共聚焦显微内镜对胃凹陷型病变的鉴别诊断价值

目的共聚焦显微内镜（CEM）是将共聚焦显微镜整合于内镜头端的一种新型内镜,可在细胞水平观察活体组织。本研究目的是评价CEM在内镜检查的同时对胃凹陷型病变的病理预测价值。方法应用CEM对43例患者的51个凹陷型病灶进行检查。将CEM诊断与相应部位活检标本的常规病理结果进行前瞻性和双盲对比。结果对每个病灶的边缘和（或）中心的共172个点进行共聚焦扫描,获得4872幅共聚焦图像。CEM可以获得活体的胃黏膜表面和表面下清晰的细胞和胃小凹结构的荧光图像。CEM对胃癌诊断的敏感度、特异度和准确度分别为95．7％、97．6％、97．1％。结论CEM可以在内镜检查的同时对胃癌组织做出准确度很高的虚拟病理学检查,对于胃凹陷型病变的鉴别诊断及胃癌的早期诊断具有较高的应用价值。     

A fluorescence confocal endomicroscope for in vivo microscopy of the upper- and the lower-GI tract

BACKGROUND: This report describes the development and the clinical evaluation of a novel confocal endomicroscope for obtaining fluorescence images of cellular morphology of the mucosae of the upper- and the lower-GI tract in vivo. The work assessed the feasibility of performing in vivo microscopy at endoscopic examination and evaluated fluorescence imaging protocols. METHODS: Images were collected in real time by using two prototype endoscope configurations, featuring slightly different miniaturized fiber-optic confocal microscopes, fitted integrally into the tips of conventional endoscopes. Confocal scanning was performed at 488 nm illumination for excitation of exogenously applied fluorophores (topical acriflavine and intravenous fluorescein). The images were compared with conventional histology of biopsy specimens and the findings of white-light endoscopy. RESULTS: Confocal endomicroscopy enabled imaging of cellular and subcellular structures (i.e., nuclei) of the GI tract. The crypts of the colonic mucosa, the villi of the terminal ileum and duodenum, the gastric pits of the stomach, and the squamous epithelium of the distal esophagus could be clearly visualized. Acriflavine strongly contrasted the cell nuclei of the surface epithelium, including the absorptive epithelial cells and the mucous secreting goblet cells. Fluorescein stained the extracellular matrix of the surface epithelium and also the subepithelial layers of the lamina propria. Images at increasing depth beneath the epithelium showed the mucosal capillary network. The findings correlated with the histology of biopsy specimens. CONCLUSIONS: The development of a fluorescence confocal endomicroscope makes it practical to examine the upper- and the lower-GI mucosa in cellular detail during otherwise routine endoscopic examination. The results represent a major technical advance in the development of this new optical imaging modality for the in vivo examination of GI tissue.     

共聚焦内镜对胃黏膜肠上皮化生的诊断价值

目的确定胃黏膜肠上皮化生的共聚焦内镜下形态学特征，探讨其组织学诊断价值。方法应用共聚焦内镜对78例患者进行常规胃镜检查，标准位置及有黏膜可疑病变部位用共聚焦内镜观察，制定共聚焦内镜下肠上皮化生的判定标准，与相应部位活检的病变组织的病理学检查结果进行比较分析。结果对患者的483个位置进行共聚焦扫描，获得12497幅图像，共聚焦内镜可以获得在体的胃小凹、上皮细胞、结缔组织和微血管网的高清晰的荧光图像，与病理一致。杯状细胞有特异的形态学特征，易于识别。43位患者的165块活检组织经病理确诊为肠上皮化生，其中普通内镜诊断50处，共聚焦内镜诊断163处，共聚焦内镜对肠上皮化生诊断明显优于普通内镜，其敏感性、特异性和准确性分别为98．79％，98．43％和98．76％。结论共聚焦内镜是一种全新的诊断工具，可以在内镜检查同时进行活体的虚拟组织学诊断，是准确诊断肠上皮化生的一种新方法。     

