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Comparative Study of Microvascular Architecture and Pit Pattern in Gastric Differentiated Adenocarcinomas
Abstracts
W1391 Comparative Study of Microvascular Architecture and Pit Pattern in Gastric Differentiated Adenocarcinomas Kazuyosi Yagi, Atsuo Nakamura, Atsuo Sekine Background: Whitening of the gastric mucosa can be observed in resected specimens after application of acetic acid, and this technique can also be used for detailed observation of the gastric mucosa by magnifying endoscopy. In the present study we confirmed which types of pit pattern corresponded to vascular patterns using magnifying endoscopy with NBI in early gastric cancers. Methods: Thirty-five patients with mucosal gastric differentiated adenocarccinoma were observed using magnifying endoscopy with NBI, and all of the cancers were then resected by ESD. The resected specimens were treated with acetic acid and their surface structures were observed by magnifying endoscopy. All of the pit patterns revealed by acetic acid were compared with the vascular patterns revealed by NBI. Results: The pit patterns were divisible into three types; round pits type (24 patients), granular pattern (5 patients) and tubular pattern (6 patients). The round pit type was subdivided into three types; small round pits, oval round pits and long oval pits. Vascular patterns revealed by NBI were divided into four types; fine network pattern (type 1), change in density of microvascular architecture without a gastritislike surface (type 2), change in density of microvascular artitecture with a gastritislike surface (type 3) and a similar pattern of microvascular architecture with a gastritis-like surface (type 4). Type 1 was evident in 20 patients, type 2 in 8, type 3 in 4 and type 4 in 3. All of the 19 patients with a type 1 vascular pattern showed a round pit pattern, 4 of the patients with a type 2 vascular pattern had round pits, 3 had a granular pattern and one had a tubular pattern. Two of the patients with a type 3 vascular pattern had a granular pit pattern and 2 had a tubular pattern. All of the patients with a type 4 vascular pattern showed a tubular pit pattern. Conclusions: Gastric cancerous mucosa with a type 1 or type 2 microvascular architecture tends to show a round pit type pattern. These features are thought to be typical of differentiated adenocarcinoma and to aid diagnosis. Gastric cancerous mucosa with a type 3 or type 4 microvascular architecture tends to have a granular or tubular pit pattern, similar to that seen in gastritis. These features are difficult to visualized by magnifying endoscopy with NBI. However, 5 patients with types 2 and 3 showed a unique vascular arrangement consisting of dots and unconnected thick microvessels. This appearance, termed the dot and stick pattern, is thought to be characteristic of differentiated adenocarcinoma.
W1392 In-Vivo Pathological Assessment of Barrett’s Esophagus with Endo-Cytoscopy Sarah Cho, Maria Cirocco, Nancy Basset, Gabor Kandel, Paul Kortan, Gary May, Cathy Streutker, Norman Marcon Background and Aims: The current endoscopic surveillance of Barrett’s esophagus with random biopsies is limited by sampling errors, as most dysplastic lesions and non-invasive cancers are indistinguishable from background Barrett’s esophagus on conventional endoscopy. Endo-cytoscopy is a novel ultra-high magnification endoscopy system which enables observation of the mucosa at the cellular level. The aims of this study were to observe and describe endo-cytoscopic characteristics of normal, metaplastic and dysplastic esophageal mucosa in-vivo and to assess the ability of endo-cytoscopy to improve the diagnostic yield of dysplasia in biopsies for surveillance of Barrett’s esophagus. Methods: Patients with known Barrett’s esophagus undergoing endoscopic surveillance were included in this prospective study and were evaluated by endo-cytoscopy following a standard endoscopy examination. The endo-cytoscopy system (XEC 300, Olympus Corporation, Tokyo, Japan) used in the study consists of a flexible endoscope which is passed through the instrument channel of the standard therapeutic gastroscope (GIF-1T, Olympus). It provides 450 magnification and a field of view of 300 300mm of tissue. Prior to endo-cytoscopy examination, the esophageal mucosa was stained with 1% methylene blue, and macroscopically suspicious lesions seen with standard endoscopy were examined followed by endoscopically unremarkable Barrett’s mucosa in circumferential fashion at 1 to 2 cm intervals. Mucosal biopsies were then taken from the respective areas to correlate with the endo-cytoscopic images followed by four-quadrant, 1 to 2 cm interval biopsies as per current practice of care. Results: Twenty patients have undergone the endo-cytoscopy examinations so far. It was possible to obtain clear images from normal squamous, Barrett’s epithelium and dysplastic esophageal mucosa, and assess the characteristics of nuclei, cell density and glandular architecture which correlated with the histological findings. Conclusion: Endo-cytoscopy provides real-time histological images and has potential to improve the diagnostic yield of conventional endoscopic surveillance for early neoplasia in Barrett’s esophagus by allowing targeted biopsies and avoiding sampling errors. Further studies are warranted to better define and classify the images obtained by endo-cytoscopy for clinical use in Barrett’s esophagus as well as elsewhere in the gastrointestinal tract.
