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1
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Dong J, Grant C, Vuong B, Nishioka N, Gao AH, Beatty M, Baldwin G, Bailargeon A, Bablouzian A, Grahmann P, Bhat N, Ryan E, Barrios A, Giddings S, Ford T, Beaulieu-Ouellet E, Hosseiny SH, Lerman I, Trasischker W, Reddy R, Singh K, Gora M, Hyun D, Queneherve L, Wallace M, Wolfsen H, Sharma P, Wang KK, Leggett CL, Poneros J, Abrams JA, Lightdale C, Leeds S, Rosenberg M, Tearney G. Feasibility and Safety of Tethered Capsule Endomicroscopy in Patients With Barrett's Esophagus in a Multi-Center Study. Clin Gastroenterol Hepatol 2022; 20:756-765.e3. [PMID: 33549871 PMCID: PMC8715859 DOI: 10.1016/j.cgh.2021.02.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Tethered capsule endomicroscopy (TCE) involves swallowing a small tethered pill that implements optical coherence tomography (OCT) imaging, procuring high resolution images of the whole esophagus. Here, we demonstrate and evaluate the feasibility and safety of TCE and a portable OCT imaging system in patients with Barrett's esophagus (BE) in a multi-center (5-site) clinical study. METHODS Untreated patients with BE as per endoscopic biopsy diagnosis were eligible to participate in the study. TCE procedures were performed in unsedated patients by either doctors or nurses. After the capsule was swallowed, the device continuously obtained 10-μm-resolution cross-sectional images as it traversed the esophagus. Following imaging, the device was withdrawn through mouth, and disinfected for subsequent reuse. BE lengths were compared to endoscopy findings when available. OCT-TCE images were compared to volumetric laser endomicroscopy (VLE) images from a patient who had undergone VLE on the same day as TCE. RESULTS 147 patients with BE were enrolled across all sites. 116 swallowed the capsule (79%), 95/114 (83.3%) men and 21/33 (63.6%) women (P = .01). High-quality OCT images were obtained in 104/111 swallowers (93.7%) who completed the procedure. The average imaging duration was 5.55 ± 1.92 minutes. The mean length of esophagus imaged per patient was 21.69 ± 5.90 cm. A blinded comparison of maximum extent of BE measured by OCT-TCE and EGD showed a strong correlation (r = 0.77-0.79). OCT-TCE images were of similar quality to those obtained by OCT-VLE. CONCLUSIONS The capabilities of TCE to be used across multiple sites, be administered to unsedated patients by either physicians or nurses who are not expert in OCT-TCE, and to rapidly and safely evaluate the microscopic structure of the esophagus make it an emerging tool for screening and surveillance of BE patients. Clinical trial registry website and trial number: NCT02994693 and NCT03459339.
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Affiliation(s)
- Jing Dong
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Catriona Grant
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Barry Vuong
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Norman Nishioka
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Anna Huizi Gao
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Matthew Beatty
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Grace Baldwin
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Aaron Bailargeon
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Ara Bablouzian
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Patricia Grahmann
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Nitasha Bhat
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Emily Ryan
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Amilcar Barrios
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Sarah Giddings
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Timothy Ford
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | | | | | - Irene Lerman
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Wolfgang Trasischker
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Rohith Reddy
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Kanwarpal Singh
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Michalina Gora
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA,ICube Laboratory, CNRS, Strasbourg University, France
| | - Daryl Hyun
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Lucille Queneherve
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Michael Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City Veterans Administration and University of Kansas School of Medicine, MO
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology,, Mayo Clinic Rochester, MN
| | - Cadman L. Leggett
- Division of Gastroenterology and Hepatology,, Mayo Clinic Rochester, MN
| | | | | | | | | | - Mireille Rosenberg
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Guillermo Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA,Department of Pathology, Massachusetts General Hospital, MA,Harvard-MIT Division of Health Science and Technology (HST)
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Abstract
Because of the rising incidence and lethality of esophageal adenocarcinoma, Barrett's esophagus (BE) is an increasingly important premalignant target for cancer prevention. BE-associated neoplasia can be safely and effectively treated with endoscopic eradication therapy (EET), incorporating tissue resection and ablation. Because EET has proliferated, managing patients after complete eradication of intestinal metaplasia has taken on increasing importance. Recurrence after complete eradication of intestinal metaplasia occurs in 8%-10% of the patients yearly, and the incidence may remain constant over time. Most recurrences occur at the gastroesophageal junction, whereas those in the tubular esophagus are endoscopically visible and distally located. A simplified biopsy protocol limited to the distal aspect of the BE segment, in addition to gastroesophageal junction sampling, may enhance efficiency and cost without significantly reducing recurrence detection. Similarly, research suggests that current surveillance intervals may be excessively frequent, failing to reflect the cancer risk reduction of EET. If validated, longer surveillance intervals could reduce the burden of resource-intensive endoscopic surveillance. Several important questions in post-EET management remain unanswered, including surveillance duration, the significance of gastric cardia intestinal metaplasia, and the role of advanced imaging and nonendoscopic sampling techniques in detecting recurrence. These merit further research to enhance quality of care and promote a more evidence-based approach.