Diagnosing Helicobacter pylori in vivo by confocal laser endoscopy

BACKGROUND & AIMS: Confocal laser endomicroscopy enables subsurface microscopic imaging of living tissue during ongoing endoscopy. This case report describes the in vivo detection of Helicobacter pylori by endomicroscopy. METHODS: Endomicroscopy (Pentax, Tokyo, EC-3870CIFK) was performed by using two different contrast stains: Topical Acriflavine in addition to intravenously applied fluorescein netted the surface and allowed identification of focal accumulation of Helicobacter pylori at the surface and in deeper layer of the gastric epithelium. Biopsies were performed at the antrum and corpus for urease testing and histology. In addition, biopsies were cultured for Helicobacter pylori. Cultured bacteria were re-assessed ex vivo using confocal microscopy with and without acriflavine staining. RESULTS: Helicobacter pylori infection could be detected in a 70-year-old male by endomicroscopy. Accumulated, as well as single bacteria, could be observed and the distinct shape and flagella of Helicobacter pylori could be identified. Helicobacter pylori infection was proved by histology. Furthermore, ex vivo examination of cultures proved the presence of Helicobacter pylori and the active uptake of acriflavine into the bacteria. CONCLUSIONS: Endomicroscopy is a new diagnostic approach, which enables the immediate diagnosis of Helicobacter pylori in vivo during standard video endoscopy.     

In vivo histology of Barrett's esophagus and associated neoplasia by confocal laser endomicroscopy.

BACKGROUND & AIMS: Confocal laser endomicroscopy allows subsurface analysis of the intestinal mucosa and in vivo histology during ongoing endoscopy. Here, we have applied this technique to the in vivo diagnosis of Barrett's epithelium and associated neoplasia. METHODS: Fluorescein-aided endomicroscopy was performed by applying the endomicroscope over the whole columnar-lined lower esophagus. Images obtained within 1 cm of the columnar-lined lower esophagus were stored digitally and a targeted biopsy examination or endoscopic mucosal resection of the examined areas was performed. In vivo histology was compared with the histologic specimens. All digitally stored images were re-assessed by a blinded investigator by the confocal Barrett classification system to predict histology. Intraobserver and interobserver variations of the involved endoscopists were evaluated by using kappa statistics. RESULTS: Endomicroscopy allowed distinguishing between different types of epithelial cells and detected cellular and vascular changes in Barrett's epithelium at high resolution during ongoing endoscopy in 63 patients. Barrett's esophagus and associated neoplasia could be predicted with a sensitivity of 98.1% and 92.9% and a specificity of 94.1% and 98.4%, respectively (accuracy, 96.8% and 97.4%). The mean kappa value for interobserver agreement for the prediction of histopathological diagnosis was .843, whereas the intraobserver agreement showed a mean kappa value of .892. CONCLUSIONS: Fluorescence-aided endomicroscopy of Barrett's esophagus allows in vivo histology of the mucosal layer during ongoing endoscopy. Gastric and Barrett's epithelium and Barrett's-associated neoplastic changes can be diagnosed with high accuracy. Thus, endomicroscopy may be helpful in the management of patients with Barrett's esophagus.     

New endoscopic imaging techniques in surveillance of inflammatory bowel disease

Endoscopy plays a crucial role in the management of inflammatory bowel disease(IBD). Advancesimaging techniques allow visualization of mucosal details, tissue characteristics and cellular alteration. In particular chromoendoscopy, magnification endoscopy, confocal laser endomicroscopy and endocytoscopy seem to have the possibility to radically modify the approach to surveillance and decision making. Dyebased chromoendoscopy(DBC) and magnification chromoendoscopy improve detection of dysplasia, and evaluation of inflammatory activity and extension of ulcerative colitis and are thus considered the standard of care. Dye-less chromoendoscopy could probably replace conventional DBC for surveillance. Narrow band imaging and i-scan have shown to improve activity and extent assessment in comparison to white-light endoscopy. Confocal laser endomicroscopy(CLE) can detect more dysplastic lesions in surveillance colonoscopy and predict neoplastic and inflammatory changes with high accuracy compared to histology. This technology is best used in conjunction with chromoendoscopy, narrow-band imaging, or autofluorescence because of its minute scanning area. This combination is useful for appropriate tissue classification of mucosal lesions already detected by standard or optically enhanced endoscopy. The best combination for IBD surveillance appear to be chromoendoscopy for identification of areas of suspicion, with further examination with CLE to detect intraepithelial neoplasia. However cost, availability, and experience are still an issue.     

