digital contrast
enhancement•NBI, FICE, I-Scan
Advanced• EUS• Autoflourescence• Endomicroscopy
(CLE) –Probe (pCLE)–Endoscope
(eCLE)
Presenter
Presentation Notes
Clinically available imaging techniques
Endoscopic Diagnosis
• 79 year old man• Upper GI bleeding• No Hx of GERD or BE• EGD: esoph ulcer• Bx: BE adenoCA
Endoscopic Mucosal Resection
T1 Mucosal AdenoCA in BE
Assess deep & lateral margins
Haggitt, Human Pathol 1994
How do we find the needle in the haystack?
4
3
7
6
5
21
BE Surveillance Biopsies4-Quadrant, Random
the ultimate jumbo biopsy
Presenter
Presentation Notes
Note: Mucomyst digest the mucus by reducing the disulfide bonds that maintain mucus integrity
What are our unmet needs for endoscopic imaging?
• Something that helps improve our detection of neoplasia–Random biopsy for BE – still gold standard
• Something that helps link diagnosis to therapy in real time and improves efficiency and outcomes–EMR for localized neoplasia–Ablate multifocal flat neoplasia
See Better, Do Better?SE vs. HR-WLE vs. NBI
I-Scan
Photoshop - live
Focal Diffuse
Methylene blue selectively stains IM in Barrett’s esophagus
Canto, 1996; Canto 2000
Presenter
Presentation Notes
MB staining can stain short segment BE in a focal pattern and long BE in a diffuse pattern. The blue arrows show unstained gastric metaplasia, which generally occurs in short BE near the GE junction.
Localizing BE Neoplasia with MB
MBDBRB Canto, 1996; Canto 2000
Presenter
Presentation Notes
MB can improve surveillance as shown here in this long BE with many areas of nodularity and an intramucosal carcinoma that was missed by 4-quadrant RB and diagnosed by MBDB. The cancer was right here in this unstained, heterogeneous area.
Mechanism for MB Effect
BE without
dysplasia
BE HGD
Presenter
Presentation Notes
What is the reason for the differential staining of dysplastic BE? The current hypothesis is that MB readily diffuses into the cytoplasm and goblet cells of nondysplastic BE, as shown by confocal laser fluorescence microscopy. In severely dysplastic and malignant BE, the nuclear-cytoplasmic ratio is increased with less cytoplasm and much fewer goblet cells for MB uptake.
Lugol’s chromoendoscopy
Narrow Band Imaging
• Sharma et al, multicenter RCT with crossover
• NBI + TB detected comparable number of neoplastic lesions, fewer biopsies (3.6 vs. 7.6, p < 0.0001) compared to HD WLE + 4Q RB
Sharma, Gut 2012
Presenter
Presentation Notes
Gut doi:10.1136/gutjnl-2011-300962 Endoscopy Original article Standard endoscopy with random biopsies versus narrow band imaging targeted biopsies in Barrett's oesophagus: a prospective, international, randomised controlled trial Prateek Sharma1,2, Robert H Hawes3, Ajay Bansal1,2, Neil Gupta1,2, Wouter Curvers4, Amit Rastogi1,2, Mandeep Singh1,2, Matt Hall5, Sharad C Mathur6,7, Sachin B Wani1,2, Brenda Hoffman3, Srinivas Gaddam1, Paul Fockens4, Jacques J Bergman4 +Author Affiliations 1Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA 2Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Missouri, USA 3Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA 4Division of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands 5Child Health Corporation of America, Shawnee Mission, Kansas, Missouri, USA 6Department of Pathology and Laboratory Medicine, Veterans Affairs Medical Center, Kansas City, Missouri, USA 7Department of Pathology and Laboratory Medicine, University of Kansas School of Medicine, Kansas City, Missouri, USA Correspondence toProfessor Prateek Sharma, Division of Gastroenterology, Department of Veterans Affairs Medical Center, 4801 E Linwood Blvd, Kansas City, MO 64128, USA; [email protected] Contributors PS—study concept and design, acquisition of data, drafting of manuscript, critical revision of the manuscript for important intellectual content, obtained funding, study supervision; RHH, AB, WC, AR, BH, PF—acquisition of data, critical revision of the manuscript for important intellectual content; NG—analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, statistical analysis; MS—administrative, technical