Chromoendoscopy and magnification endoscopy for diagnosing esophageal cancer and dysplasia

Endoscopic Advances in the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is one of the most common diseases that occurs secondary to failure of the antireflux barrier system, resulting in the frequent and abnormal reflux of gastric contents to the esophagus. GERD is diagnosed in routine clinical practice based on the classic symptoms of heartburn and regurgitation. However, a subset of patients with atypical symptoms can pose challenges in diagnosing GERD. An esophagogastroduodenoscopy (EGD) is the most common initial diagnostic test used in the assessment for GERD, although half of these patients will not have any positive endoscopic findings suggestive of GERD. The advanced endoscopic techniques have improved the diagnostic yield of GERD diagnosis and its complications, such as Barrett's esophagus and early esophageal adenocarcinoma. These newer endoscopic tools can better detect subtle irregularities in the mucosa and vascular structures. The management options for GERD include lifestyle modifications, pharmacological therapy, and endoscopic and surgical interventions. The latest addition to the armamentarium is the minimally invasive endoscopic interventions in carefully selected patients, including the electrical stimulation of the LES, Antireflux mucosectomy, Radiofrequency therapy, Transoral Incisionless Fundoplication, Endoscopic Full-Thickness plication (GERDx™), and suturing devices. With the emergence of these advanced endoscopic techniques, it is crucial to understand their selection criteria, advantages, and disadvantages.

Diagnosis and Management of Barrett's Esophagus

Barrett's esophagus is a metaplastic change of esophageal mucosa, which can be characterized by its salmon-colored lining and the presence of columnar epithelium with goblet cells. It is a well-established precancerous state of esophageal adenocarcinoma, a tumor with very poor survival rates, which incidence is rapidly growing. Despite numerous research, the debate about its diagnosis and management is still ongoing. This article aims to provide an overview of the current recommendations and new discoveries regarding the subject.

Squamous Cell Carcinoma of the Esophagus

Esophageal squamous cell carcinoma (ESCC) is common in the developing world with decreasing incidence in developed countries and carries significant morbidity and mortality. Major risk factors for ESCC development include significant use of alcohol and tobacco. Screening for ESCC can be recommended in high-risk populations living in highly endemic regions. The treatment of ESCC ranges from endoscopic resection therapy or surgery in localized disease to chemoradiotherapy in metastatic disease, and prognosis is directly related to the stage at diagnosis. New immunotherapies and molecular targeted therapies may improve the dismal survival outcomes in patients with metastatic ESCC.

Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.

Advanced Imaging for Barrett's Esophagus and Early Neoplasia: Surface and Subsurface Imaging for Diagnosis and Management

PURPOSE OF REVIEW

Esophageal adenocarcinoma bears one of the fastest rising incidence of any cancers and generally arises in the setting of gastroesophageal reflux and Barrett's esophagus. However, early detection of neoplasia can be challenging since most patients are asymptomatic until they progress to more advanced and less curable stages, and early dysplastic lesions can be small, multifocal, and difficult to detect. Clearly, new imaging tools are needed in light of sampling error associated with random biopsies, the current standard of practice.

RECENT FINDINGS

Advances in endoscopic imaging including virtual chromoendoscopy, confocal laser endomicroscopy, and subsurface imaging with optical coherence tomography have ushered in a new era for detecting subtle neoplastic lesions. Moreover, in light of esophagus-sparing treatments for neoplastic lesions, such tools are likely to guide ablation and follow-up management. While there is no ideal single imaging modality to facilitate improved detection, staging, ablation, and follow-up of patients with dysplastic Barrett's esophagus, new advances in available technology, the potential for multimodal imaging, and the use of computer-aided diagnosis and biomarkers all hold great promise for improving detection and treatment.

