Development of virtual histology and virtual biopsy using laser-scanning confocal microscopy

The aim of this project is to acquire a direct image of histology from in vivo gastrointestinal mucosa. In other words, the task of 'endo-microscope' is to observe the cellular architecture of tissue in vivo during routine endoscopic examination. As the first step to completing this study, resected fresh specimens from the oesophagus. stomach and colon were examined by laser-scanning confocal microscopy (LCM) (Fluoview, Olympus, Tokyo). Fresh untreated mucosal specimens obtained by endoscopic pinch biopsy, polypectomy or endoscopic mucosal resection were collected and placed in normal saline and examined by LCM, collecting the reflective light of a 488-nm wavelength argon laser beam. As the second step, a probe-type LCM 'endo-microscope' was designed and applied to observe the human oral-cavity mucosa. The probe has 4.5-mm outer diameter and 20-cm length, which enables easy access to oral cavity mucosa. The estimated special resolution of the probe is 1-5 microm. A real-time microscopic image directly from ex vivo fresh specimens was acquired. The acquired LCM images corresponded well with the conventional H-E light microscopic images. Cell wall, nucleus and cytoplasm were simultaneously visualized by LCM scanning. This novel method enables serial imaginary microscopic sections on fresh specimens. In addition, a probe-type LCM 'endo-microscope' was designed and was applied to observe human oral cavity mucosa. Virtual histological images from the living oral squamous cell were successfully obtained. LCM images from ex vivo fresh specimens demonstrated the features of the H-E staining histological image. In the next step to accomplish our project, we developed a LCM probe with 4.5-mm outer diameter to obtain a virtual image of human oral cavity mucosa.     

CT-guided transbronchial biopsy using an ultrathin bronchoscope with virtual bronchoscopic navigation

STUDY OBJECTIVES: We evaluated the feasibility, safety, and efficacy of CT-guided transbronchial biopsy (TBB) using an ultrathin bronchoscope with navigation by virtual bronchoscopy (VB) for small peripheral pulmonary lesions of < 20 mm in diameter. DESIGN: A pilot study. SETTING: A national university hospital. PATIENTS: We performed CT-guided TBB after VB navigation for 25 patients with 26 small peripheral pulmonary lesions (average diameter, 13.2 mm) between June 1, 2001, and October 31, 2002. Of the 26 lesions, 10 were in the right upper lobe, 2 were in the right middle lobe, 6 were in the right lower lobe, and 8 were in the left upper lobe. Nineteen lesions were not detected on chest radiographs. INTERVENTIONS: VB images were reconstructed from helical CT scans. CT-guided TBB was performed using an ultrathin bronchoscope after studying the VB image. RESULTS: CT-guided TBB was performed safely without any complications for all patients. The bronchi seen under VB imaging were highly consistent with the actual bronchi confirmed using an ultrathin bronchoscope. The ultrathin bronchoscope was inserted between the fifth and eighth generation bronchi. The average durations of the initial scan, the first biopsy, and the total examination were 5.46, 12.96, and 29.27 min, respectively. Seventeen lesions (65.4%) were diagnosed from pathology examinations (primary lung cancers, 13; atypical adenomatous hyperplasia, 1; metastatic cancer, 1; sarcoidosis, 1; and nontuberculous mycobacteriosis, 1). Diagnoses were not obtained for the remaining lesions due to an insufficient number of specimens (six specimens) or to the inability to reach the lesions even using the ultrathin bronchoscope (three specimens). CONCLUSIONS: In summary, CT-guided TBB using an ultrathin bronchoscope with VB navigation was safely performed and was effective for diagnosing small peripheral pulmonary lesions.     