共聚焦激光显微内镜对早期上消化道肿瘤的诊断价值

上消化道肿瘤的早期诊断对改善患者的预后至关重要。共聚焦激光显微内镜是新近发展起来的新型内镜，可在常规内镜检查的同时获得放大1000倍的胃肠道表面和表面下的虚拟组织学图像。从而有可能提高诊断准确率。本文就共聚焦激光显微内镜在诊断早期上消化道肿瘤中的应用作一概述。     

In vivo subsurface morphological and functional cellular and subcellular imaging of the gastrointestinal tract with confocal mini-microscopy

AIM： To evaluate a newly developed hand-held confocal probe for in vivo microscopic imaging of the complete gastrointestinal tract in rodents.
METHODS： A novel rigid confocal probe （diameter 7 mm） was designed with optical features similar to the flexible endomicroscopy system for use in humans using a 488 nm single line laser for fluorophore excitation, Light emission was detected at 505 to 750 nm. The field of view was 475 μm × 475 μm. Optical slice thickness was 7 μm with a lateral resolution of 0.7 μm. Subsurface serial images at different depths （surface to 250 μm） were generated in real time at 1024 × 1024 pixels （0.8 frames/s） by placing the probe onto the tissue in gentle, stable contact. Tissue specimens were sampled for histopathological correlation.
RESULTS： The esophagus, stomach, small and large intestine and meso, liver, pancreas and gall bladder were visualised in vivo at high resolution in n = 48 mice. Real time microscopic imaging with the confocal minimicroscopy probe was easy to achieve. The different staining protocols （fluorescein, acriflavine, FITC-labelled dextran and L. esculentum lectin） each highlighted specific aspects of the tissue, and in vivo imaging correlated excellently with conventional histology. In vivo blood flow monitoring added a functional quality to morphologic imaging.
CONCLUSION： Confocal microscopy is feasible in vivo allowing the visualisation of the complete GI tract at high resolution even of subsurface tissue structures. The new confocal probe design evaluated in this study is compatible with laparoscopy and significantly expands the field of possible applications to intra-abdominal organs. It allows immediate testing of new in vivo staining and application options and therefore permits rapid transfer from animal studies to clinical use in patients.     

Computed virtual chromoendoscopy for classification of small colorectal lesions: a prospective comparative study

OBJECTIVES: Standard colonoscopy offers no reliable discrimination between neoplastic and nonneoplastic colorectal lesions. Computed virtual chromoendoscopy with the Fujinon intelligent color enhancement (FICE) system is a new dyeless imaging technique that enhances mucosal and vascular patterns. This prospective trial compared the feasibility of FICE, standard colonoscopy, and conventional chromoendoscopy with indigo carmine in low- and high-magnification modes for determination of colonic lesion histology. METHODS: Sixty-three patients with 150 flat or sessile lesions less than 20 mm in diameter were enrolled. At colonoscopy, each lesion was observed with six different endoscopic modalities: standard colonoscopy, FICE, and conventional chromoendoscopy with indigo carmine (0.2%) dye spraying in both low- and high-magnification modes. Histopathology of all lesions was confirmed by evaluation of endoscopic resection or biopsy specimens. Endoscopic images were stored electronically and randomly allocated to a blinded reader. RESULTS: Of the 150 polyps, 89 were adenomas and 61 were hyperplastic polyps with an average size of 7 mm. For identifying adenomas, the FICE system with low and high magnifications revealed a sensitivity of 89.9% and 96.6%, specificity of 73.8% and 80.3%, and diagnostic accuracy of 83% and 90%, respectively. Compared with standard colonoscopy, the sensitivity and diagnostic accuracy achieved by FICE were significantly better under both low (P < 0.02) and high (P < 0.03) magnification and were comparable to that of conventional chromoendoscopy. CONCLUSIONS: The FICE system identified morphological details that efficiently predict adenomatous histology. For distinguishing neoplastic from nonneoplastic lesions, FICE was superior to standard colonoscopy and equivalent to conventional chromoendoscopy.     