Colposcopic Characteristics and Lugol's Staining Differentiate Anal High-Grade and Low-Grade Squamous Intraepithelial Lesions During High Resolution Anoscopy

Background

Methods

Results

Conclusions

Quantitative analysis of high-resolution microendoscopic images for diagnosis of esophageal squamous cell carcinoma

BACKGROUND & AIMS

High-resolution microendoscopy is an optical imaging technique with the potential to improve the accuracy of endoscopic screening for esophageal squamous neoplasia. Although these microscopic images can be interpreted readily by trained personnel, quantitative image analysis software could facilitate the use of this technology in low-resource settings. In this study, we developed and evaluated quantitative image analysis criteria for the evaluation of neoplastic and non-neoplastic squamous esophageal mucosa.

METHODS

We performed an image analysis of 177 patients undergoing standard upper endoscopy for screening or surveillance of esophageal squamous neoplasia, using high-resolution microendoscopy, at 2 hospitals in China and at 1 hospital in the United States from May 2010 to October 2012. Biopsy specimens were collected from imaged sites (n = 375), and a consensus diagnosis was provided by 2 expert gastrointestinal pathologists and used as the standard.

RESULTS

Quantitative information from the high-resolution images was used to develop an algorithm to identify high-grade squamous dysplasia or invasive squamous cell cancer, based on histopathology findings. Optimal performance was obtained using the mean nuclear area as the basis for classification, resulting in sensitivities and specificities of 93% and 92% in the training set, 87% and 97% in the test set, and 84% and 95% in an independent validation set, respectively.

CONCLUSIONS

High-resolution microendoscopy with quantitative image analysis can aid in the identification of esophageal squamous neoplasia. Use of software-based image guides may overcome issues of training and expertise in low-resource settings, allowing for widespread use of these optical biopsy technologies.

Esophageal cancer: Recent advances in screening, targeted therapy, and management

The incidence of esophageal cancer remains on the rise worldwide and despite aggressive research in the field of gastrointestinal oncology, the survival remains poor. Much remains to be defined in esophageal cancer, including the development of an effective screening tool, identifying a good tumor marker for surveillance purposes, ways to target esophageal cancer stem cells as well as circulating tumor cells, and developing minimally invasive protocols to treat early-stage disease. The goal of this chapter is to highlight some of the recent advances and ongoing research in the field of esophageal cancer.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

Endotherapy for Barrett's esophagus

Endotherapy is now the mainstay of therapy for Barrett's associated neoplasia. The approach should begin with confirmation of neoplasia by a gastrointestinal pathologist, patient counseling, and appropriate endoscopic work up. Detailed examination with high-resolution white light endoscopy is the most important tool for detection of neoplasia. Further validation studies are needed for many enhanced imaging modalities before being recommended as part of the standard work up and assessment of patients with Barrett's esophagus (BE). Endoscopic mucosal resection is required for any visible lesion in the setting of dysplasia for accurate histological diagnosis. The remainder of the epithelium may be treated with resection or ablative therapy, followed by adequate surveillance. Patients with nondysplastic Barrett's require further risk stratification before incorporation of ablative therapy for this population. The future will fortify the endoscopic role in Barrett's with validation trials for endoscopic assessment, further long-term results for each of the treatment modalities, potential risk stratification for patients with BE, and improved guidelines for surveillance after therapy.

Early detection in head and neck cancer - current state and future perspectives

Survival and quality of life in head and neck cancer are directly linked to the size of the primary tumor at first detection. In order to achieve substantial gain at these issues, both, primary prevention and secondary prevention, which is early detection of malignant lesions at a small size, have to be improved. So far, there is not only a lack in the necessary infrastructure not only in Germany, but rather worldwide, but additionally the techniques developed so far for early detection have a significance and specificity too low as to warrant safe implementation for screening programs. However, the advancements recently achieved in endoscopy and in quantitative analysis of hypocellular specimens open new perspectives for secondary prevention. Chromoendoscopy and narrow band imaging (NBI) pinpoint suspicious lesions more easily, confocal endomicroscopy and optical coherence tomography obtain optical sections through those lesions, and hyperspectral imaging classifies lesions according to characteristic spectral signatures. These techniques therefore obtain optical biopsies. Once a "bloody" biopsy has been taken, the plethora of parameters that can be quantified objectively has been increased and could be the basis for an objective and quantitative classification of epithelial lesions (multiparametric cytometry, quantitative histology). Finally, cytomics and proteomics approaches, and lab-on-the-chip technology might help to identify patients at high-risk. Sensitivity and specificity of these approaches have to be validated, yet, and some techniques have to be adapted for the specific conditions for early detection of head and neck cancer. On this background it has to be stated that it is still a long way to go until a population based screening for head and neck cancer is available. The recent results of screening for cancer of the prostate and breast highlight the difficulties implemented in such a task.