AB354 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
W1393 Interobserver Variation and Standardized Training for Confocal Laser Endomicroscopy Image Interpretation in the Upper and Lower GI Tract Ralf Kiesslich, Georgios K. Anagnostopoulos, Anthony Axon, Katja Deinert, Horst Neuhaus, Martin Goetz, Emmanuel Coron, Oliver Pech, Michael Vieth, Constantin Schneider, Peter R. Galle, Markus Neurath Background: Confocal laser endomicroscopy (CLE) is a newly developed diagnostic tool enabling in vivo microscopy of the mucosal layer at subcellular resolution during ongoing endoscopy. Microscopic images are displayed in addition to white light endoscopy. Aim of the current study was to investigate the blinded judgment (Inter- and intraobserver agreement) of confocal images among gastroenterologists with different experience levels of CLE. Methods: Images at different locations were generated and digitally stored using EC-3870CIFK [Pentax, Tokyo, Japan] between 8/2003 and 10/2006. Subsequently, 100 optical biopsies were randomly selected from the image library of the Johannes Gutenberg University (1123 digitally stored CLE procedures) with histologically proven normal and abnormal images of the esophagus, stomach, small bowel and colon. Two representative images per optical biopsy from the surface and subsurface of the mucosal layer were presented twice to 6 gastroenterologists with different experience level of CLE (0 procedures: 2; 30100 procedures: 2; O100 procedures: 2. Selected investigators with experience in CLE received a standardized training progam at Mainz University. Each selected the most likely diagnosis for displayed images from a list generated for each image pair [‘normal’, ‘non-neoplastic abnormalities’ and ‘neoplasia’]. Kappa statistics (k) with two-sided, 95% confidence intervals (CI) were generated to measure inter- and intraobserver agreement overall and by strata. Results: The interobserver kappa for the 6 participants was fair at .49 (CI.21-.89), intraobserver was moderate at .59 (CI .32-.92). Significant higher kappa values were observed in participants with limited and high experience in CLE (O30 procedures) with .72 [CI .62-.89] and .81 [.71-.92] showing substantial and good agreement compared to gastroenterologist without CLE experience (.34 [CI.21-.46]; .43 [CI .32-.57]). Among gastroenterologists with experience in CLE agreement was highest for normal images (.79), followed by neoplastic images (.73) and abnormal non-neoplastic images (.69). The overall accuracy rate was 72% comparing confocal images with final histology with significant difference between experienced (85%) and inexperienced investigators (53%) [p ! .0001]. Conclusions: Blinded assessment of confocal laser endomicroscopy is strongly dependent on the experience with this method. Investigators with at least 30 endomicroscopy examinations judge significant better regardless of their overall experience in gastroenterology. Thus, endomicroscopy is an examiner dependent method and needs standardized training.