Transbronchial biopsy using endobronchial ultrasonography with a guide sheath and virtual bronchoscopic navigation

STUDY OBJECTIVES: We evaluated the feasibility, safety, and efficacy of transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS) and virtual bronchoscopy (VB) navigation for small peripheral pulmonary lesions < or = 30 mm in diameter. DESIGN: Pilot study. SETTING: A national university hospital. PATIENTS: We performed TBB using EBUS-GS with VB navigation for 29 patients with 30 small peripheral pulmonary lesions (average diameter, 18.6 mm) between January 1, 2004, and August 31, 2004. INTERVENTIONS: VB images were reconstructed from helical CT data. TBB was then performed using EBUS-GS with VB navigation. RESULTS: In all patients, TBB was performed safely with no complications. Bronchi seen on VB imaging were highly consistent with the actual structures confirmed using fiberoptic bronchoscopy. Following VB navigation, the endobronchial ultrasonography (EBUS) probe was inserted into third- to sixth-generation bronchi. Twenty-four lesions (80%) were visualized on EBUS images. Average durations of the initial EBUS examination of lesions, first biopsy, and the total procedure were 9.56 min, 11.99 min, and 25.72 min, respectively. Nineteen lesions (63.3%) were diagnosed from histopathologic or cytologic examination. Diagnostic sensitivities were 44.4% (8 of 18) for lesions < 20 mm in mean diameter and 91.7% (11 of 12) for lesions 20 to 30 mm in mean diameter. CONCLUSIONS: In summary, TBB using EBUS-GS with VB navigation was safely performed and was effective in diagnosing small peripheral pulmonary lesions.     

虚拟导航技术引导经支气管肺活检对肺外周结节的诊断价值

目的探讨虚拟导航引导经支气管肺活检对外周型肺孤立性小结节的诊断价值。 方法回顾性分析2016年1月至12月于成都医学院第一附属医院呼吸内科通过不同方法经支气管肺组织活检的96例外周型肺孤立性小结节患者的临床资料,根据活检方法的不同分为传统活检钳肺活检组、虚拟导航引导活检钳肺活检组、虚拟导航引导冷冻肺活检组,比较3组间的诊断率及虚拟导航引导活检钳肺活检组和虚拟导航引导冷冻肺活检组的操作时间。 结果传统活检钳肺活检组、虚拟导航引导活检钳肺活检组、虚拟导航引导冷冻肺活检组的病灶大小分别为(21±7)mm、(22±8)mm、(19±8)mm。3组比较差异无统计学意义(F＝0.48,P＝0.54)。传统活检钳肺活检组、虚拟导航引导活检钳肺活检组、虚拟导航引导冷冻肺活检组的诊断率分别为43.3%(13/30)、66.7%(23/35)和77.4%(24/31),传统活检钳肺活检组明显低于其他2个组(χ²＝7.801,P＝0.020),而虚拟导航引导活检钳肺活检组与虚拟导航引导冷冻肺活检组比较差异无统计学意义(χ²＝1.099,P＝0.295),且虚拟导航引导活检钳肺活检组与虚拟导航引导冷冻肺活检组在肺各个叶以及病灶良恶性间诊断率差异均无统计学意义(均P>0.05)。虚拟导航引导活检钳肺活检组与虚拟导航引导冷冻肺活检组的操作时间分别为(436±201)s和(363±185)s,两组差异有统计学意义(t＝1.56,P＝0.038)。 结论虚拟导航技术引导经支气管肺活检术可以提高外周型肺孤立性小结节的诊断率,并且虚拟导航引导冷冻肺活检可以明显减少操作时间。     

Utility of virtual bronchoscopy-guided transbronchial biopsy for the diagnosis of pulmonary sarcoidosis: report of two cases

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that usually affects the lungs. Although flexible fiberoptic bronchoscopy with transbronchial lung biopsy (TBBx) has a high diagnostic yield in patients with pulmonary sarcoidosis, variously ranging from 40 to 90%, more invasive procedures often prove necessary. We report two cases of successful diagnosis of pulmonary sarcoidosis using a new technique that may increase the accuracy of TBBx. Previously described for diagnosis of peripheral lung cancer, this technique relies on real-time virtual bronchoscopic guidance to biopsy preselected peripheral areas of the lung preferentially affected by the disease using a pediatric bronchoscope. In each case, while procedures were performed under direct CT guidance allowing precise confirmation of the tip of the biopsy catheter, it is anticipated that this technique will be primarily used as a guide to bronchoscopic biopsies without the need for direct CT guidance, thus increasing routine utilization of multidetector low-dose high-resolution CT to improve histologic diagnosis.     