and material support; MH—statistical analysis; SCM—acquisition of data; SBW, SG—drafting of manuscript, critical revision of the manuscript for important intellectual content, analysis and interpretation of data; JJB— study concept and design, critical revision of the manuscript for important intellectual content. Revised 4 January 2012 Accepted 5 January 2012 Published Online First 7 February 2012 Abstract Background White light endoscopy with random biopsies is the standard for detection of intestinal metaplasia (IM) and neoplasia in patients with Barrett's oesophagus (BO). Narrow band imaging (NBI) highlights surface patterns that correlate with IM and neoplasia in BO. Objective To compare high-definition white light (HD-WLE) and NBI for detection of IM and neoplasia in BO. Design International, randomised, crossover trial comparing HD-WLE and NBI. Patients referred for BO screening/surveillance at three tertiary referral centres were prospectively enrolled and randomised to HD-WLE or NBI followed by other procedures in 3–8 weeks. During HD-WLE, four quadrant biopsies every 2 cm, together with targeted biopsies of visible lesions (Seattle protocol), were obtained. During NBI examination, mucosal and vascular patterns were noted and targeted biopsies were obtained. All biopsies were read by a single expert gastrointestinal pathologist in a blinded fashion. Results 123 patients with BO (mean age 61; 93% male; 97% Caucasian) with mean circumferential and maximal extents of 1.8 and 3.6 cm, respectively, were enrolled. Both HD-WLE and NBI detected 104/113 (92%) patients with IM, but NBI required fewer biopsies per patient (3.6 vs 7.6, p<0.0001). NBI detected a higher proportion of areas with dysplasia (30% vs 21%, p=0.01). During examination with NBI, all areas of high-grade dysplasia and cancer had an irregular mucosal or vascular pattern. Conclusions NBI targeted biopsies can have the same IM detection rate as an HD-WLE examination with the Seattle protocol while requiring fewer biopsies. In addition, NBI targeted biopsies can detect more areas with dysplasia. Regular appearing NBI surface patterns did not harbour high-grade dysplasia/cancer, suggesting that biopsies could be avoided in these areas. However, since this was not the primary goal of our study, the routine use of NBI target biopsies only for detection of HGD/cancer cannot be recommended. HD-WLE (targeted and random biopsies) had a sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for the detection of patients with IM of 92%, 100%, 53% and 100%. NBI (targeted biopsies only) had a sensitivity, specificity, NPV and PPV for the detection of patients with IM of 87.6%, 100%, 41.7% and 100%.
• Best imaging modality of the GIT wall and periampullary area
mucosa
submucosam propriaserosa
transducer
water-filledballoon
EUS of normal stomach
Indications for EUS
• Aid in diagnosis and localization–Target tissue sampling
• Stage GI cancer–Leads to stage-specific therapy
• Assess submucosal lesions
EUS and Occult CA
40 year old lawyerwith anemia and heme (+) stools
Endo : GERD,reflux esophagitis
Biopsies: BE withfocal HGDin 1 biopsy
T1 CA
20 Mhz EUS probe
Occult CA in BE HGD
Presenter
Presentation Notes
EUS visualized a focal cancer invading into the submucosa, which led to bite-on-bite jumbo biopsy and a histologic diagnosis of CA not made by previous endoscopy. Hence, EUS directly impacted on the decision to treat with esophagectomy versus repeat EGD in 3 months after treatment with PPI
Abnormal Stomach
EUS Pancreas Mass Core Biopsy
Pseudotumor - AIP
In Vivo Confocal Laser Endomicroscopy (CLE)
Confocal Laser Endomicroscopy
Field of view: 550x550µmImaging depth: 0-250µmLateral and axial resolution: <1µm 1024 x 1024 pixels
the true optical biopsy
Presenter
Presentation Notes
When endomicroscopy is performed, the endoscope is placed against the mucosa and blue laser light is used to obtain images. The field of view is 550 um and the imaging depth can be adjusted from 0 to 250 microns. The lateral and axial resolution are < 1 um.
