Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands.
Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands.
Gastrointest Endosc. 2017 Sep;86(3):464-472. doi: 10.1016/j.gie.2017.01.030. Epub 2017 Feb 2.
BACKGROUND AND AIM: Volumetric laser endomicroscopy (VLE) provides a circumferential scan of the esophageal wall layers and has potential to improve detection of neoplasia in Barrett's esophagus (BE). The novel VLE laser marking system enables direct in vivo marking of suspicious areas as identified on VLE. These laser marked areas can subsequently be targeted for biopsies. The aim was to evaluate the visibility and positional accuracy of laser marks (LMs) in different esophageal tissue types on white light endoscopy (WLE) and VLE. METHODS: Patients with BE with or without neoplasia underwent imaging with VLE. Protocol refinements were practiced in a learning phase. In the second phase, visibility of LMs was assessed by random marking in squamous, BE, and gastric tissue. In phase 3, positional accuracy of the LMs was tested by identifying and laser marking surrogate targets (endoscopically placed cautery marks). In the final phase, the most suspicious areas for neoplasia were identified in each patient using VLE, targeted by LMs, and biopsy samples subsequently obtained. RESULTS: Sixteen patients with BE were included (14 men; median age, 68 years), 1 of whom was included twice in different study phases. Worst histologic diagnoses were 9 non-dysplastic Barrett's esophagus (NDBE), 3 low-grade dysplasia (LGD), 4 high-grade dysplasia (HGD), and 1 early adenocarcinoma (EAC). In total, 222 LMs were placed, of which 97% was visible on WLE. All LMs were visible on VLE directly after marking, and 86% could be confirmed during post hoc analysis. LM targeting was successful with positional accuracy in 85% of cautery marks. Inaccurate targeting was caused by system errors or difficult cautery mark visualization on VLE. In the final phase (5 patients), 18 areas suspicious on VLE were identified, which were all successfully targeted by LMs (3 EAC, 3 HGD, 1 LGD, and 11 NDBE). Mean VLE procedure time was 22 minutes (±6 minutes standard deviation); mean endoscopy time was 56 minutes (±17 minutes). No adverse events were reported. CONCLUSIONS: This first-in-human study of VLE-guided laser marking was found to be feasible and safe in 17 procedures. Most LMs were visible on WLE and VLE. Targeting VLE areas of interest proved to be highly successful. VLE-guided laser marking may improve the detection and delineation of Barrett's neoplasia in the future.
背景与目的：容积激光内窥镜（VLE）可对食管壁各层进行环形扫描，有望提高 Barrett 食管（BE）中肿瘤的检出率。新型 VLE 激光标记系统可对 VLE 上识别到的可疑区域进行直接体内标记。随后可对这些激光标记区域进行活检。本研究旨在评估不同食管组织类型在白光内镜（WLE）和 VLE 下激光标记（LM）的可视性和定位准确性。
方法：患有或不患有肿瘤的 BE 患者接受 VLE 成像。在学习阶段进行了方案改进。在第二阶段，在鳞状上皮、BE 和胃组织中随机标记评估 LM 的可视性。在第三阶段，通过识别和激光标记替代靶标（内镜放置的电烙标记）来测试 LM 的定位准确性。在最后阶段，每位患者均使用 VLE 识别出最可疑的肿瘤区域，然后通过 LM 进行靶向，并随后获得活检样本。
结果：共纳入 16 例 BE 患者（14 例男性；中位年龄 68 岁），其中 1 例患者分两次在不同的研究阶段入组。最差的组织学诊断为 9 例非异型增生性 Barrett 食管（NDBE）、3 例低级别异型增生（LGD）、4 例高级别异型增生（HGD）和 1 例早期腺癌（EAC）。共放置了 222 个 LM，其中 97%在 WLE 上可见。所有 LM 在标记后立即在 VLE 上直接可见，86%在事后分析中可确认。85%的电烙标记的 LM 靶向具有定位准确性。定位不准确的原因是系统误差或 VLE 上难以可视化电烙标记。在最后阶段（5 例患者），共识别出 18 个 VLE 上可疑的区域，均通过 LM 成功靶向（3 例 EAC、3 例 HGD、1 例 LGD 和 11 例 NDBE）。VLE 程序的平均时间为 22 分钟（±6 分钟标准差）；内镜的平均时间为 56 分钟（±17 分钟）。未报告不良事件。
结论：这项在 17 例患者中开展的首例 VLE 引导激光标记的人体研究被证明是可行和安全的。大多数 LM 在 WLE 和 VLE 上可见。对 VLE 感兴趣区域的靶向定位证明是非常成功的。VLE 引导激光标记未来可能会提高 Barrett 肿瘤的检出和描绘能力。
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