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Mora OC, Zanne P, Zorn L, Nageotte F, Zulina N, Gravelyn S, Montgomery P, de Mathelin M, Dallemagne B, Gora MJ. Steerable OCT catheter for real-time assistance during teleoperated endoscopic treatment of colorectal cancer. BIOMEDICAL OPTICS EXPRESS 2020; 11:1231-1243. [PMID: 32206405 PMCID: PMC7075597 DOI: 10.1364/boe.381357] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/22/2019] [Accepted: 12/27/2019] [Indexed: 05/06/2023]
Abstract
When detected early, colorectal cancer can be treated with minimally invasive flexible endoscopy. However, since only specialized experts can delineate margins and perform endoscopic resections of lesions, patients still often undergo colon resections. To better assist in the performance of surgical tasks, a robotized flexible interventional endoscope was previously developed, having two additional side channels for surgical instrument. We propose to enhance the imaging capabilities of this device by combining it with optical coherence tomography (OCT). For this purpose, we have developed a new steerable OCT instrument with an outer diameter of 3.5 mm. The steerable instrument is terminated with a 2 cm long transparent sheath to allow three-dimensional OCT imaging using a side-focusing optical probe with two external scanning actuators. The instrument is connected to an OCT imaging system built around the OCT Axsun engine, with a 1310 nm center wavelength swept source laser and 100 kHz A-line rate. Once inserted in one of the side channels of the robotized endoscope, bending, rotation and translation of the steerable OCT instrument can be controlled by a physician using a joystick. Ex vivo and in vivo tests show that the novel, steerable and teleoperated OCT device enhances dexterity, allowing for inspection of the surgical field without the need for changing the position of the main endoscope.
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Affiliation(s)
- Oscar Caravaca Mora
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Philippe Zanne
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Lucile Zorn
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Florent Nageotte
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Natalia Zulina
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Sara Gravelyn
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Paul Montgomery
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Michel de Mathelin
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
| | - Bernard Dallemagne
- IRCAD - Hôpitaux Universitaires - 1, place de l'Hôpital - 67091 Strasbourg Cedex, France
| | - Michalina J Gora
- ICube Laboratory, CNRS, Strasbourg University, 4, rue Kirschleger - 67085 Strasbourg Cedex, France
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Trindade AJ, Navaneethan U, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Melson J, Pannala R, Parsi MA, Schulman AR, Sethi A, Trikudanathan G, Watson RR, Maple JT. Advances in the diagnosis and surveillance of Barrett's esophagus (with videos). Gastrointest Endosc 2019; 90:325-334. [PMID: 31113535 DOI: 10.1016/j.gie.2019.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Most patients diagnosed with esophageal adenocarcinoma do not carry a known diagnosis of Barrett's esophagus (BE), suggesting that an improved approach to screening may potentially be of benefit. The use of dysplasia as a biomarker and random biopsy protocols for its detection has limitations. In addition, detecting and appropriately classifying dysplasia in patients with known BE can be difficult. METHODS This document reviews several technologies with a recently established or potential role in the diagnosis and/or surveillance of BE as well as risk stratification for progression to esophageal adenocarcinoma. RESULTS Two technologies were reviewed for imaging or tissue sampling: (1) wide-area transepithelial sampling and (2) volumetric laser endomicroscopy. Four technologies were reviewed for molecular and biomarker technologies for diagnosis and risk stratification: (1) Cytosponge, (2) mutational load, (3) fluorescence in situ hybridization, and (4) immunohistochemistry. CONCLUSION Several technologies discussed in this document may improve dysplasia detection in BE in a wide-field manner. Moreover, the addition of different biomarkers may aid in enhanced risk stratification to optimize approaches to surveillance or treatment for patients with BE.
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Affiliation(s)
- Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York
| | | | - Harry R Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Mansour A Parsi
- Department of Gastroenterology and Hepatology, Tulane University, New Orleans, Louisiana
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Medical Center-New York-Presbyterian, New York, New York
| | - Guru Trikudanathan
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Zihni AM, DeMeester SR. Advanced Endoluminal Technologies for Barrett's Esophagus: Focus on Optical Coherence Tomography and Confocal Laser Endomicroscopy. Thorac Surg Clin 2018; 28:465-472. [PMID: 30268292 DOI: 10.1016/j.thorsurg.2018.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Barrett's esophagus (BE) may progress to dysplasia and adenocarcinoma. The value of Barrett's surveillance with random biopsies is being questioned, but new technologies may enhance detection of progression within BE and guide endoscopic resection and ablation techniques. This review will focus on optical coherence tomography and endomicroscopy for patients with BE.
