Elisa Ryoka Baba, MD, from the Institute of Cancer of the Department of Gastroenterology, University of São Paulo Medical School, in São Paulo, Brazil writes about this video case “Probe-based confocal laser endomicroscopy for the differential diagnosis of gastric tubular adenoma and intestinal metaplasia in a patient with severe atrophic pangastritis.”

We reported a 65-year-old female Japanese descendant who presented dyspeptic complaints. The upper endoscopy revealed severe atrophic pangastritis with numerous slightly elevated whitish lesions, measuring 5 to 15 mm, mostly located at the antrum. We performed pCLE of the lesions. The images of the antrum lesions were suggestive of intestinal metaplasia, which was characterized by goblet cells filled with oval appearance dark mucin, within small and round glands. The surrounding columnar cells were small and the mucosal surface was flat. Forceps biopsies were taken and histology confirmed intestinal metaplasia. At the distal portion of gastric body, pCLE demonstrated a lesion with homogeneous elongated cells in palisade arrangement, and diminishing number of goblet cells. The tubules were also elongated, and the mucosal surface was composed of regular and homogeneous villiform structures, compatible with adenoma. It was resected by endoscopic submucosal dissection and histology confirmed low-grade adenoma.

Figure 1. A, Confocal endomicroscopic image of intestinal metaplasia of gastric antrum with goblet cells. B, Microscopic view of histologic findings (H&E, orig. mag. 40).

In the circumstances that upper GI endoscopy reveals lesions suspicious for neoplasia, chromoendoscopy, virtual chromoendoscopy, and magnification are some of the available tools to suggest a definitive diagnosis. In addition, probe-based confocal endomicroscopy (pCLE) has the particularity to offer virtual real time histology. In this particular video, pCLE was useful for the differential diagnosis of intestinal metaplasia and gastric adenoma, both present in this patient. The pCLE findings oriented the adequate endoscopic treatment.

The pCLE images showed an agreement with the histology during endoscopy in real time. It could be useful for the histological diagnosis of suspicious lesions, as well as for the surveillance of gastric mucosa in patients with increased risk for gastric cancer.

The correct interpretation of pCLE images is probably facilitated by the presence of an operator with some pathology expertise. In this sense, the interaction between the endoscopist and the pathologist might be useful for the pCLE learning curve.

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