W1394 Computer-Aided Quality Control for Colonoscopy: Automatic Documentation of Cecal Intubation Petrus C. De Groen, Wallapak Tavanapong, Junghwan Oh, Johnny Wong Background: There is consensus among gastroenterology societies, that there is an urgent need to develop performance measures. In 2005 the AGA launched the Center for Quality in Practice (CQIP); two of the first three identified goals of CQIP relate to colonoscopy: creating measures for polyp surveillance and performance of colonoscopy. A consensus report by the ACG and ASGE in 2006 specified in detail a number of measures to be obtained during screening colonoscopy: evidence of cecal intubation, withdrawal time and average number of polyps identified. We are developing a computerized system that automatically obtains key performance measures such as withdrawal time and cecal intubation. Previously we reported the ability of this system to determine withdrawal time. Aim: To investigate whether automatic documentation of cecal intubation can be extracted from video files obtained during colonoscopy. Methods: We used a previously described manual video capture system to create a colonoscopy video file test bed. Standard video splitters were used to feed the colonoscopy video signal to standard monitors for view by endoscopists and to automated image capture workstations. Software was created that automatically uploaded colonoscopy video files from the capture workstations to an analytical server and then automatically combined a sequence of frames belonging to the same procedure into a single MPEG file without other intervening, non-relevant images. Finally, we developed novel software based on shape-fitting to automatically detect the appendiceal orifice. Results: A video file prototype ‘‘pipeline’’ was developed that automatically captures video files during colonoscopy, forwards the files to an analytical server, and combines all images belonging to a single procedure. No human intervention is required in any of these steps at any time: the system automatically starts at 5:30 AM and finishes at 5:30 PM. Uploading starts at 6:00 PM until complete, followed by combining of frames belonging to a single colonoscopy. In a next step our software reports the number of images with a clearly seen appendiceal orifice. The specificity and sensitivity for recognition of the appendiceal orifice was at least 90% when tested on ten colonoscopy videos in our test bed. Conclusions: Automated documentation of cecal intubation, based on automated detection of the appendiceal orifice in colonoscopy video files, can be used as a performance measure for colonoscopy. Combination of withdrawal time and cecal intubation rate monitoring within a computerized system will support large-scale, continuous quality control for colonoscopy in the day-to-day medical practice setting.
www.giejournal.org
W1391 Comparative Study of Microvascular Architecture and Pit Pattern in Gastric Differentiated Adenocarcinomas Kazuyosi Yagi, Atsuo Nakamura, Atsuo Sekine Background: Whitening of the gastric mucosa can be observed in resected specimens after application of acetic acid, and this technique can also be used for detailed observation of the gastric mucosa by magnifying endoscopy. In the present study we confirmed which types of pit pattern corresponded to vascular patterns using magnifying endoscopy with NBI in early gastric cancers. Methods: Thirty-five patients with mucosal gastric differentiated adenocarccinoma were observed using magnifying endoscopy with NBI, and all of the cancers were then resected by ESD. The resected specimens were treated with acetic acid and their surface structures were observed by magnifying endoscopy. All of the pit patterns revealed by acetic acid were compared with the vascular patterns revealed by NBI. Results: The pit patterns were divisible into three types; round pits type (24 patients), granular pattern (5 patients) and tubular pattern (6 patients). The round pit type was subdivided into three types; small round pits, oval round pits and long oval pits. Vascular patterns revealed by NBI were divided into four types; fine network pattern (type 1), change in density of microvascular architecture without a gastritislike surface (type 2), change in density of microvascular artitecture with a gastritislike surface (type 3) and a similar pattern of microvascular architecture with a gastritis-like surface (type 4). Type 1 was evident in 20 patients, type 2 in 8, type 3 in 4 and type 4 in 3. All of the 19 patients with a type 1 vascular pattern showed a round pit pattern, 4 of the patients with a type 2 vascular pattern had round pits, 3 had a granular pattern and one had a tubular pattern. Two of the patients with a type 3 vascular pattern had a granular pit pattern and 2 had a tubular pattern. All of the patients with a type 4 vascular pattern showed a tubular pit pattern. Conclusions: Gastric cancerous mucosa with a type 1 or type 2 microvascular architecture tends to show a round pit type pattern. These features are thought to be typical of differentiated adenocarcinoma and to aid diagnosis. Gastric cancerous mucosa with a type 3 or type 4 microvascular architecture tends to have a granular or tubular pit pattern, similar to that seen in gastritis. These features are difficult to visualized by magnifying endoscopy with NBI. However, 5 patients with types 2 and 3 showed a unique vascular arrangement consisting of dots and unconnected thick microvessels. This appearance, termed the dot and stick pattern, is thought to be characteristic of differentiated adenocarcinoma.