Normal Colonic Mucosa
Slide courtesy of Ralf Kiesslich, Mainz Germany
Transverse View Normal Small Bowel (Villi)
Contrast dyes
IV FluoresceinStains surface cells,
lamina propria, b.v., RBC, WBC but not nuclei
Topical AcriflavineStains surface cells, absorbed into nuclei
b.m.
nuclei
Presenter
Presentation Notes
10% IV fluorescein (not diluted)– 10 ml, 5 ml enough, can re-inject if like but can get bleaching; after 30 minutes good views, tract up to 60 min; disadvantage – cannot see nuclei because of pharmacokinetic properties of fluorescein not because of the endomicroscope; advantage; can highlight vascular bright structures underneath mucosa in LP with RBC in b.v; WBC Acriflavine only – can see nuclei (dots at bases), lamina propria (tissue between , and basal membrane (white strings around crypts); eg. collagenous colitis (can see collagen bland); absorption limited to 10-100 um from surface,; mucosa becomes more yellow endoscopically; microscopically – nuclei readily available (absorbed into muclei – can even see chromatin);
Contrast dyes
IV FluoresceinStains surface cells,
lamina propria, b.v., RBC, WBC but not nuclei
Topical AcriflavineStains surface cells, absorbed into nuclei
b.m.
nuclei
b.v.
Presenter
Presentation Notes
10% IV fluorescein (not diluted)– 10 ml, 5 ml enough, can re-inject if like but can get bleaching; after 30 minutes good views, tract up to 60 min; disadvantage – cannot see nuclei because of pharmacokinetic properties of fluorescein not because of the endomicroscope; advantage; can highlight vascular bright structures underneath mucosa in LP with RBC in b.v; WBC Acriflavine only – can see nuclei (dots at bases), lamina propria (tissue between , and basal membrane (white strings around crypts); eg. collagenous colitis (can see collagen bland); absorption limited to 10-100 um from surface,; mucosa becomes more yellow endoscopically; microscopically – nuclei readily available (absorbed into muclei – can even see chromatin);
EndomicroscopySubsurface Imaging
25
0µ
m
7µm
Optical Resolution
lateral and axial <1µm
5 ml 10% fluorescein
Acriflavine 0.05%
Presenter
Presentation Notes
Confocal imaging allows a transverse sectioning from surface to deeper parts of the mucosa. However, the submucosal layer can not be reached and imaged. The optical resolution is less than 1µm, optical slice thickness 7µm and the infiltration depth ranges from 0 to 250µm. Prerequisite for confocal imaging is the application of a contrast agent. In the current study 5 ml fluorescein (10%) was applied intravenously after reaching the cecum.
