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Novel imaging modalities in the detection of oesophageal neoplasia

https://doi.org/10.1016/j.bpg.2008.01.001Get rights and content

The prognosis of oesophageal neoplasia is dependent on the stage of the disease at the time of detection. Early lesions have an excellent prognosis in contrast to more advanced stages that usually have a dismal prognosis. Therefore, the early detection of these lesions is of the utmost importance. In recent years, several new techniques have been introduced to improve the endoscopic detection of early lesions. The most important improvement, in general, has been the introduction of high-resolution/high-definition endoscopy into daily clinical practice. The value of superimposing techniques such as chromoendoscopy, narrow band imaging and computed virtual chromoendoscopy onto high-resolution/high-definition endoscopy will have to be proven in randomised cross-over trials comparing these techniques with standard techniques. Important future adjuncts to white-light endoscopy serving as ‘red-flag’ techniques for the detection of early neoplasia may be broad field functional imaging techniques such as video autofluorescence endoscopy. In addition, real-time histopathology during endoscopy has become possible with endocytoscopy and confocal endomicroscopy. The clinical value of these techniques needs to be ascertained in the coming years.

Introduction

Squamous cell carcinoma (SCC) and oesophageal adenocarcinoma (OAC) are the two most important neoplasms of the oesophagus. SCC is the most common oesophageal neoplasm around the world and is more common in Asia. Important risk factors for SSC are alcohol consumption and smoking. In contrast to SCC, the incidence of OAC has been rising dramatically over the last decades in Western countries. OAC has a known precursor lesion called Barrett's oesophagus (BO). BO is defined as columnar lined epithelium of the distal oesophagus containing intestinal metaplasia on histology. This is thought to be a consequence of chronic gastro-oesophageal reflux disease. OAC develops from intestinal metaplasia through various stages of dysplasia (i.e. low-grade and high-grade dysplasia) to early mucosal carcinoma and eventually invasive carcinoma.

The prognosis of these two oesophageal tumours is determined by the stage of the disease. Early neoplastic lesions have an excellent prognosis, for more advanced stages the prognosis is dismal. In general, most oesophageal tumours are detected when symptoms occur and the tumour is then usually at an advanced stage. Detection of an oesophageal neoplasm at an early and curable stage is, therefore, of crucial clinical importance. The endoscopic detection of early oesophageal neoplastic lesions is, however, difficult since they are associated with only subtle mucosal changes. New imaging modalities may allow for better detection of these early neoplastic lesions and thus improve the survival of these frequently fatal carcinomas. In this review we will present the most important and recent endoscopic techniques that are of interest for improving the imaging of early oesophageal cancer and its precursors. We will discuss the principles, current status and possible future role in clinical practice of these techniques. The different techniques are divided in three categories: ‘enhanced imaging of the oesophageal surface’, ‘functional imaging of the oesophageal mucosa’ and ‘imaging beyond the oesophageal surface’.

Section snippets

High-resolution/high-definition/magnification endoscopy

In the last two decades, endoscopes with charge-coupled devices (CCD), i.e. electronic endoscopes, have largely replaced fibreoptic endoscopes. For CCD-based instruments, the resolution depends on the total number of pixels on the CCD surface and on the total number of pixels used to generate the image. CCDs in standard video endoscopes have a total number of pixels of 100,000–300,000.1 Endoscopes containing CCDs with larger numbers of pixels (600,000–1 million) are commercially available.

Enhanced imaging of the oesophageal surface: summary

Standard endoscopy has developed from rigid endoscopes through fibreoptic endoscopes to today's video endoscopes. Each of these steps was accompanied by a clear improvement in imaging quality. The endoscopic community is now moving from standard video endoscopy into the era of high-resolution/high-definition endoscopy, which is simply the next logical step in the evolution of endoscopy.

Several adjuncts to white light endoscopy have been investigated for enhancing surface imaging.

Functional imaging of the oesophageal mucosa and submucosa

In standard endoscopy, reflection and absorption are the two light-tissue interactions that are used to generate an image. When incident light hits the mucosa several other tissue interactions, such as autofluorescence, elastic scattering and Raman scattering, also occur. Optical signals resulting from these light-tissue interactions are dependant on the molecular and structural composition of the tissue. Since neoplastic progression in tissues leads to changes in these compositions,

Optical coherence tomography

Optical coherence tomography (OCT) is a high-resolution cross-sectional imaging technique. It is analogous to B-mode high-resolution endosonography but uses light waves instead of acoustic waves. As a result, OCT has a high resolution (∼10 μm), up to 10 times higher than high-frequency ultrasound, enabling microstructural features of tissue to be identified, but it has a limited sampling depth of 1–2 mm.90 OCT measures the intensity of back scattered light from tissue at various depths using

Summary

In this review we have discussed the most important advances in endoscopy that are relevant for the detection of early neoplastic lesions in the oesophagus. The different techniques serve two different purposes: (1) the primary detection of lesions in overview (e.g. high-resolution/high-definition endoscopy, chromoendoscopy and autofluorescence imaging); and (2) the targeted inspection of lesions after primary detection (e.g. magnification endoscopy, spectroscopy techniques, endocytoscopy and

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