Diagnosis of poorly differentiated adenocarcinoma of the stomach by confocal laser endomicroscopy:A case report

BACKGROUND In recent years,confocal laser endomicroscopy(CLE)has become a new endoscopic imaging technology at the microscopic level,which is extensively performed for real-time in vivo histological examination.CLE can be performed to distinguish benign from malignant lesions.In this study,we diagnosed using CLE an asymptomatic patient with poorly differentiated gastric adenocarcinoma.CASE SUMMARY A 63-year-old woman was diagnosed with gastric mucosal lesions,which may be gastric cancer,in the small curvature of the stomach by gastroscopy.She consented to undergo CLE for morphological observation of the gastric mucosa.Through the combination of CLE diagnosis and postoperative pathology,the intraoperative CLE diagnosis was considered to be reliable.According to our experience,CLE can be performed as the first choice for the diagnosis of gastric cancer.CONCLUSION CLE has several advantages over pathological diagnosis.We believe that CLE has great potential in the diagnosis of benign and malignant gastric lesions.

Confocal laser endomicroscopy as a new diagnostic tool for poorly differentiated gastric adenocarcinoma

Gastric cancer(GC)is a multifactorial disease,where both environmental and genetic features can have an impact on its occurrence and development.GC represents one of the leading causes of cancer-related deaths worldwide.GC is most frequent in males and is believed to arise from a series of premalignant lesions.The detection of GC at an early stage is crucial because early GC,which is an invasive stomach cancer confined to the mucosal or submucosal lining,may be curable with a reported 5-year survival rate of more than 90%.Advanced GC usually has a poor prognosis despite current treatment standards.The diagnostic efficacy of conventional endoscopy(with light endoscopy)is currently limited.Confocal laser endomicroscopy is a novel imaging technique that allows real-time in vivo histological examination of mucosal surfaces during endoscopy.Confocal laser endomicroscopy may be of great importance in the surveillance of precancerous gastric lesions and in the diagnosis of GC.In this editorial we commented on the article about this topic published by Lou et al in the recent issue of the World Journal of Clinical Cases.

Confocal laser endomicroscopy for gastric neoplasm

Confocal laser endomicroscopy(CLE)is a novel endoscopic modality that provides real-time histological information via high-resolution magnified view of the mucosa.CLE has a higher sensitivity,specificity,and diagnostic accuracy in detecting atrophic gastritis as compared to chromoendoscopy and narrow-band imaging.It can even predict low-grade and high-grade intraepithelial neoplasia by analyzing gastric pit patterns.CLE may have some advantages over the standard biopsy protocol,such as higher diagnostic yield and fewer biopsy requirements.Its diagnostic accuracy in detecting superficial gastric cancer is higher than that of white-light endoscopy.Inherent limitations,such as a narrow field of vision,can be surpassed by technological advancements and integration with other detection methods.Artificial intelligence holds promise in automated analysis of histopathological images.Thus,CLE can be helpful in screening for early gastric cancer and may help reduce the risk of complications from repeated biopsies,such as mucosal damage,bleeding,and infection.

Confocal Laser Endomicroscopy in the Field of Esophageal Diseases

Confocal laser endomicroscopy (CLE) is a new endoscopic imaging technology that allows real-time, high-resolution observation of tomographic images of mucosal cells and subcellular levels in vivo, detecting microscopic structural changes in mucosal morphology, and its in vivo immediate pathological diagnostic capability can avoid delays in mucosal pathological diagnosis and reduce the pain caused by repeated biopsies. CLE is known as “optical biopsy” and compared with other endoscopic techniques, it has obvious advantages. CLE systems include probe-based confocal laser endomicroscopy (pCLE) and endoscope-based confocal laser endomicroscopy (eCLE). Since 2006, CLE has been widely used for the evaluation of various lesions in the digestive system, including esophageal, gastric, and colonic neoplasia, pancreatic cysts and solid lesions, and inflammatory bowel disease. The advent of CLE has made in vivo microscopic imaging possible, which has changed the endoscopic screening and diagnosis of multiple gastrointestinal (GI) lesions. However, the value of its use in GI diseases is still controversial. In this review, we focus on the application of CLE in the field of esophageal diseases.

