New Endoscopic Imaging Techniques
Ross M Bremner MD, PhD
Director, Norton Thoracic Institute
St Joseph’s Hospital and Medical Center
William Pilcher Chair Thoracic Surgery and Transplantation
Professor Surgery, Creighton Medical School
Phoenix
AATS 2015
Disclosures
None relevant to this talk
Problem of Barrett’s
1. Barrett’s greatest risk factor for Cancer
2. Most will not develop cancer
3. No way to stratify risk at present with
exception of degrees of dysplasia
4. Biopsies VERY unreliable
•
•
Histology difficult
Biopsies random!
5. Expense of surveillance very, very high
Biopsies are UNRELIABLE
• While 84% of GI’s will endoscope every 2 years, only
42% do adequate biopsies**
– (4 quadrant every 2 cm)
• Barrett’s segment is heterogeneous
• Sampling error can lead to major error
• “1% of 1%”
** Abrams, J: Ther Adv Gastroenterol 2009(2)73
How to improve biopsy “yield”
• Focussed biopsies
• Chromoendoscopy
• Non-dye chromoendoscopy
• OCT/VLE - (Optical Coherence Tomography, Volume Laser
Endoscopy)
• Confocal Endomicroscopy
• The Future
•
•
•
Future – cell surface markers (Glycans/Lectin)
Periostin – Ab-dye congugate
Peptides with flourescent labelling
Dye-less chromoendoscopy
NBI
High resolution white light
Little mucosal or vascular
detail
Narro Band Imaging – Blue light
Superficial layer and vascularity
Dectect dysplasia
Chromoendoscopy
Acetic Acid
20 cc 1.5% Acetic acid
(Balsamic 3% also been used)
Disulfide bonds of glycoproteins
Denatures intracellular proteins
Pit Patterns
Pattern I-II: round pits/circular pattern
predicting gastric epithelium;
Pattern III-IV: ridged/villous pattern
predicting Barrett's epithelium SCE
Enhances borders
.
Chromoendoscopy
Lugol’s Iodine
10 cc 1.2% Lugol’s Iodine
Stains Glycogen of healthy Squamous
cells
Can detect Dysplasia in SCC
Unstained streaks may be useful in
NERD
Normal Sq regrowth after ablation
Watch for iodine allergy!
Gastrointest Endosc 2005;62:698-703
Endoscopy 2001 Jan; 33(1):75-9
Optical Coherence Tomography
(Volume laser endomicroscopy)
Backscattering of light to get
cross-sectional images of tissue
Similar to Ultrasound but used
light (near infra-red)
Limited to 1-3 mm
SCE – multilayer, homogenous
Barrett’s, glands and crypts, mucin
Optical Coherence Tomography
(Volume laser endomicroscopy)
25x higher resolution than EUS
No dye’s or injectables
Excellent software for later
analysis
Optical Coherence Tomography
(Volume laser endomicroscopy)
Confocal Laser Endomicroscopy
Illumination of tissue with low power
laser and detecting fluorescent light
reflected from tissue
Intravenous flourescein
(vasculature, LP and intracellular spaces)
Confocal endomicroscopy
Fundic glands, red cells
•
•
•
•
“Optical Biopsies”
Real-time cytologic images
Clean mucous with Mucolytic
Relies on flourescence
– Flourescein
Confocal endomicroscopy
Barrett’s – No Dysplasia
Goblet cells
No nuclear atypia
No stratification
Surface maturation
Concensus Panel - Human Pathology: 2001; 32: 368
Indefinite for Dysplasia
Goblet cells
Prominent hyperchromasia
Glandular crowding
Increased mitotic activity
Mild cytologic atypia
Surface maturation
Human Pathology: 2001; 32: 368
Low Grade Dysplasia
Maintenance of nuclear polarity
No architectural complexity
No Surface maturation
Human Pathology: 2001; 32: 368
Confocal endomicroscopy
Barrett’s – HGD Dysplasia
Nuclear atypia
Loss Nuclear polarity
Architectural complexity
Basement membrane in tact
No Surface maturation
Concensus Panel - Human Pathology: 2001; 32: 368
Confocal endomicroscopy
Intramucosal Carcinoma
Complex glandular budding
Desmoplasia
Barrett’s cells below
Basement membrane
Concensus Panel - Human Pathology: 2001; 32: 368
Summary
• NBI – Enables better imaging of surface
detail and vascular patterns
• Acetic Acid, and Lugols add value
• OCT/VLE – early days, resolution is
impressive
• Confocal (CLE)– really helps focus
biopsies
Summary
• Focussed biopsies and new
imaging technologies will help our
diagnostic yield
• Help to stratify those patients with
early cancer and those at risk for
developing cancer.