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Affiliation(s)
- Ahmed M Zihni
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, 4805 NE Glisan Street, Suite 6N60, Portland, OR 97213, USA; Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR 97213, USA; The Foundation for Surgical Innovation and Education, 4805 NE Glisan Street, Suite 6N60, Portland, OR 97213, USA
| | - Steven R DeMeester
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, 4805 NE Glisan Street, Suite 6N60, Portland, OR 97213, USA; The Foundation for Surgical Innovation and Education, 4805 NE Glisan Street, Suite 6N60, Portland, OR 97213, USA.
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6
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Abstract
New improved methods are required for the early detection of esophageal adenocarcinoma in order to reduce mortality from this aggressive cancer. In this review we discuss different screening methods which are currently under evaluation ranging from image-based methods to cell collection devices coupled with biomarkers. As Barrett's esophagus is a low prevalence disease, potential screening tests must be applied to an enriched population to reduce the false-positive rate and improve the cost-effectiveness of the program.
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Affiliation(s)
- Maria O'Donovan
- MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Hills Road, Cambridge, CB2 0XZ, UK
- Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - Rebecca C Fitzgerald
- MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Hills Road, Cambridge, CB2 0XZ, UK.
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7
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Alshelleh M, Inamdar S, McKinley M, Stewart M, Novak JS, Greenberg RE, Sultan K, Devito B, Cheung M, Cerulli MA, Miller LS, Sejpal DV, Vegesna AK, Trindade AJ. Incremental yield of dysplasia detection in Barrett's esophagus using volumetric laser endomicroscopy with and without laser marking compared with a standardized random biopsy protocol. Gastrointest Endosc 2018; 88:35-42. [PMID: 29410080 DOI: 10.1016/j.gie.2018.01.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Volumetric laser endomicroscopy (VLE) is a new wide-field advanced imaging technology for Barrett's esophagus (BE). No data exist on incremental yield of dysplasia detection. Our aim is to report the incremental yield of dysplasia detection in BE using VLE. METHODS This is a retrospective study from a prospectively maintained database from 2011 to 2017 comparing the dysplasia yield of 4 different surveillance strategies in an academic BE tertiary care referral center. The groups were (1) random biopsies (RB), (2) Seattle protocol random biopsies (SP), (3) VLE without laser marking (VLE), and (4) VLE with laser marking (VLEL). RESULTS A total of 448 consecutive patients (79 RB, 95 SP, 168 VLE, and 106 VLEL) met the inclusion criteria. After adjusting for visible lesions, the total dysplasia yield was 5.7%, 19.6%, 24.8%, and 33.7%, respectively. When compared with just the SP group, the VLEL group had statistically higher rates of overall dysplasia yield (19.6% vs 33.7%, P = .03; odds ratio, 2.1, P = .03). Both the VLEL and VLE groups had statistically significant differences in neoplasia (high-grade dysplasia and intramucosal cancer) detection compared with the SP group (14% vs 1%, P = .001 and 11% vs 1%, P = .003). CONCLUSION A surveillance strategy involving VLEL led to a statistically significant higher yield of dysplasia and neoplasia detection compared with a standard random biopsy protocol. These results support the use of VLEL for surveillance in BE in academic centers.
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Affiliation(s)
- Mohammad Alshelleh
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Sumant Inamdar
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Matthew McKinley
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Molly Stewart
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Jeffrey S Novak
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Ronald E Greenberg
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Keith Sultan
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Bethany Devito
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Mary Cheung
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Maurice A Cerulli
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Larry S Miller
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Divyesh V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Anil K Vegesna
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
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Tsai TH, Leggett CL, Trindade AJ, Sethi A, Swager AF, Joshi V, Bergman JJ, Mashimo H, Nishioka NS, Namati E. Optical coherence tomography in gastroenterology: a review and future outlook. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:1-17. [PMID: 29260538 DOI: 10.1117/1.jbo.22.12.121716] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 12/05/2017] [Indexed: 05/18/2023]
Abstract
Optical coherence tomography (OCT) is an imaging technique optically analogous to ultrasound that can generate depth-resolved images with micrometer-scale resolution. Advances in fiber optics and miniaturized actuation technologies allow OCT imaging of the human body and further expand OCT utilization in applications including but not limited to cardiology and gastroenterology. This review article provides an overview of current OCT development and its clinical utility in the gastrointestinal tract, including disease detection/differentiation and endoscopic therapy guidance, as well as a discussion of its future applications.
