Diagnostic utility of probe-based confocal laser endomicroscopy in superficial non-ampullary duodenal epithelial tumors

Abstract

Background and study aims Endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors (SNADETs) has not been established. Probe-based confocal laser endomicroscopy (pCLE: Cellvizio) provides real-time endomicroscopic analysis. We developed and validated a new pCLE classification of SNADET based on abnormal findings.

Patients and methods pCLE scanning of 20 SNADET lesions including 16 adenomas and four carcinomas was retrospectively evaluated to explore abnormal pCLE findings in relation to histological features. Diagnostic yield of pCLE findings was prospectively evaluated in an additional 20 SNADET lesions including 16 adenomas and four carcinomas.

Results In a retrospective study, we identified four abnormal pCLE findings of SNADETs: (1) dark epithelium, (2) columnar cells irregularly extending to the lumen, (3) distorted crypt structure, and (4) fluorescein leakage. Dark epithelium distinguished neoplastic lesions (adenomas and carcinomas) from non-neoplastic duodenal mucosa with a sensitivity of 90 % and a specificity of 100 %. Distorted crypt structure distinguished carcinomas from adenomas and non-neoplastic duodenal mucosa with a sensitivity of 100% and a specificity of 94 %. In the prospective study, the sensitivity and the specificity of the dark epithelium for the diagnosis of neoplastic lesions (adenomas + carcinomas) was 75% and 100 %. Sensitivity and the specificity of the distorted crypt structure for discrimination of carcinoma from adenoma were 100 % and 94 %, respectively.

Conclusions The pCLE findings correlated with the histopathology of the SNADETs. Dark epithelium and distorted crypt structure were informative pCLE findings to predict presence of neoplasia and cancer in the SNADET, respectively.

UMIN-CTR
UMIN000013857
TRIAL REGISTRATION: Single-Center, prospective observational trial UMIN000013857 at upload.umin.ac.jp

• References

• 1 Seifert E, Schulte F, Stolte M. Adenoma and carcinoma of the duodenum and papilla of Vater: a clinicopathologic study. Am J Gastroenterol 1992; 87: 37-42
• 2 Okada K, Fujisaki J, Kasuga A. et al. Sporadic nonampullary duodenal adenoma in the natural history of duodenal cancer: a study of follow-up surveillance. Am J Gastroenterol 2011; 106: 357-64
• 3 Kinoshita S, Nishizawa T, Ochiai Y. et al. Accuracy of biopsy for the preoperative diagnosis of superficial nonampullary duodenal adenocarcinoma. Gastrointest Endosc 2017; 86: 329-32
• 4 Wallace M, Lauwers GY, Chen Y. et al. Miami classification for probe-based confocal laser endomicroscopy. Endoscopy 2011; 43: 882-91
• 5 Neumann H, Kiesslich R, Wallace MB. et al. Confocal laser endomicroscopy: technical advances and clinical applications. Gastroenterology 2010; 139: 388-92.e1-2
• 6 Canto MI, Anandasabapathy S, Brugge W. et al. Confocal Endomicroscopy for Barrett's Esophagus or Confocal Endomicroscopy for Barrett's Esophagus (CEBE) Trial Group. In vivo endomicroscopy improves detection of Barrett’s esophagus-related neoplasia: a multicenter international randomized controlled trial (with video). Gastrointest Endosc 2014; 79: 211-221
• 7 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
• 8 Li Z, Yu T, Zuo XL. et al. Confocal laser endomicroscopy for in vivo diagnosis of gastric intraepithelial neoplasia: a feasibility study. Gastrointest Endosc 2010; 72: 1146-1153
• 9 Buchner AM, Shahid MW, Heckman MG. et al. Comparison of probe-based confocal laser endomicroscopy with virtual chromoendoscopy for classification of colon polyps. Gastroenterology 2010; 138: 834-842
• 10 Wanders LK, East JE, Uitentuis SE. et al. Diagnostic performance of narrowed spectrum endoscopy, autofluorescence imaging, and confocal laser endomicroscopy for optical diagnosis of colonic polyps: a meta-analysis. Lancet Oncol 2013; 14: 1337-1347
• 11 Lim LG, Neumann J, Hansen T. et al. Confocal endomicroscopy identifies loss of local barrier function in the duodenum of patients with Crohn's disease and ulcerative colitis. Inflamm Bowel Dis 2014; 20: 892-900
• 12 Shahid MW, Buchner A, Gomez V. et al. Diagnostic accuracy of probe-based confocal laser endomicroscopy and narrow band imaging in detection of dysplasia in duodenal polyps. J Clin Gastroenterol 2012; 46: 382-389
• 13 Nonaka K, Ohata K, Ichihara S. et al. Development of a new classification for in vivo diagnosis of duodenal epithelial tumors with confocal laser endomicroscopy: A pilot study. Dig Endosc 2016; 28: 186-193
• 14 Tahara T, Horiguchi N, Nagasaka M. et al. Probe-based confocal laser endomicroscopy (pCLE) images of submucosal growth of a duodenal mucous neck cell adenoma. Endoscopy 2016; 48 (Suppl. 01) E19-E21
• 15 Horiguchi N, Tahara T, Yamada H. et al. In vivo diagnosis of early-stage gastric cancer found after Helicobacter pylori eradication using probe-based confocal laser endomicroscopy. Dig Endosc 2018; 30: 219-227
• 16 Ohmiya N, Horiguchi N, Tahara T. et al. Usefulness of confocal laser endomicroscopy to diagnose ulcerative colitis-associated neoplasia. Dig Endosc 2017; 29: 626-633
• 17 Royer C, Lu X. Epithelial cell polarity: a major gatekeeper against cancer?. Cell Death Differ 2011; 18: 1470-1477
• 18 Prueksapanich P, Pittayanon R, Rerknimitr R. et al. Value of probe-based confocal laser endomicroscopy (pCLE) and dual focus narrow-band imaging (dNBI) in diagnosing early squamous cell neoplasms in esophageal Lugol's voiding lesions. Endosc Int Open 2015; 3: E281-E288
• 19 Oya M, Yao T, Nakamura T. et al. Intestinal phenotypic expression of gastric depressed adenomas and the surrounding mucosa. Gastric Cancer 2003; 6: 179-84
• 20 Kasuga A, Yamamoto Y, Fujisaki J. et al. Clinical characterization of gastric lesions initially diagnosed as low-grade adenomas on forceps biopsy. Dig Endosc 2012; 24: 331-338
• 21 Kikuchi D, Hoteya S, Iizuka T. et al. Diagnostic algorithm of magnifying endoscopy with narrow band imaging for superficial non-ampullary duodenal epithelial tumors. Dig Endosc 2014; 26 (Suppl. 02) 16-22
• 22 Pittayanon R, Rerknimitr R, Imraporn B. et al. Diagnostic values of dual focus narrow band imaging and probe-based confocal laser endomicroscopy in FAP-related duodenal adenoma. Endosc Int Open 2015; 3: E450-E455
• 23 Becker V, von Delius S, Bajbouj M. et al. Intravenous application of fluorescein for confocal laser scanning microscopy: evaluation of contrast dynamics and image quality with increasing injection-to-imaging time. Gastrointest Endosc 2008; 68: 319-323