Endoscopic imaging: emerging optical techniques for the detection of colorectal neoplasia.

PURPOSE OF REVIEW: Advances in bioengineering have spawned various imaging modalities which have revolutionized endoscopy. Some of these technologies provide real-time, high-resolution, subcellular imaging. This review provides an update on these technologies and their role in the evaluation of colorectal neoplasia. RECENT FINDINGS: Narrow band imaging has been shown to visualize capillary patterns in early cancer and is complementary to magnification endoscopy. Optical coherence tomography has been used to evaluate neoplastic progression and distinguish Crohn's from ulcerative colitis. Confocal endomicroscopy has been shown to accurately predict neoplastic changes in polyps and identify areas of neoplasia in patients with colitis. Among the spectroscopic techniques, autofluorescence is best studied in the colon and has been used to identify adenomas and dysplasia in inflammatory bowel disease. Endocytoscopy is a relatively new technology but shows promise in distinguishing neoplastic lesions. SUMMARY: Recently a number of imaging technologies have arisen that have the potential to enhance our detection of colorectal neoplasia. Several of these, such as autofluorescent imaging and narrow band imaging, are 'red flag' techniques which enhance our visualization of mucosal change(s). Complementary technologies, such as confocal endomicroscopy and endocytoscopy, provide subcellular imaging. Combined with a 'red flag' technique, these may transform our approach to colonoscopy, allowing the real-time detection and diagnosis of neoplasia.     

Efficacy of magnifying chromoendoscopy for the differential diagnosis of colorectal lesions

Magnifying chromoendoscopy is an exciting new tool and offers detailed analysis of the morphological architecture of mucosal crypt orifices. In this review, we principally show the efficacy of magnifying chromoendoscopy for the differential diagnosis of colorectal lesions such as prediction between non‐neoplastic lesions and neoplastic ones, and distinction between endoscopically treatable early invasive cancers and untreatable cancers based on a review of the literature and our experience at two National Cancer Centers in Japan. Overall diagnostic accuracy by conventional view, chromoendoscopy and chromoendoscopy with magnification ranged from 68% to 83%, 82% to 92%, and 80% to 96%, respectively, and diagnostic accuracy of accessing the stage of early colorectal cancer using magnifying colonoscopy was over 85%. Although the reliability depends on the skill in magnifying observation, widespread applications of the magnification technique could influence the indications for biopsy sampling during colonoscopy and the indication for mucosectomy. Moreover, the new detailed images seen with magnifying chromoendoscopy are the beginning of a new period in which new optical developments, such as narrow band imaging system, endocytoscopy system, and laser‐scanning confocal microscopy, will allow a unique look at glandular and cellular structures.     

共聚焦内镜对胃黏膜肠上皮化生诊断价值的初步研究

目的探讨共聚焦内镜对胃黏膜肠上皮化生诊断的可行性及准确度。方法对受检者胃底、胃体、胃窦行全面的普通内镜视野扫查后，对胃窦、胃体、贲门部位进行共聚焦图像采集，并在图像采集部位取活组织进行病理检查，然后将共聚焦图像诊断结果与病理诊断进行对照分析。结果扫查部位共42个，其中贲门4个，胃体5个，胃窦33个。共聚焦内镜诊断的符合率为90．5％（38／42），敏感度为100．0％（15／15），特异度85．2％（23／27），阳性预测值为78．9％（15／19），阴性预测值为100．0％（23／23）。结论共聚焦内镜能够显示出胃黏膜肠上皮化生的主要形态，对于肠上皮化生的诊断具有较高的准确度、敏感性以及阴性预测值。     

In vivo characterisation of superficial colorectal neoplastic lesions with high-resolution probe-based confocal laser endomicroscopy in combination with video-mosaicing: A feasibility study to enhance routine endoscopy

Background

Recent technological advances in miniaturisation have allowed for a confocal scanning microscope to be integrated into trans-endoscopic probes enabling endoscopists to collect in vivo virtual biopsies of the gastrointestinal mucosa during endoscopy.

Aims

The aim of the present study was to assess prospectively the clinical applicability and predictive power of a probe-based confocal laser endomicroscopy for the in vivo diagnosis of colorectal neoplasia.

