Multicenter study on the diagnostic performance of multiframe volumetric laser endomicroscopy targets for Barrett's esophagus neoplasia with histopathology correlation.

Volumetric laser endomicroscopy (VLE) has been shown to improve detection of early neoplasia in Barrett's esophagus (BE). However, diagnostic performance using histopathology-correlated VLE regions of interest (ROIs) has not been adequately studied. We evaluated the diagnostic accuracy of VLE assessors for identification of early BE neoplasia in histopathology-correlated VLE ROIs. In total, 191 ROIs (120 nondysplastic and 71 neoplastic) from 50 BE patients were evaluated in a random order using a web-based module. All ROIs contained histopathology correlations enabled by VLE laser marking. Assessors were blinded to endoscopic BE images and histology. ROIs were first scored as nondysplastic or neoplastic. Level of confidence was assigned to the predicted diagnosis. Outcome measures were: (i) diagnostic performance of VLE assessors for identification of BE neoplasia in all VLE ROIs, defined as accuracy, sensitivity, and specificity; (ii) diagnostic performance of VLE assessors for only high level of confidence predictions; and (iii) interobserver agreement. Accuracy, sensitivity, and specificity for BE neoplasia identification were 79% (confidence interval [CI], 75-83), 75% (CI, 71-79), and 81% (CI, 76-86), respectively. When neoplasia was identified with a high level of confidence, accuracy, sensitivity, and specificity were 88%, 83%, and 90%, respectively. The overall strength of interobserver agreement was fair (k = 0.29). VLE assessors can identify BE neoplasia with reasonable diagnostic accuracy in histopathology-correlated VLE ROIs, and accuracy is enhanced when BE neoplasia is identified with high level of confidence. Future work should focus on renewed VLE image reviewing criteria and real-time automatic assessment of VLE scans.

Perceptions of risk and therapy among patients with Barrett's esophagus: a patient survey study.

Nondysplastic Barrett's esophagus has a risk of progression to esophageal adenocarcinoma as low as 0.18-0.3% per person per year, and low-grade dysplasia as low as 0.5%. While adherence to guidelines and selection of management options varies, little is known about what modifies patient decision-making. This study aims to evaluate and identify factors that influence patient perceptions of risk and decisions about management. An independently developed and piloted survey was administered to patients at an academic hospital. Risk perception and desire for therapy were assessed using a standard reference gamble paradigm, and responses were stratified based on patient and disease characteristics. Data were analyzed with Student's t and chi-squared tests. A total of 42 of 50 patients with Barrett's esophagus and no prior endoscopic therapy participated (84% response; 76% nondysplastic Barrett's esophagus, 22% low-grade dysplasia, 2% indeterminate for dysplasia; mean age 61 years, 29% female). On average, patients perceived their risk of developing esophageal adenocarcinoma in the next year, 10 years and lifetime as 6, 14, and 19%, respectively. Nearly half viewed their lifetime risk of developing esophageal adenocarcinoma to be the same or higher than diabetes, heart disease, or colon cancer. Although 92% of patients felt surveillance beneficial, only 54% believed endoscopic therapy to be effective in most or all cases. As many as 83% of patients were willing to undergo endoscopic therapy with a hypothetical success rate as low as 70%, and a majority (64%) accepted complication rates up to 30%. Compared to patients with low risk perception of developing esophageal adenocarcinoma, those with high risk perception more often believed their risk for developing esophageal adenocarcinoma was greater than diabetes (p = 0.04) or colon cancer (p = 0.002). Those with lifetime low risk perception were less likely to accept modest complication rates (<10%) of therapy (P < 0.05). Age, gender, degree of dysplasia, lifetime endoscopies and duration of symptoms had no impact on perceived effectiveness of surveillance or therapy, and did not correlate with desire for treatment at varying levels of risk and effectiveness. Patients with Barrett's esophagus overestimate their risk of developing esophageal adenocarcinoma and will accept low success rates and high risk of complications to undergo endoscopic therapy. Baseline risk perception correlates with the desire for endoscopic therapy.

Early diagnosis and management of esophageal and gastric cancer.

Esophageal and gastric cancers have high mortality rates secondary to the late presentation of most patients at advanced stages. Improved survival is achievable when the disease is confined to the more superficial mucosal layers and treated. This review will focus on the detection, screening, staging, endoscopic treatment, and surveillance of early upper gastrointestinal cancer - squamous cell carcinoma of the esophagus, esophageal adenocarcinoma, and gastric adenocarcinoma.

Confocal laser endomicroscopy: potential in the management of Barrett's esophagus.

Confocal laser endomicroscopy (CLE) can serve as a useful adjunct imaging modality for targeted endoscopic biopsies during surveillance of Barrett's esophagus (BE). In addition, CLE may also have potential roles during therapeutic procedures that include localization of pathology, targeting of resections, guiding which therapy to use, and determining adequacy of treatment. This case series illustrates a range of cases in which endomicroscopy was performed during the procedure and offers possibilities of real-time decision-making to select specific therapies in patients with known high-grade dysplasia (HGD) and intramucosal carcinoma in the setting of BE presented for endoscopic treatment or follow-up. Patients with BE with HGD and intramucosal carcinoma presented for management for initial treatment or follow-up. Examinations were performed sequentially with detailed white light endoscopy, narrow band imaging (NBI), acetic acid, and CLE. This is a retrospective case series describing the characteristics of the exam findings and illustrating the role of endomicroscopy on real-time case management. Seven patients with Barrett-associated neoplasia underwent endomicroscopy as part of their endoscopic examination. CLE confirmed findings of neoplasia seen with red flag techniques such as NBI, and in one case independently suggested findings of neoplasia. In the majority of cases, these findings were incorporated into the decision of which modality of treatment was used. Future prospective studies should be done to validate the role of endomicroscopy in BE.