W1392 In-Vivo Pathological Assessment of Barrett’s Esophagus with Endo-Cytoscopy Sarah Cho, Maria Cirocco, Nancy Basset, Gabor Kandel, Paul Kortan, Gary May, Cathy Streutker, Norman Marcon Background and Aims: The current endoscopic surveillance of Barrett’s esophagus with random biopsies is limited by sampling errors, as most dysplastic lesions and non-invasive cancers are indistinguishable from background Barrett’s esophagus on conventional endoscopy. Endo-cytoscopy is a novel ultra-high magnification endoscopy system which enables observation of the mucosa at the cellular level. The aims of this study were to observe and describe endo-cytoscopic characteristics of normal, metaplastic and dysplastic esophageal mucosa in-vivo and to assess the ability of endo-cytoscopy to improve the diagnostic yield of dysplasia in biopsies for surveillance of Barrett’s esophagus. Methods: Patients with known Barrett’s esophagus undergoing endoscopic surveillance were included in this prospective study and were evaluated by endo-cytoscopy following a standard endoscopy examination. The endo-cytoscopy system (XEC 300, Olympus Corporation, Tokyo, Japan) used in the study consists of a flexible endoscope which is passed through the instrument channel of the standard therapeutic gastroscope (GIF-1T, Olympus). It provides 450 magnification and a field of view of 300 300mm of tissue. Prior to endo-cytoscopy examination, the esophageal mucosa was stained with 1% methylene blue, and macroscopically suspicious lesions seen with standard endoscopy were examined followed by endoscopically unremarkable Barrett’s mucosa in circumferential fashion at 1 to 2 cm intervals. Mucosal biopsies were then taken from the respective areas to correlate with the endo-cytoscopic images followed by four-quadrant, 1 to 2 cm interval biopsies as per current practice of care. Results: Twenty patients have undergone the endo-cytoscopy examinations so far. It was possible to obtain clear images from normal squamous, Barrett’s epithelium and dysplastic esophageal mucosa, and assess the characteristics of nuclei, cell density and glandular architecture which correlated with the histological findings. Conclusion: Endo-cytoscopy provides real-time histological images and has potential to improve the diagnostic yield of conventional endoscopic surveillance for early neoplasia in Barrett’s esophagus by allowing targeted biopsies and avoiding sampling errors. Further studies are warranted to better define and classify the images obtained by endo-cytoscopy for clinical use in Barrett’s esophagus as well as elsewhere in the gastrointestinal tract.
