Ralf Kiesslich Johannes Gutenberg University Mainz, Germany
DIAGNOSIS
Unmask lesions - Chromoendoscopy -NBI Red flag technology - Autofluorescence Surface and detail analysis - Magnifying endoscopy - High resolution endoscopy In vivo histology: Cellular architecture - Endocytoscopy (surface) - Endomicroscopy (whole mucosal layer) Tissue architecture -OCT
CHROMOENDOSCOPY
Japanese Classification Type O-I: Protruted type Type O-IIa: Superficial elevated type Type O-IIb: Flat type Type O-IIc: Superficial depressed type Type O-III: Excavated type
Type I
Type IIa
Type IIa+IIc
Magnifying Endoscopy
High risk population
Hereditary diffuse gastric Hereditary diffuse gastric cancer is defined by germline mutations in the E-cadherin gene, CDH-1. Penetrance is 70%. Congo red/methylene blue detected carcinoma foci 4-10 mm in size but not foci <4 mm. Chromogastroscopy represents an improved surveillance technique that can be safely considered alongside prophylactic gastrectomy. Shaw et al. Gut 2005
Shaw et al. Gut 2005
Filter Technology NBI FICE - SURFACE
Narrow Band Imaging Conventional Filter B G R B G R NBI Filter B G R
NBI of HGD in Barrett s University Mainz Prediction of HGD Sensitivity 94%; Specificity 76% Kara et al. Gastrointest Endosc 2006
Tamai et al. Endoscopy 2006
Tamai et al. Endoscopy 2006
Differentiated Undifferentiated
HDTV & HD+
Pentax-EPKi
Pentax-EPKi
Pentax-EPKi
Autofluorescence & Video endoscopy
Autofluorescence Chromoendoscopy Uedo et al. GI Endosc 2005
Uedo et al. GI Endosc 2005
ENDOMICROSCOPY
Endomicroscopy Field of view: 475x475µm Range: 0-250µm Lateral resolution: <1µm
Helicobacter pylori Kiesslich et al., Gastroenterology 2005
Gastritis Metaplasia - Cancer Intestinale Metaplasia Tumor Tumor vessel Final histology: poorly differentiated adenocarcinoma
Well differentiated Adenocarcinoma
Subtle Changes
Normal gastric architecture Malignant transformation
Signet ring cells
Gastritis Metaplasia - Cancer Prospective blinded evaluation predicting gastric cancer (132 locations) Sensitivity 84%; Specificity 95%; Accuracy 80% Inter-observer agreement by kappa statistics for sites (antrum, corpus, cardia) presence of intestinal metaplasia and cancer: 0.83, 0.89, and 0.63 Yeoh et al., DDW 2005
MALT Lymphoma
MALT-Lymphoma
MALT-Lymphoma
Endosonography & OCT
Mini-Probes Endosonography Accuracy 65-87% Rösch, Gastrointest Clin North Am 1995
Optical Coherence Tomography OCT provides noninvasive, subsurface high-resolution imaging of tissue microstructure. In contrast to ultrasound, OCT utilizes light instead of sound reflectivity, which provides a 10-fold higher resolution Resolution 10-20 microns; Penetration depth <2.5mm
OCT: Barrett Esophagus Barrett s epithelium Squamous Epithelium Prediction of Barrett s Epithelium: Sensitivity 97%; Specificity 92% Poneros et al. Gastroenterology 2001 Image: Rabenstein, Ell, Wiesbaden 2005
Gastric Cancer?
THERAPY
Gotoda, Gastric Cancer 2007
EMR
Classic Guidelines Recurrence rates: 3-36%! Gotoda, Gastric Cancer 2007
Crucial question Lymphovascular invasion
Gotoda, Gastric Cancer 2007
Extended Guidelines Gotoda, Gastric Cancer 2007
ESD
ESD - Instruments Gotoda, Gastric Cancer 2007
Bleeding
Perforation
Perforation
Conclusions Diagnosis Chromoendoscopy helps to characterize gastric lesions (size, type) Magnifying endoscopy adds surface detail HDTV (HD+) will replace conventional video endoscopy Endomicroscopy see histology in vivo Therapy EMR/ESD for selected cases and trained endoscopists
THANK YOU