Study shows in vivo endomicroscopy improves detection of Barrett's esophagus-related neoplasia

New research shows that the addition of confocal laser endomicroscopy to high-definition white-light endoscopy enables improved real-time endoscopic diagnosis of Barrett's esophagus dysplasia (neoplastic tissue) by using targeted biopsies of abnormal mucosa to reduce unnecessary mucosal biopsies and potentially reduce costs. It may also positively influence patient care by changing the plan for immediate endoscopic management. The study appears in the February issue of GIE: Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the American Society for Gastrointestinal Endoscopy (ASGE).

Barrett's esophagus (BE) is a precancerous change in the epithelial lining of the esophagus that is associated with the development of esophageal cancer. The current best, though imperfect, marker of neoplastic progression is dysplasia (abnormality in cells which have undergone early changes on a path toward possible malignancy) detected in mucosal biopsy specimens of the lining of the esophagus obtained at the time of endoscopy. High-grade dysplasia is associated with a high rate of progression to invasive esophageal cancer. Detection and pathologic confirmation of early BE neoplasia (high-grade dysplasia or early esophageal cancer) is important because endoscopic therapy at this point is highly successful. Unfortunately, neoplasia in BE may not be evident even with only endoscopic inspection, so the current standard of care is endoscopic surveillance with high-quality white-light endoscopy using systematic 4-quadrant biopsies every 1 to 2 cm of BE length and targeted biopsies of any mucosal irregularities. A large number of biopsies may be required using this random biopsy method, resulting in high cost and increased time. This method has a low (1 percent to 10 percent) diagnostic yield for neoplasia and may result in lower adherence to practice guidelines.

Confocal laser endomicroscopy (CLE) is a relatively new endoscopic imaging technique that combines endoscopy and microscopic imaging of the gastrointestinal (GI) mucosa (the superficial lining of the GI tract). A previous single-center, randomized, crossover study, demonstrated a greater diagnostic yield for the detection of BE neoplasia with an in vivo fluorescein-aided endoscope-based CLE system (eCLE).

"Our study compared the diagnostic yield and accuracy of high definition white-light endoscopy (HDWLE) and random biopsy with that of HDWLE plus real-time eCLE imaging and targeted tissue sampling of BE, and determined the impact of in vivo eCLE on real-time clinical decision making in patients with BE," said study lead author Marcia Irene Canto, MD, MHS, FASGE, Johns Hopkins University, Baltimore, Maryland. "We found that real-time eCLE and targeted biopsy after HDWLE can improve the diagnostic yield and accuracy for neoplasia and significantly impact in vivo decision making by altering the diagnosis and guiding therapy."

Methods

This was a multicenter, randomized, controlled trial of 192 adult patients with BE undergoing routine surveillance or referred for early neoplasia from February 2010 to December 2012 at academic medical centers. The researchers' objective was to compare high-definition white-light endoscopy (HDWLE) alone with random biopsy (RB) and HDWLE plus eCLE and targeted biopsy (TB) for diagnosis of BE neoplasia. Patients were randomized to HDWLE plus RB (group 1) or HDWLE with eCLE and TB (group 2). Real-time diagnoses and management plans were recorded after HDWLE in both groups and after eCLE in group 2. Blinded expert pathology diagnosis was the reference standard. The main outcomes were diagnostic yield, performance characteristics, and clinical impact.