AB354 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
W1393 Interobserver Variation and Standardized Training for Confocal Laser Endomicroscopy Image Interpretation in the Upper and Lower GI Tract Ralf Kiesslich, Georgios K. Anagnostopoulos, Anthony Axon, Katja Deinert, Horst Neuhaus, Martin Goetz, Emmanuel Coron, Oliver Pech, Michael Vieth, Constantin Schneider, Peter R. Galle, Markus Neurath Background: Confocal laser endomicroscopy (CLE) is a newly developed diagnostic tool enabling in vivo microscopy of the mucosal layer at subcellular resolution during ongoing endoscopy. Microscopic images are displayed in addition to white light endoscopy. Aim of the current study was to investigate the blinded judgment (Inter- and intraobserver agreement) of confocal images among gastroenterologists with different experience levels of CLE. Methods: Images at different locations were generated and digitally stored using EC-3870CIFK [Pentax, Tokyo, Japan] between 8/2003 and 10/2006. Subsequently, 100 optical biopsies were randomly selected from the image library of the Johannes Gutenberg University (1123 digitally stored CLE procedures) with histologically proven normal and abnormal images of the esophagus, stomach, small bowel and colon. Two representative images per optical biopsy from the surface and subsurface of the mucosal layer were presented twice to 6 gastroenterologists with different experience level of CLE (0 procedures: 2; 30100 procedures: 2; O100 procedures: 2. Selected investigators with experience in CLE received a standardized training progam at Mainz University. Each selected the most likely diagnosis for displayed images from a list generated for each image pair [‘normal’, ‘non-neoplastic abnormalities’ and ‘neoplasia’]. Kappa statistics (k) with two-sided, 95% confidence intervals (CI) were generated to measure inter- and intraobserver agreement overall and by strata. Results: The interobserver kappa for the 6 participants was fair at .49 (CI.21-.89), intraobserver was moderate at .59 (CI .32-.92). Significant higher kappa values were observed in participants with limited and high experience in CLE (O30 procedures) with .72 [CI .62-.89] and .81 [.71-.92] showing substantial and good agreement compared to gastroenterologist without CLE experience (.34 [CI.21-.46]; .43 [CI .32-.57]). Among gastroenterologists with experience in CLE agreement was highest for normal images (.79), followed by neoplastic images (.73) and abnormal non-neoplastic images (.69). The overall accuracy rate was 72% comparing confocal images with final histology with significant difference between experienced (85%) and inexperienced investigators (53%) [p ! .0001]. Conclusions: Blinded assessment of confocal laser endomicroscopy is strongly dependent on the experience with this method. Investigators with at least 30 endomicroscopy examinations judge significant better regardless of their overall experience in gastroenterology. Thus, endomicroscopy is an examiner dependent method and needs standardized training.
W1394 Computer-Aided Quality Control for Colonoscopy: Automatic Documentation of Cecal Intubation Petrus C. De Groen, Wallapak Tavanapong, Junghwan Oh, Johnny Wong Background: There is consensus among gastroenterology societies, that there is an urgent need to develop performance measures. In 2005 the AGA launched the Center for Quality in Practice (CQIP); two of the first three identified goals of CQIP relate to colonoscopy: creating measures for polyp surveillance and performance of colonoscopy. A consensus report by the ACG and ASGE in 2006 specified in detail a number of measures to be obtained during screening colonoscopy: evidence of cecal intubation, withdrawal time and average number of polyps identified. We are developing a computerized system that automatically obtains key performance measures such as withdrawal time and cecal intubation. Previously we reported the ability of this system to determine withdrawal time. Aim: To investigate whether automatic documentation of cecal intubation can be extracted from video files obtained during colonoscopy. Methods: We used a previously described manual video capture system to create a colonoscopy video file test bed. Standard video splitters were used to feed the colonoscopy video signal to standard monitors for view by endoscopists and to automated image capture workstations. Software was created that automatically uploaded colonoscopy video files from the capture workstations to an analytical server and then automatically combined a sequence of frames belonging to the same procedure into a single MPEG file without other intervening, non-relevant images. Finally, we developed novel software based on shape-fitting to automatically detect the appendiceal orifice. Results: A video file prototype ‘‘pipeline’’ was developed that automatically captures video files during colonoscopy, forwards the files to an analytical server, and combines all images belonging to a single procedure. No human intervention is required in any of these steps at any time: the system automatically starts at 5:30 AM and finishes at 5:30 PM. Uploading starts at 6:00 PM until complete, followed by combining of frames belonging to a single colonoscopy. In a next step our software reports the number of images with a clearly seen appendiceal orifice. The specificity and sensitivity for recognition of the appendiceal orifice was at least 90% when tested on ten colonoscopy videos in our test bed. Conclusions: Automated documentation of cecal intubation, based on automated detection of the appendiceal orifice in colonoscopy video files, can be used as a performance measure for colonoscopy. Combination of withdrawal time and cecal intubation rate monitoring within a computerized system will support large-scale, continuous quality control for colonoscopy in the day-to-day medical practice setting.
www.giejournal.org