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Affiliation(s)
- Tsung-Han Tsai
- NinePoint Medical, Inc., Bedford, Massachusetts, United States
| | - Cadman L Leggett
- Mayo Clinics, Division of Gastroenterology and Hepatology, Rochester, Minnesota, United States
| | - Arvind J Trindade
- North Shore University Hospital and Hofstra Northwell School of Medicine, Division of Gastroenterolo, United States
| | - Amrita Sethi
- Columbia University Medical Center, Department of Gastroenterology, New York City, New York, United States
| | - Anne-Fré Swager
- Spaarne Gasthuis and Free University Medical Center, Amsterdam, The Netherlands
| | - Virendra Joshi
- Ochsner Clinic Foundation, Department of Gastroenterology, New Orleans, Louisiana, United States
| | - Jacques J Bergman
- Academic Medical Center, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Hiroshi Mashimo
- Veterans Affairs Boston Healthcare System and Harvard Medical School, Department of Gastroenterology, United States
| | - Norman S Nishioka
- Massachusetts General Hospital, Gastrointestinal Unit, Boston, Massachusetts, United States
| | - Eman Namati
- NinePoint Medical, Inc., Bedford, Massachusetts, United States
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Shimamura Y, Ikeya T, Marcon N, Mosko JD. Endoscopic diagnosis and treatment of early esophageal squamous neoplasia. World J Gastrointest Endosc 2017; 9:438-447. [PMID: 28979708 PMCID: PMC5605343 DOI: 10.4253/wjge.v9.i9.438] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/14/2017] [Accepted: 08/17/2017] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is one of the leading causes of cancer-related death and is associated with high morbidity and mortality. It carries a poor prognosis as more than half of patients present with advanced and unresectable disease. One contributing factor is the increased risk of lymph node metastases at early stages of disease. As such, it is essential to detect squamous cell neoplasia (SCN) at an early stage. In order to risk stratify lesions, endoscopists must be able to perform image enhanced endoscopy including magnification and Lugol’s chromoendoscopy. The assessment of both the horizontal extent and depth of any lesion is also of utmost importance prior to treatment. Endoscopic mucosal resection and submucosal dissection remain the standard of care with literature supportive their respective use. Radiofrequency ablation and other endoscopic treatments are currently available although should not be considered first line at this time. Our objective is to review the current options for the endoscopic diagnosis and treatment of esophageal SCN.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo 104-8560, Japan
| | - Norman Marcon
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
| | - Jeffrey D Mosko
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
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10
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Trindade AJ, Leggett CL, Chang KJ. Volumetric laser endomicroscopy in the management of Barrett's esophagus. Curr Opin Gastroenterol 2017; 33:254-260. [PMID: 28402993 DOI: 10.1097/mog.0000000000000366] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The incidence of esophageal adenocarcinoma is on the rise despite widespread appreciation that the precursor lesion is Barrett's esophagus. Studies have shown that some patients known to have Barrett's esophagus develop cancer despite their enrollment in conventional endoscopic surveillance programs. This highlights the need for advanced endoscopic imaging to help identify early neoplasia and prevent its progression to esophageal cancer. Recently, a wide-field, second-generation optical coherence tomography endoscopic platform called volumetric laser endomicroscopy (VLE) was cleared by the Food and Drug Administration and made commercially available for advanced imaging in Barrett's esophagus. RECENT FINDINGS The current review discusses current literature on VLE imaging in Barrett's esophagus. Based on ex-vivo studies, criteria have been established for identifying Barrett's esophagus-associated neoplasia. In addition, recent studies, case series, and case reports have demonstrated that VLE is well tolerated, efficacious, and can target neoplasia. SUMMARY VLE is a new advanced imaging platform for Barrett's esophagus with considerable promise to target Barrett's esophagus-associated neoplasia. The following are needed to establish VLE's clinical role: studies showing incremental yield of dysplasia detection using VLE, studies to determine VLE's in-vivo diagnostic accuracy for identifying and classifying Barrett's esophagus-associated neoplasia, and studies on the cost-efficacy of VLE.
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Affiliation(s)
- Arvind J Trindade
- aDivision of Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York bDivision of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, Minnesota cH.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, California, USA
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11
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Trindade AJ, Inamdar S, Smith MS, Chang KJ, Leggett CL, Lightdale CJ, Pleskow DK, Sejpal DV, Tearney GJ, Thomas RM, Wallace MB. Volumetric laser endomicroscopy in Barrett's esophagus: interobserver agreement for interpretation of Barrett's esophagus and associated neoplasia among high-frequency users. Gastrointest Endosc 2017; 86:133-139. [PMID: 27899321 DOI: 10.1016/j.gie.2016.11.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Targeting neoplasia in Barrett's esophagus (BE) is challenging. Volumetric laser endomicroscopy (VLE) is a new imaging technique that allows for real time cross-sectional microstructure imaging that can detect BE neoplasia. The interobserver agreement among users in practice is unknown. METHODS Eight high-volume users of VLE from different academic centers in the United States evaluated 120 stored VLE images blinded to the endoscopic and clinical findings. There were 30 images for each tissue type: gastric cardia, esophageal squamous mucosa, nonneoplastic BE, and neoplastic BE. Each image with BE had corresponding histology confirming the tissue diagnosis. Each normal esophagus and gastric cardia had matching endoscopic images confirming normal mucosa. These were considered the criterion standard. Respondents were asked to classify the images into 1 of each category. Agreement among the users was measured. RESULTS The overall agreement among users was almost perfect (kappa = 0.81; 95% confidence interval [CI], 0.79-0.83). For esophageal squamous and gastric cardia, the agreement was almost perfect (kappa 0.95 and 0.86, respectively [95% CI, 0.92-0.98 and 0.83-0.89]). For nonneoplastic BE and neoplastic BE, the agreement was strong (kappa 0.66 [95% CI, 0.63-0.69] and 0.79 [95% CI, 0.75-0.82], respectively). When compared with the criterion standard, the median accuracy for identifying normal squamous mucosa, normal gastric mucosa, nonneoplastic BE, neoplastic BE, and all tissue types was 99% (95% CI, 98%-100%), 97% (95% CI, 95%-99%), 93% (95% CI, 88%-98%), 95% (95% CI, 91%-99%), and 96% (95% CI, 94%-99%), respectively. CONCLUSIONS VLE has a high level of agreement and accuracy among high-volume users.