Methods

Patients with evidence of colorectal superficial neoplasia at routine endoscopy, were included prospectively in this study. Lesions were identified using white-light endoscopy followed by pCLE imaging recorded by a Coloflex UHD-type probe. The images were interpreted as either neoplastic or not according to vascular and cellular changes. pCLE readings were then compared with histopathological results from endoscopically resected lesions and/or targeted biopsy specimens.

Results

A total of 32 lesions were identified in 20 consecutive patients. Histopathology diagnosis was of adenomas in 19 cases, hyperplastic polyps in 11 cases and adenocarcinoma in 2 cases. For the detection of neoplastic tissue pCLE had a sensitivity of 100%, a specificity of 84.6%, an accuracy of 92.3, a PPV of 90.5% and a NPV of 100%.

Conclusions

pCLE permits high-quality imaging, enabling prediction of intraepithelial neoplasia with a high level of accuracy.     

Technicalities of colonoscopy: endoscopic microscopy - where are we heading?

Confocal laser endomicroscopy (CLE) is a new endoscopic imaging tool enabling in vivo histology during ongoing endoscopy. Basically, three different patterns can be seen in the colon: normal, neoplastic and inflammatory mucosa. Several pilot studies have shown an excellent correlation with classical histology. However, what could be the future indications of CLE? (1) Differentiating neoplastic from inflammatory changes constitutes a promising diagnostic tool in screening for dysplasia in ulcerative colitis. This can help to further increase the efficacy of chromoendoscopy in dysplasia detection and reduce the number of biopsies. The possibility to differentiate sporadic adenoma from dysplasia-associated lesion or mass could have an immediate impact on patient management. (2) The diagnosis of collagenous colitis depends on multiple random biopsies. Case series have shown that CLE can guide the endoscopist to take more representative biopsies to make the diagnosis. Large prospective trials are needed to confirm this finding. (3) An interesting clinical application is graft-versus-host disease (GVHD). A pilot study showed that it was possible to predict the presence of GVHD in 14/19 patients with GVHD out of 35 patients who were referred for diarrhea after stem cell transplantation. (4) CLE for standard polyp surveillance is probably redundant since it will not change patient management at this stage. Moreover, it can currently not differentiate between classical hyperplastic and sessile serrated adenomas. (5) Future additional technological improvements of the system with faster Z-scanning, deeper light penetration and 3D reconstruction will help to improve the quality of CLE. Reports on in vivo molecular imaging and assessment of physiological changes provide a promising glance at the future possibilities of CLE imaging.     

In Vivo Detection of Experimental Ulcerative Colitis in Rats Using Fiberoptic Confocal Imaging (FOCI)

Fiberoptic confocal imaging (FOCI) is a noninvasive microscopic technique that enables subsurface imaging of living tissue in vivo. The aim of the present study was to assess the suitability of FOCI for the in vivo detection of early subsurface changes in the mucosal architecture of the colon in a rat model of ulcerative colitis. Mild colitis was induced in Sprague-Dawley rats (180–250 g) by the oral ingestion of 5% (w/v) dextran sulfate sodium (DSS; Mr 40,000 Da) in drinking water. Control animals were provided with water ad libitum. After three, five or seven days of oral consumption of DSS, the mucosal surface of the colon of anesthetised rats was surgically exposed. Morphological changes in the mucosa were examined (Optiscan F900e personal confocal system with rigid endomicroscope attachment; excitation 488 nm argon ion laser, detection above 515 nm) following the topical application of a fluorescent dye (fluorescein, eosin, or acridine orange). Confocal images were correlated with conventional histology and clinical parameters including occult blood and stool consistency. Histological evaluation of colon sections demonstrated that DSS-induced colitis was characterized by focal loss of mucous crypts, loss of epithelial cells, and neutrophilic infiltration into the mucosa. The extent of mucosal damage was positively correlated with the time of ingestion of DSS. Morphological changes associated with disease activity could be detected microscopically in vivo using FOCI but were not evident by visual inspection of the colon surface. Acridine orange enabled imaging of the colonic crypts at the surface of the mucosa. Morphological changes associated with colitis, including inflammatory cell infiltrate, crypt loss, and crypt distortion, could be detected using this fluorophore. Application of fluorescein and eosin enabled subsurface imaging of the lamina propria surrounding the crypts; however, no change in structure was detected in association with colitic disease activity. This study has shown that the topical application of acridine orange enables in vivo imaging of early colitis in a rat model. FOCI may be suitable for the diagnosis and monitoring of human inflammatory bowel disease.     