60 m depth, high resolution probe - only few crypts per fields of view
Normal Esophageal MucosaNonkeratinized Squamous Epithelium
Normal Esophageal MucosaNonkeratinized Squamous Epithelium
Normal Esophageal MucosaNonkeratinized Squamous Epithelium
Normal Esophageal MucosaNonkeratinized Squamous Epithelium
Squamous Cell Epithelium
Normal Squamo-Columnar Junction
Normal Squamous Mucosa
NERD
Increased number and tortuosityof intrapapillary capillary loops
Dilated intracellular spaces
Presenter
Presentation Notes
Slide 30 Esophagus NERD – proliferation of basal cells and elongation of papilla—more IPCL capillaries in upper parts and close to surface; can scan from surf to deep (early capillaries present with RBC) within squamous mucosa – diagnostic of NERD Cellular junctions not so close compared to normal squamous (no borders, all gray cant identify single cells) – dilated intracellular spaces
In-Vivo Confocal BE ClassificationBE Cell architecture
Columnar-lined villiform epithelium with dark goblet cells (upper mucosa)
Confocal laser endomicroscopy (CLE) is a new endoscopic technology allowing in vivo cellular imaging of gastrointestinal mucosa at subcellular resolution. Aim: To determine the interobserver agreement of CLE optical biopsy diagnosis made by gastroenterologists with different CLE experience levels and pathologists. Methods: 25 single confocal images were randomly selected from 2 image de-identified libraries with histologically proven normal and abnormal images of the esophagus, stomach, small bowel and colon obtained prospectively during fluorescein-aided CLE. The seven participants included gastroenterologists with different levels of CLE experience and pathologists with.different levels of CLE exposure. Each participant independently selected the most likely specific diagnosis for each image from a list of possibilities without knowledge of the final pathological diagnoses. Interobserver agreement was analyzed and kappa statistics overall and by strata were determined. The proportion of correctly identified images was also determined for each participant. Results: The overall agreement for the 7 participants was moderate (=0.56). Agreement for all gastroenterologists was substantial (=0.68) and was moderate for all pathologists (=0.58), with no significant difference between the 2 groups. Moroever, there was also no significant difference for GIs with different experience levels, with both groups having substantial agreement (=0.64 for experienced GIs and =0.76 for novice GIs). Agreement was substantial and highest for neoplastic images (=0.70), followed by normal images (=0.38) and abnormal non-neoplastic images (=0.19). The overall mean proportion of correct answers (optical biopsy interpretation matching tissue pathology) per participant was 74% (range 68-84%), with no significant difference by experience level in CLE or background (GI vs. pathology). Conclusions: In vivo histology images provided by confocal laser endomicroscopy can be correctly and reliably interpreted by gastroenterologists, even after limited experience with this new endoscopic imaging technique. The agreement among gastroenterologists is not significantly different from GI pathologists. Interobserver agreement was moderate to substantial in both groups. Thus, the reliability of CLE as a diagnostic test performed by gastroenterologists is high regardless of experience level.
Interobserver Agreement
Modality kappaCLE –gastroenterologists and pathologists 0.56CLE – gastroenterologists, dif. experience 0.81EUS staging of esophageal tumors, T1-T4 0.19 – 0.41
Diagnostic yield for neoplasia (per biopsy analysis)
33% 17% 0.03
CLE-DB = SE-RB comparable for detection of HGD/CA (per patient)
Dunbar et al, GIE October 2009
Presenter
Presentation Notes
CLE almost doubled the diagnostic yield fo neoplasia (fewer smarter biopsies)
BE Surveillance
Per Patient Analysis CLE-TB SE-RB p
Mean number of positive biopsies 0 0 -
Mean number of mucosal biopsies 1.8 12.9 <0.0001
Two thirds of patients in the surveillance group had NO mucosal biopsies taken
Dunbar et al, GIE 2009
Presenter
Presentation Notes
In the group referred for BE surveillance, there were no cases of HGD or cancer. The mean number of mucosal biopsies taken per case was singificantly lower in the CLE-TB group at 1.8 compared to 12.9 biopsies in the standard endoscopy group.