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Affiliation(s)
- Arvind J Trindade
- Hofstra Northwell School of Medicine, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Sumant Inamdar
- Hofstra Northwell School of Medicine, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Michael S Smith
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, California, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles J Lightdale
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA
| | - Douglas K Pleskow
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Divyesh V Sejpal
- Hofstra Northwell School of Medicine, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard-MIT Division of Health Sciences Technology, Cambridge, USA
| | - Rebecca M Thomas
- Hofstra Northwell School of Medicine, Northwell Health System, Department of Pathology, New Hyde Park, New York, USA
| | - Michael B Wallace
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
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Eluri S, Shaheen NJ. Barrett's esophagus: diagnosis and management. Gastrointest Endosc 2017; 85:889-903. [PMID: 28109913 PMCID: PMC5392444 DOI: 10.1016/j.gie.2017.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 01/07/2017] [Indexed: 02/08/2023]
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13
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Trindade AJ, Smith MS, Pleskow DK. The new kid on the block for advanced imaging in Barrett's esophagus: a review of volumetric laser endomicroscopy. Therap Adv Gastroenterol 2016; 9:408-16. [PMID: 27134668 PMCID: PMC4830110 DOI: 10.1177/1756283x16639003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Advanced imaging techniques used in the management of Barrett's esophagus include electronic imaging enhancement (e.g. narrow band imaging, flexible spectral imaging color enhancement, and i-Scan), chromoendoscopy, and confocal laser endomicroscopy. Electronic imaging enhancement is used frequently in daily practice, but use of the other advanced technologies is not routine. High-definition white light endoscopy and random four quadrant biopsy remain the standard of care for evaluation of Barrett's esophagus; this is largely due to the value of advanced imaging technologies not having been validated in large studies or in everyday practice. A new advanced imaging technology called volumetric laser endomicroscopy is commercially available in the United States. Its ease of use and rapid acquisition of high-resolution images make this technology very promising for widespread application. In this article we review the technology and its potential for advanced imaging in Barrett's esophagus.
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Affiliation(s)
| | - Michael S. Smith
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Douglas K. Pleskow
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Hatta W, Uno K, Koike T, Ara N, Asano N, Iijima K, Imatani A, Fujishima F, Shimosegawa T. Feasibility of optical coherence tomography for the evaluation of Barrett's mucosa buried underneath esophageal squamous epithelium. Dig Endosc 2016; 28:427-433. [PMID: 26583560 DOI: 10.1111/den.12576] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 11/12/2015] [Accepted: 11/16/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The evaluation of Barrett's glands buried underneath esophageal squamous epithelium becomes increasingly important to achieve curative treatments. However, clinically available endoscopies have critical limitations in depicting the subsurface structure, resulting in non-curative treatments. Optical coherence tomography (OCT) can acquire a high-resolution cross-sectional image, equivalent to an 'optical biopsy'. We aimed to assess the feasibility of the in vivo use of probe-type OCT imaging to evaluate Barrett's mucosa buried underneath esophageal squamous epithelium METHODS: We conducted a single-center prospective study with 14 consecutive patients with Barrett's adenocarcinoma from 2008 to 2014. The enrolled patients were examined by a probe-type OCT in vivo, followed by en bloc endoscopic submucosal dissection (ESD) with electric marking. Then, the one-to-one correlations between the OCT images of the buried mucosa and their histological assessment were examined. RESULTS The overall accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the buried mucosa in the OCT imaging were 85.7% (12/14), 77.8% (7/9), 100% (5/5), 100% (7/7) and 71.4% (5/7), respectively. However, OCT could not easily distinguish non-dysplastic glands from dysplastic glands. Additionally, the linear distance from the histological squamo-columnar junction in correct cases tended to be longer than that in incorrect cases (mm, median [range]: 2.0 [0.7-7.5] vs. 0.5 [0.5-0.5]). CONCLUSIONS We demonstrated, for the first time, that pre-operative OCT imaging might be feasible for detecting the oral side extension of buried Barrett's mucosa to remove the entire area with malignant potential by ESD. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Nobuyuki Ara