Accuracy and agreement of a large panel of endosonographers for endomicroscopy-guided virtual biopsy of pancreatic cystic lesions

BackgroundAlthough emerging data evidences that EUS-guided needle-based confocal laser endomicroscopy (nCLE) accurately diagnoses pancreatic cystic lesions (PCLs), there are a lack of interobserver agreement (IOA) studies utilizing reference histopathological diagnosis and for specific PCL subtypes. Hence, we sought to assess the IOA, intra-observer reliability (IOR), and diagnostic performance of EUS-nCLE using a large cohort of patients with histopathological diagnosis amongst a broad panel of international observers.MethodsEUS-nCLE videos (n = 76) of subjects with PCLs [intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystadenoma (SCA), pseudocyst, and cystic-neuroendocrine tumors/solid pseudopapillary neoplasm (cystic-NET/SPN)], simulating clinical prevalence rates were obtained from 3 prospective studies. An international panel of 13 endosonographers with nCLE experience, blinded to all PCL data, evaluated the video library twice with a two-week washout for PCL differentiation (mucinous vs. non-mucinous) and subtype diagnosis.ResultsThe IOA (κ = 0.82, 95% CI 0.77–0.87) and IOR (κ = 0.82, 95% CI 0.78–0.85) were “almost perfect” to differentiate mucinous vs. non-mucinous PCLs. For PCL subtype, IOA was highest for SCA (almost perfect; κ = 0.85), followed by IPMN (substantial, κ = 0.72), and cystic-NET/SPN (substantial, κ = 0.73). The IOA was moderate for MCN (κ = 0.47), and pseudocyst (κ = 0.57). Compared to histopathology, observers differentiated mucinous vs. non-mucinous PCLs with high accuracy (94.8%, 95% CI 93.3–96.1). For detecting specific PCLs subtypes, EUS-nCLE was highly accurate in diagnosing non-mucinous cysts (SCA: 98%; cystic-NET/SPN: 96%; pseudocyst: 96%) and slightly less accurate for mucinous lesions (IPMN: 86%; MCN: 84%).ConclusionDiagnosis of PCLs by EUS-nCLE guided virtual biopsy is very accurate and reliable for the most prevalent pancreatic cysts in clinical practice.     

Endobiliary biopsy

The differential diagnosis between benign and malignant biliary strictures is challenging and requires a multidisciplinary approach with the use of serum biomarkers, imaging techniques, and several modalities of endoscopic or percutaneous tissue sampling. The diagnosis of biliary strictures consists of laboratory markers, and invasive and non-invasive imaging examinations such as computed tomography (CT), contrast-enhanced magnetic resonance cholangiopancreatography, and endoscopic ultrasonography (EUS). Nevertheless, invasive imaging modalities combined with tissue sampling are usually required to confirm the diagnosis of suspected malignant biliary strictures, while pathological diagnosis is mandatory to decide the optimal therapeutic strategy. Although EUS-guided fine-needle aspiration biopsy is currently the standard procedure for tissue sampling of solid pancreatic mass lesions, its diagnostic value in intraductal infiltrating type of cholangiocarcinoma remains limited. Moreover, the “endobiliary approach” using novel slim biopsy forceps, transpapillary and percutaneous cholangioscopy, and intraductal ultrasound-guided biopsy, is gaining ground on traditional endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography endobiliary forceps biopsy. This review focuses on the available endobiliary techniques currently used to perform biliary strictures biopsy, comparing the diagnostic performance of endoscopic and percutaneous approaches.     

Endomyocardial biopsy

Endomyocardial biopsy has been used more frequently over the past 10 years in an increasing number of centers in this country and abroad. When done by an experienced physician, it is as safe as routine cardiac catheterization. Although biopsy is not yet applicable in all cases of myocardial disease, many investigators have found this procedure valuable in specific circumstances, including cardiac allograft rejection, anthracycline-induced cardiomyopathy, and myocarditis. With this technique diagnoses can be made for various disorders including cardiac amyloidosis, sarcoidosis, hemochromatosis, and endomyocardial fibrosis. Although helpful in detecting an unsuspected condition or in formulating prognosis in some patients, biopsy is not diagnostically specific in patients with dilated or hypertrophic cardiomyopathy, because these diseases have no completely pathognomonic features under current examination methods. The proper practice of endomyocardial biopsy requires both technical proficiency and expert pathologic interpretation. As a research tool, biopsy will continue to yield new knowledge about myocardial disease and its treatment.