Post written by Adriana Vaz Safatle-Ribeiro from the Cancer Institute, Department of Gastroenterology, University of São Paulo, Brazil.

The focus was to evaluate the accuracy of probe-based confocal laser endomicroscopy (pCLE) for the diagnostic differentiation of non-neoplastic and neoplastic Lugol-unstained esophageal lesions in patients with head and neck cancer (HNC) under surveillance for a second primary esophageal squamous cell carcinoma (ESCC).

Esophageal cancer is the eighth most common cancer worldwide, with high mortality. Since the risk of lymph node metastases of superficial esophageal cancer is related to the depth of invasion, the diagnosis of early lesions is desirable so the patient can be successfully managed by minimally invasive treatments. High magnification through confocal endomicroscopy (CLE) allowed in vivo histological diagnosis, demonstrating that patients with ESCC presented an irregular arrangement of squamous epithelial cells, increased diameter of intra-papillary capillary loops (IPCLs), long branching IPCLs, and massive IPCLs with tortuous vessels (Liu et al, 2009). CLE was also employed to differentiate benign and malignant lesions (Li et al, 2013). After the development of pCLE that can be passed through the working channel of the endoscope, it was demonstrated that this technique facilitates and may also improve the diagnosis by allowing acquisition of high-resolution in vivo images at the cellular and microvascular levels.

pCLE was highly accurate for real time histology of Lugol-unstained esophageal lesions in patients with HNC. pCLE could differentiate adequately the lesions in 91.9% of the unstained Lugol suspicious areas (34/37 lesions). The sensitivity and specificity were also high, 94.1% and 90%, respectively.

In the present study, two suspected lesions with previous histological diagnosis of esophagitis were biopsied guided by pCLE, resulting in a final histological diagnosis of ESCC. These two cases demonstrated a major impact on further therapeutic management. Both lesions (50 mm and 20 mm in size) were endoscopically removed by ESD.

In our study, it was hypothesized that the combination of all criteria, evaluating cellular, IPCLs, and surface maturation features might improve the diagnosis accuracy. We noticed that the combination of both classification systems reduced both accuracy and specificity without changing sensitivity. This might be explained by the fact that inflammatory lesions may also be presented with enlarged and tortuous vessels. It means that IPCLs features should not be independently considered for the diagnosis of malignancy.

This study confirmed the importance of pCLE, especially with the application of the score maturation classification and evaluation of vascular features for differentiation between malignant and benign superficial esophageal lesions in patients with HNC.

pCLE method may alter the management of patients under surveillance for ESCC, guiding biopsies and endoscopic resection, avoiding further diagnostic workup or therapy of benign lesions.

Find the article abstract here.

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