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Katsunori Iijima
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Akira Imatani
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Fumiyoshi Fujishima
- Department of Pathology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
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Trindade AJ, George BJ, Berkowitz J, Sejpal DV, McKinley MJ. Volumetric laser endomicroscopy can target neoplasia not detected by conventional endoscopic measures in long segment Barrett's esophagus. Endosc Int Open 2016; 4:E318-22. [PMID: 27004250 PMCID: PMC4798840 DOI: 10.1055/s-0042-101409] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/04/2016] [Indexed: 01/03/2023] Open
Abstract
Methods and study aims: The incidence of esophageal cancer is rising despite increased surveillance efforts. Volumetric laser endomicroscopy (VLE) is a new endoscopic imaging tool that can allow for targeted biopsy of neoplasia in Barrett's esophagus. We report a series of 6 patients with long-segment Barrett's esophagus ( > 3 cm), who underwent a session of endoscopy with volumetric laser endomicroscopy, after a separate prior session of standard high-definition endoscopy with narrow band imaging (NBI) and random biopsies that did not reveal neoplasia. In all six patients, the first endoscopy was the index endoscopy diagnosing the Barrett's esophagus. All VLE exams were performed within 6 months of the previous endoscopy. In five patients, VLE-targeted biopsy resulted in upstaged disease/diagnosed dysplasia that then qualified the patient for endoscopic ablation therapy. In one patient, VLE localized a focus of intramucosal cancer that allowed for curative endoscopic mucosal resection. This case series shows that endoscopy with VLE can target neoplasia that cannot be localized by high-definition endoscopy with NBI and random biopsies.
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Affiliation(s)
- Arvind J. Trindade
- Hofstra North Shore-Long Island Jewish School of Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Benley J. George
- Hofstra North Shore-Long Island Jewish School of Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Joshua Berkowitz
- Hofstra North Shore-Long Island Jewish School of Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Divyesh V. Sejpal
- Hofstra North Shore-Long Island Jewish School of Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Matthew J. McKinley
- Hofstra North Shore-Long Island Jewish School of Medicine, North Shore University Hospital, Manhasset, NY, United States
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Ughi GJ, Gora MJ, Swager AF, Soomro A, Grant C, Tiernan A, Rosenberg M, Sauk JS, Nishioka NS, Tearney GJ. Automated segmentation and characterization of esophageal wall in vivo by tethered capsule optical coherence tomography endomicroscopy. BIOMEDICAL OPTICS EXPRESS 2016; 7:409-19. [PMID: 26977350 PMCID: PMC4771459 DOI: 10.1364/boe.7.000409] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 05/18/2023]
Abstract
Optical coherence tomography (OCT) is an optical diagnostic modality that can acquire cross-sectional images of the microscopic structure of the esophagus, including Barrett's esophagus (BE) and associated dysplasia. We developed a swallowable tethered capsule OCT endomicroscopy (TCE) device that acquires high-resolution images of entire gastrointestinal (GI) tract luminal organs. This device has a potential to become a screening method that identifies patients with an abnormal esophagus that should be further referred for upper endoscopy. Currently, the characterization of the OCT-TCE esophageal wall data set is performed manually, which is time-consuming and inefficient. Additionally, since the capsule optics optimally focus light approximately 500 µm outside the capsule wall and the best quality images are obtained when the tissue is in full contact with the capsule, it is crucial to provide feedback for the operator about tissue contact during the imaging procedure. In this study, we developed a fully automated algorithm for the segmentation of in vivo OCT-TCE data sets and characterization of the esophageal wall. The algorithm provides a two-dimensional representation of both the contact map from the data collected in human clinical studies as well as a tissue map depicting areas of BE with or without dysplasia. Results suggest that these techniques can potentially improve the current TCE data acquisition procedure and provide an efficient characterization of the diseased esophageal wall.