共聚焦内镜在消化道疾病诊断中的应用

共聚焦内镜是一种新的内镜成像技术,在做内镜检查的同时,即可通过点扫描激光分析获得消化道上皮高度放大的图像,不需活检和组织病理检查,就可获得组织学诊断。此文主要通过介绍该内镜技术及其所能诊断的疾病谱,来说明其在消化道疾病尤其是消化道早期肿瘤及癌前期病变的诊断和监测中的独特价值。     

Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis

BACKGROUND AND AIMS: Because of the large number of biopsy specimens, surveillance colonoscopy in ulcerative colitis (UC) is currently time consuming and significant flat lesions still may be missed. In this study we assessed the value of combined chromoscopy and endomicroscopy for the diagnosis of intraepithelial neoplasias in a randomized controlled trial. METHODS: A total of 161 patients with long-term UC in clinical remission were randomized at a 1:1 ratio to undergo conventional colonoscopy or chromoscopy with endomicroscopy. Eight patients were excluded because of insufficient bowel preparation. In the conventional colonoscopic group (n = 73), random biopsy examinations and targeted biopsy examinations were performed. In the endomicroscopy group (n = 80), circumscribed mucosal lesions were identified by chromoscopy and evaluated for targeted biopsy examination by endomicroscopy. The primary outcome analysis was based on the detection of neoplasias. RESULTS: By using chromoscopy with endomicroscopy, 4.75-fold more neoplasias could be detected (P = .005) than with conventional colonoscopy, although 50% fewer biopsy specimens (P = .008) were required. If only circumscribed lesions would have been biopsied in the first group, the total number of biopsy specimens could have been reduced by more than 90%. A total of 5580 confocal endomicroscopic images from 134 circumscribed lesions were compared with histologic results. The presence of neoplastic changes could be predicted by endomicroscopy with high accuracy (sensitivity, 94.7%; specificity, 98.3%; accuracy, 97.8%). CONCLUSIONS: Endomicroscopy based on in vivo histology can determine if UC lesions identified by chromoscopy should undergo biopsy examination, thereby increasing the diagnostic yield and reducing the need for biopsy examinations. Thus, chromoscopy-guided endomicroscopy may lead to significant improvements in the clinical management of UC.     

Pilot study on confocal endomicroscopy for determination of the depth of squamous cell esophageal cancer in vivo

Background and Aim:  Confocal endomicroscopy is ultra-high-magnification endoscopy with histological observation during ongoing endoscopy. We planned a pilot study of the diagnosis of the depth of esophageal cancer using confocal endomicroscopy for treatment strategies.
Methods:  Patients had 14 superficial esophageal cancers and one dysplasia. The depth of neoplasms in 15 lesions was confirmed by endoscopic mucosal resection or surgery.
We examined the rate of delineation and compared results of confocal imaging with histological findings. We classified two cellular and three microvascular patterns on confocal endomicroscopic images: CP-N for normal squamous mucosa and CP-Ca for cancerous lesion; VP-type A for normal squamous mucosa; VP-type B for T1a-EP and T1a-LPM cancers; and VP-type C for T1a-MM or a more invasive cancer pattern. We measured diameters of microvessels for the three patterns of confocal endomicroscopic images and histological specimens.
Results:  The rate of delineation was 73.3% (11/15) for esophageal cancer. The results of confocal imaging coincided well with microvessel distribution on horizontal histology. Two endoscopists blindly diagnosed the two types by cellular pattern and the three types by vascular pattern: their overall accuracies were 96% and 89% for the cellular pattern and 85% and 85% for the vascular pattern, respectively. The k value of the cellular pattern and the vascular pattern diagnosis was 0.84 and 0.75, respectively.
Conclusion:  Scoring and quantification of confocal endomicroscopic images may be useful for the differential diagnosis and diagnosis of superficial invasion by squamous cell carcinoma.