Endoscopic techniques for recognizing neoplasia in Barrett's esophagus: which should the clinician use?

PURPOSE OF REVIEW

The key to prevention and cure of esophageal adenocarcinoma is the detection and eradication of neoplasia in patients with Barrett's esophagus. Multiple tools and technologies are emerging for this purpose.

RECENT FINDINGS

A detailed white light examination with high-resolution endoscopy and recognition of lesions is paramount. A variety of imaging modalities are being studied for the detection of neoplasia in Barrett's esophagus. Chromoendoscopy, narrow band imaging, and autofluorescence provide a way to target suspicious areas. Confocal endomicroscopy and optical coherence tomography are means to pinpoint imaging to obtain information about the tissue microarchitecture.

SUMMARY

The key to detection of neoplasia is a careful white light examination with high-resolution endoscopy and recognition of lesion characteristics. Additional imaging modalities may enhance targeting of lesions or provide more information at a focused level. Many of these modalities have yet to be validated in prospective randomized, multicenter trials.

Transnasal endoscopy with narrow-band imaging and Lugol staining to screen patients with head and neck cancer whose condition limits oral intubation with standard endoscope (with video)

BACKGROUND

Early detection of esophageal cancer in patients with head and neck cancers may alter treatment planning and improve survival. However, standard endoscopic screening is not feasible for some patients with tumor-related airway compromise or postirradiation trismus.

OBJECTIVE

To evaluate a novel, sequential approach by integrating ultrathin endoscopy with narrow-band imaging and Lugol chromoendoscopy.

DESIGN

Cross-sectional study.

SETTING

Single center in Taiwan.

PATIENTS

Forty-four consecutive patients with transoral difficulty screened for synchronous or metachronous esophageal cancer.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and accuracy in the detection of mucosal high-grade neoplasia or invasive cancer.

RESULTS

Fifty-four endoscopic interpretations were obtained, and 11 mucosal high-grade neoplasia and 7 invasive cancers were confirmed by histology. The mean examination time was 19.4 minutes (range 7.9-35.2 minutes), and all patients tolerated the procedure well. Sensitivity, specificity, and accuracy (with 95% CI) were 55.6% (95% CI, 33.5%-75.6%), 97.2% (95% CI, 85.8%-99.3%), and 83.3% (95% CI, 71.2%-90.9%), respectively, for standard endoscopy; 88.9% (95% CI, 66.9%-96.6%), 97.2% (95% CI, 85.8%-99.3%), and 94.4% (95% CI, 84.9%-97.9%), respectively, with the adjunct of narrow-band imaging; and 88.9% (95% CI, 66.9%-96.6%), 72.2% (95% CI, 55.9%-84.1%), and 77.8% (95% CI, 64.9%-86.8%), respectively, with the adjunct of Lugol chromoendoscopy. When we integrated all interpretations on the basis of the sequential approach, the estimated probability of false-negative findings was 1.2% (95% CI, 0.1%-4.6%).

LIMITATIONS

Inherent shortcomings of ultrathin endoscopy, such as its resolution, light source, and lack of magnification.

CONCLUSIONS

The use of ultrathin endoscopy in a sequential approach for multimodal detection is feasible in patients with transoral difficulty and substantially increases the detection rate of synchronous or metachronous neoplasms.