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Affiliation(s)
- Giovanni J. Ughi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michalina J. Gora
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- ICube, CNRS, Strasbourg University, France
| | - Anne-Fré Swager
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Amna Soomro
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Catriona Grant
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Aubrey Tiernan
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mireille Rosenberg
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Norman S. Nishioka
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Guillermo J. Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard-MIT Division of Health Sciences Technology, Cambridge, MA, USA
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17
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Safety and feasibility of volumetric laser endomicroscopy in patients with Barrett's esophagus (with videos). Gastrointest Endosc 2015; 82:631-40. [PMID: 25956472 DOI: 10.1016/j.gie.2015.03.1968] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 03/18/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Volumetric laser endomicroscopy (VLE) produces high-resolution, cross-sectional surface, and subsurface images for detecting neoplasia, targeting biopsies, and guiding real-time treatment. OBJECTIVE To evaluate the safety and feasibility of the Nvision VLE system. DESIGN Prospective, multicenter study. SETTING Tertiary-care medical centers. PATIENTS One hundred patients with suspected Barrett's esophagus, including 52 patients with prior endotherapy. INTERVENTIONS The first-generation Nvision VLE Imaging System, a balloon-centered, rotating optical probe provided images of the mucosa and submucosa through a 6-cm segment length and 360° scan of the distal esophagus. MAIN OUTCOME MEASUREMENTS Acquisition of a complete, 6-cm scan from the distal esophagus, demographic and procedural data, and final histologic diagnosis. RESULTS VLE imaging was successfully performed in 87 cases. After VLE imaging, biopsy specimens were obtained in 77 patients and mucosal resection was performed in 20 patients. The final pathologic diagnoses of the patients studied were adenocarcinoma (4 patients), high-grade dysplasia (10 patients), low-grade dysplasia (11 patients), indefinite (5 patients), intestinal metaplasia (29 patients), and normal squamous cells (18 patients). VLE was not completed in 13 of 100 (13%) because of optical probe and console issues. There were 2 minor adverse events (mucosal lacerations not requiring therapy). LIMITATIONS This was a feasibility study with a first-generation device. There was no direct histopathologic correlation with the VLE images or any comparative analysis with white-light endoscopy or narrow-band imaging findings. CONCLUSION VLE is a safe procedure for patients with suspected or confirmed Barrett's esophagus. Real-time VLE images enabled visualization of the mucosa and submucosa in 87% of cases. Further studies are needed to evaluate the in vivo diagnostic accuracy and clinical utility of VLE.
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18
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Cotton CC, Duits LC, Wolf WA, Peery AF, Dellon ES, Bergman JJ, Shaheen NJ. Spatial predisposition of dysplasia in Barrett's esophagus segments: a pooled analysis of the SURF and AIM dysplasia trials. Am J Gastroenterol 2015; 110:1412-9. [PMID: 26346864 PMCID: PMC4785998 DOI: 10.1038/ajg.2015.263] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/02/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Surveillance endoscopy detects dysplasia within Barrett's esophagus (BE) and dictates treatment. Current biopsy regimens recommend uniformly spaced random biopsies. We assessed the distribution of dysplasia in BE to develop evidence-based biopsy regimens. METHODS We performed analysis of the distribution of dysplasia within BE using pretreatment biopsy data from two randomized controlled trials (RCTs) of radiofrequency ablation for dysplastic BE: the SURF (Surveillance vs. Radiofrequency Ablation) trial and the AIM Dysplasia (Ablation of Intestinal Metaplasia (AIM) Containing Dysplasia) trial. We used generalized linear models with generalized estimating equations (GEE) to estimate prevalence differences for dysplasia depending on the standardized location of biopsies. We performed Monte Carlo simulation of biopsy regimens to estimate their yield for any dysplasia within segments. RESULTS Dysplasia preferentially resides in the proximal-most half of the BE segment that is almost twice as likely to demonstrate dysplasia as the distal-most quartile. In pooled analysis, compared with the distal-most quarter, the prevalence difference in the proximal-most quarter was 22.6%, in the second proximal-most quarter 23.1%, and in the second distal-most quarter 15.3%. The best performing biopsy regimen in simulation studies acquired 8 biopsies in the most proximal cm of BE, 8 biopsies in the second cm, and 2 biopsies in each cm thereafter (q1cm: 8, 8, 2, 2…). A slightly simpler q2cm (every 2 cm) regimen (q2cm: 12, 12, 4…) was nearly as effective. CONCLUSIONS The post hoc analysis of two RCTs reveals a substantially increased prevalence of dysplasia proximally in BE segments. Our simulations suggest an altered biopsy regimen could increase sensitivity of biopsies in short-segment BE by >30%.
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Affiliation(s)
- Cary C Cotton
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Lucas C Duits
- Division of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - W Asher Wolf
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Anne F Peery
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Evan S. Dellon
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Jacques J. Bergman
- Division of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
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Beg S, Ragunath K. Image-enhanced endoscopy technology in the gastrointestinal tract: what is available? Best Pract Res Clin Gastroenterol 2015; 29:627-638. [PMID: 26381307 DOI: 10.1016/j.bpg.2015.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/27/2015] [Accepted: 05/21/2015] [Indexed: 02/08/2023]
Abstract
Gastrointestinal malignancy accounts for approximately a fifth of all cancer deaths in the United Kingdom. By the time patients are symptomatic, lesions are often advanced, with limited treatment options available. The development of effective endoscopic therapies means that neoplastic lesions can now be treated with improved patient outcomes. This has led to a paradigm shift, whereby the aim of digestive endoscopy is to identify premalignant conditions or early neoplastic change, in order to make an impact on their natural history. This has necessitated an improvement in imaging techniques in order to identify subtle mucosal changes that may harbour precancerous cells. At present there is an array of available imaging modalities, each with implications on cost, training and lesion detection. Here we describe the scientific rationale behind the major commercially available techniques as well as offering a glimpse at possible future directions.
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Affiliation(s)
- Sabina Beg
- Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospital, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, UK.
| | - Krish Ragunath
- Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospital, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, UK.