In Vivo Endoscope-Based Confocal Laser Endomicroscopy Improves Detection of Unlocalized Barrett’s Neoplasia Over High Resolution
Endoscopy and Impacts Clinical Decision-Making
DDW 2012
Presenter
Presentation Notes
Diagnostic Yield – Per Biopsy
p<0.0001
p<0.0001
p=0.067
Canto et al, DDW 2012
Diagnostic Yield – Per Patient
p=.0004
p=.002
p=0.353
Canto et al, DDW 2012
Presenter
Presentation Notes
eCLE : 3 of 70 patients with inaparent flat HGD/CA
Performance CharacteristicseCLE for BE Neoplasia
Per Biopsy Per Patient
HD
n=580
HD + CLE
n=398
HD
n=98
HD + CLE
n=94
Sens 10% 86%1 40% 95%4
Spec 99% 93%2 98% 92%
PPV 67% 65% 75% 77%
NPV 94% 98%3 90% 98%5
Accur 93% 92% 89% 93%
HD + eCLE vs. HD alone
• Clinical impact:–eCLE group: 10/28 (37.4%) patients had a change in plan due to in vivo change in diagnosis•50% - do EMR instead of biopsy•50% - do nothing or biopsy instead of EMR
Presenter
Presentation Notes
Flat HGD or CA found in HD alone group: 50% (5/10) random bx HD + eCLE: 81% ( / )of targeted mucosal biopsies and all EMRs Lesions: all 10 of 28 lesions with plan change were nonpolypoid or Paris 2a-c In those with + impact: 5/10= do EMR in pts with final path HGD/CA instead of Bx 5/10 = do bx in pts with final path HGD/CA2/10 , or do nothing (no bx) in pts with final path BE/gastric No change 6= change in dx no change in plan 12= no change in dx or plan
• No contrast agent –autofluorescence from NAHD, flavins, collagen
• Cellular + subcellular resolution
• Structural + biochemical
Rogart, Clin Gastro Hepatol 2009
Presenter
Presentation Notes
The recent development of a confocal endomicroscope3 provides, for the first time, the ability to perform real-time in vivo microscopy, but the usefulness of this imaging modality in patients is limited because it requires topical or systemic administration of fluorescent probes1. Multiphoton microscopy (MPM), also known as two-photon laser scanning microscopy, relies on nonlinear optical processes such as two-photon fluorescence and second harmonic generation (SHG) to achieve high resolution 3D imaging of biological tissues4,5. SHG is a coherent nonlinear scattering process in which two photons of lower energy are combined to create a single photon of exactly twice the energy of the two fundamental photons. MPM provides several advantages over single-photon, linear microscopy technologies such as confocal laser scanning microscopy (CLSM), including the generation of autofluorescence images without the need for fluorescent dyes or potentially damaging direct ultraviolet illumination and the greater capacity for deep tissue imaging. Fluorescence for multiphoton images of unstained fresh tissue derives from intrinsic molecules that are fluorescent such as NADH and flavins, and from collagen, which is an extremely effective second harmonic generator6.
In Vivo Molecular Imaging
• Real-time in vivo microscopic imaging not dependent upon morphology
• Fluorescent agent (beacon) +–Whole antibody–Parts of antibody–Peptide markers–Nanoparticles
Presenter
Presentation Notes
Beacon of light - Moon, jupiter venus
Molecular ImagingFluorescent Peptide Markers
probe-confocal microscopy(specific to disease)
fluorescence endoscopy(wide field scanning)
Hsiung et al, Nature Medicine 2008; Anastassiades 2012
Colonic Cell Shedding
Slide courtesy of Ralf Kiesslich, Mainz Germany
Slide courtesy of Ralf Kiesslich, Mainz Germany
Gaps in the gut
Kiesslich et al. Gastroenterology 2007
Mechanistic Studies in IBD
• Bacterial translocation via gaps
• Increased shedding with increased
permeability
• Epithelial destruction (micro-erosions)
Bacterial translocation via gaps
Slide courtesy of Ralf Kiesslich, Mainz Germany
Massive shedding
Slide courtesy of Ralf Kiesslich, Mainz Germany
Micro-erosions
Slide courtesy of Ralf Kiesslich, Mainz Germany
• In vivo diagnosis–can lead to smarter tissue sampling and
therapy• impacts patient care and empowers both
the endoscopist and the pathologist• may help us understand pathophysiology