Advances in endoscopic imaging of the esophagus

The introduction of flexible fiberoptic endoscopy in the 1960s was a major step forward in the diagnosis and management of various esophageal disorders. Since then, there has been steady progress in the development of novel gastrointestinal endoscopy techniques. Magnification and high-resolution endoscopy, chromoendoscopy, narrow-band imaging, autofluorescence imaging, and confocal laser endomicroscopy are some of the recent advances that have shown promise in the diagnosis of squamous cell carcinoma, gastroesophageal reflux disease, Barrett's esophagus, and adenocarcinoma of the esophagus. The purpose of this review is to summarize the recent advances in endoscopic imaging of the esophagus and their practical application for the gastroenterologist.

Developments in esophageal surgery for adenocarcinoma: a comparison of two decades

BACKGROUND

The objective of this study was to examine outcomes in patients undergoing esophageal resection for adenocarcinoma at our institution during a 20-year period and, in particular, to address temporal trends in long-term survival.

METHODS

Out of 470 patients who underwent esophagectomy for malignancy between September 1985 and September 2005, a total number of 175 patients presented with esophageal adenocarcinoma. Patients enrolled in this study included AEG (adenocarcinoma of the esophagogastric junction) type I tumors only. Time trends were studied comparing two decades, 9/1985 to 9/1995 (DI) and 10/1995 to 9/2005 (DII).

RESULTS

The overall survival was significantly more favourable in patients undergoing esophageal resection for adenocarcinoma in the recent time period (DII, 10/1995 to 9/2005) as compared to the early time period (DI, 9/1985 to 9/1995) (log rank test: p = 0.0329). Significant differences in the recent decade were seen based on lower ASA-classifications, earlier tumor stages, and the operative procedure with a higher frequency of transhiatal resections (p < 0.05). 30-day mortality improved from 8.3% to 3.1% during the 20-year time-interval, thus without statistical significance.

CONCLUSION

Based on our experience, overall survival is improving over time for adenocarcinoma of the esophagus. Factors that may play an important role in this trend include early diagnosis and improved patient selection through better preoperative staging, improved surgical technique with a tailored approach carefully evaluated by physiologic patient status, comorbidity and tumor extent.

Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging

BACKGROUND

The detection of the mucosal morphology (ie, mucosal and vascular patterns) in Barrett's esophagus (BE) by magnifying (chromo)endoscopy may improve the distinction of high-grade intraepithelial neoplasia (HGIN) from nondysplastic specialized intestinal metaplasia (SIM). Narrow band imaging (NBI) is a new technique that uses optical filters to enhance the mucosal contrast without the need for chromoendoscopy.

OBJECTIVE

To use NBI for the characterization and the classification of the mucosal morphology in nondysplastic BE and in BE with HGIN.

DESIGN

Descriptive study.

SETTING

Single-center study in a tertiary referral center for the diagnosis and treatment of patients with BE.

PATIENTS

We used NBI with magnifying endoscopy to image and biopsy randomly selected areas in 63 patients with BE. A systematic image and a biopsy specimen evaluation process was followed, including unblinded assessment of an exploratory set of images and biopsy specimens, and blinded evaluation of learning and validation sets.

MAIN OUTCOME MEASUREMENTS

The relationship between the mucosal morphology and the presence of SIM and HGIN.

RESULTS

SIM was characterized by either villous/gyrus-forming patterns (80%), which were mostly regular and had regular vascular patterns, or a flat mucosa with regular normal-appearing long branching vessels (20%). HGIN was characterized by 3 abnormalities: irregular/disrupted mucosal patterns, irregular vascular patterns, and abnormal blood vessels. All areas with HGIN had at least 1 abnormality, and 85% had 2 or more abnormalities. The frequency of abnormalities showed a significant rise with increasing grades of dysplasia. The magnified NBI images had a sensitivity of 94%, a specificity of 76%, a positive predictive value of 64%, and a negative predictive value of 98% for HGIN.

LIMITATIONS

No data on observer agreement.

CONCLUSIONS

NBI with magnification reveals the mucosal morphology characteristics of nondysplastic BE and HGIN, without the need for staining and has a relatively high diagnostic value for HGIN when used for targeted detailed examination of areas of interest.