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Uno K, Koike T, Shimosegawa T. Recent development of optical coherence tomography for preoperative diagnosis of esophageal malignancies. World J Gastrointest Endosc 2015; 7:872-80. [PMID: 26240688 PMCID: PMC4515421 DOI: 10.4253/wjge.v7.i9.872] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/20/2015] [Accepted: 06/15/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic diagnosis with histological evidence is necessary to decide the best strategy for treating esophageal squamous cell carcinoma and Barrett's-associated neoplasia, and the recent development of endoscopic technologies have made possible real-time information of malignant hallmarks. We focused on the development of optical coherence tomography (OCT), the only technology that can depict real-time cross-sectional images with high resolution. With the improvements in image resolution, acquisition rate and demonstrable area of three-dimensional devices with Doppler capability, OCT imaging was shown to enable visualization of structural/functional alterations in the mucosal/submucosal tissue of the esophagus, resulting in more accurate preoperative diagnosis of such malignancies. Moreover, it approved to be useful for targeting malignant areas for biopsy and treatment as well as for predicting the treatment effects. Therefore, further development of this technology is expected to overcome the current clinical issues in management strategies of esophageal malignancies.
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Halland M, Katzka D, Iyer PG. Recent developments in pathogenesis, diagnosis and therapy of Barrett's esophagus. World J Gastroenterol 2015; 21:6479-6490. [PMID: 26074687 PMCID: PMC4458759 DOI: 10.3748/wjg.v21.i21.6479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/31/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
The burden of illness from esophageal adenocarcinoma continues to rise in the Western world, and overall prognosis is poor. Given that Barrett’s esophagus (BE), a metaplastic change in the esophageal lining is a known cancer precursor, an opportunity to decrease disease development by screening and surveillance might exist. This review examines recent updates in the pathogenesis of BE and comprehensively discusses known risk factors. Diagnostic definitions and challenges are outlined, coupled with an in-depth review of management. Current challenges and potential solutions related to screening and surveillance are discussed. The effectiveness of currently available endoscopic treatment techniques, particularly with regards to recurrence following successful endotherapy and potential chemopreventative agents are also highlighted. The field of BE is rapidly evolving and improved understanding of pathophysiology, combined with emerging methods for screening and surveillance offer hope for future disease burden reduction.
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22
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Cotton CC, Wolf WA, Pasricha S, Li N, Madanick RD, Spacek MB, Kathleen F, Dellon ES, Shaheen NJ. Recurrent intestinal metaplasia after radiofrequency ablation for Barrett's esophagus: endoscopic findings and anatomic location. Gastrointest Endosc 2015; 81:1362-9. [PMID: 25817897 PMCID: PMC4439393 DOI: 10.1016/j.gie.2014.12.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/07/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett's esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence is common after CEIM, and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well-described. OBJECTIVE Describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence. DESIGN Retrospective cohort. SETTING Single referral center. PATIENTS A total of 198 patients with BE with at least 2 surveillance endoscopies after CEIM. INTERVENTIONS RFA, EMR, surveillance endoscopy. MAIN OUTCOME MEASUREMENTS The anatomic location and histologic grade of recurrence. RESULTS In a mean 3.0 years of follow-up, 32 (16.2%; 95% confidence interval [CI], 11.0%-22.0%) patients had recurrence of disease, 5 (2.5%; 95% CI, 0.3%-4.7%) of whom progressed beyond their worst before-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence>1 cm proximal to the GEJ always was accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white light or narrow-band imaging for recurrence was 59.4% (42.4%, 76.4%), and the specificity was 80.6% (77.2%, 84.0%). LIMITATIONS Single-center study. CONCLUSION Recurrent intestinal metaplasia often is not visible to the endoscopist and is most common near the GEJ. Random biopsies>1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.
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Affiliation(s)
- Cary C. Cotton
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - W. Asher Wolf
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sarina Pasricha
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Nan Li
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ryan D. Madanick
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Melissa B. Spacek
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ferrell Kathleen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
- Corresponding author contact information: Nicholas J. Shaheen, MD, MPH, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB#7080, Chapel Hill, North Carolina 27599- 7080. ; fax: (919) 843-2508
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Endoscopic imaging. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2015; 13:198-205. [PMID: 25783789 DOI: 10.1007/s11938-015-0052-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OPINION STATEMENT The most important tools are the eye and the brain. A detailed white-light high-resolution examination and ability to recognize subtle lesions provide the foundation of the ability to detect lesions in the gastrointestinal tract. Novel technologies are now available to provide additional information with the goals of detection, delineation, or classification often with a focus on neoplasia in the gastrointestinal tract. The observer using these new tools must still recognize, interpret, and then make a clinically relevant conclusion. Therefore, the assessment of these tools may focus on both the technical feasibility to use the respective equipment to obtain an image and then also the associated cognitive-based criteria for image interpretation.
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