Classification of histological severity of Helicobacter pylori-associated gastritis by confocal laser endomicroscopy

AIM: To classify the histological severity of Helicobacter pylori (H. pylori) infection-associated gastritis by confocal laser endomicroscopy (CLE). METHODS: Patients with upper gastrointestinal symptoms or individuals who were screened for gastric cancer were enrolled in this study. Histological severity of H. pylori infection-associated gastritis was graded according to the established CLE criteria. Diagnostic value of CLE for histo-logical gastritis was investigated and compared with that of white light endoscopy (WLE). Targeted biopsies from the sites observed by CLE were performed. RESULTS: A total of 118 consecutive patients with H. pylori infection-associated gastritis were enrolled in this study. Receiver operating characteristic curve analysis showedthat the sensitivity and specifi city of CLE were 82.9% and 90.9% for the diagnosis of H. pylori infection, 94.6% and 97.4% for predicting gastric normal mucosa, 98.5% and 94.6% for predicting histological active inflammation, 92.9% and 95.2% for predicting glan-dular atrophy, 98.6% and 100% for diagnosing intes-tinal metaplasia, respectively. Post-CLE image analysis showed that goblet cells and absorptive cells were the two most common parameters on the CLE-diagnosed intestinal metaplasia (IM) images (P < 0.001). More his-tological lesions of the stomach could be found by CLE than by WLE (P < 0.001). CONCLUSION: CLE can accurately show the histological severity of H. pylori infection-associated gastritis. Mapping IM by CLE has a rather good diagnostic accuracy.

Diagnosis of gastric intraepithelial neoplasia by narrow-band imaging and confocal laser endomicroscopy

AIM:To evaluate the diagnosis of different differentiated gastric intraepithelial neoplasia (IN) by magnifica-tion endoscopy combined with narrow-band imaging (ME-NBI) and confocal laser endomicroscopy (CLE). METHODS:Eligible patients with suspected gastric IN lesions previously diagnosed by endoscopy in secondary hospitals and scheduled for further diagnosis and tratment were recruited for this study. Excluded from the study were patients who had liver cirrhosis, impaired renal function, acute gastrointestinal (GI) bleeding, coagulopathy, esophageal varices, jaundice, and GI post-surgery. Also excluded were those who were pregnant, breastfeeding, were younger than 18 years old, or were unable to provide informed consent. All patients had all mucus and bile cleared from their stom-achs. They then received upper GI endoscopy. When a mucosal lesion is found during observation with whitelight imaging, the lesion is visualized using maximal magnification, employing gradual movement of the tip of the endoscope to bring the image into focus. Saved images are analyzed. Confocal images were evaluated by two endoscopists (Huang J and Li MY), who were familiar with CLE, blinded to the related information about the lesions, and asked to classify each lesion as either a low grade dysplasia (LGD) or high grade dysplasia (HGD) according to given criteria. The results were compared with the final histopathologic diagnosis. ME-NBI images were evaluated by two endoscopists (Lu ZS and Ling-Hu EQ) who were familiar with NBI, blinded to the related information about the lesions and CLE images, and were asked to classify each lesion as a LGD or HGD according to the "microvascular pattern and surface pattern" classification system. The results were compared with the final histopathologic diagnosis. RESULTS: The study included 32 pathology-proven low grade gastric IN and 26 pathology-proven high grade gastric IN that were detected with any of the modalities. CLE and ME-NBI enabled clear visualization of the vascular microsurface patterns and microvascular structures of the gastric mucosa. The accuracy of the CLE and the ME-NBI diagnosis was 88% (95% CI:78%-98%) and 81% (95% CI: 69%-93%), respectively. The kappa coefficient of agreement between the histopathology and the in vivo CLE imaging was 0.755; between the histopathology and the in vivo CLE imaging was 0.615. McNemar's test (binomial distribution used) indicated that the agreement was significant (P < 0.05). When patients were diagnosed by MENBI with CLE, the overall accuracy of the diagnosis was 86.21% (95% CI:73%-96%), and the kappa coefficient of agreement was 0.713, according to McNemar's test (P < 0.05). CONCLUSION:Higher diagnostic accuracy, sensitivityand specificity of CLE over ME-NBI indicate the feasibility of these two techniques for the efficacious diagnostic classification of gastric IN.

Confocal laser endomicroscopy and immunoendoscopy for real-time assessment of vascularization in gastrointestinal malignancies

Gastrointestinal cancers represent a major cause of morbidity and mortality,with incomplete response to chemotherapy in the advanced stages and poor prognosis.Angiogenesis plays a crucial part in tumor growth and metastasis,with most gastrointestinal cancers depending strictly on the development of a new and devoted capillary network.Confocal laser endomicroscopy is a new technology which allows in vivo microscopic analysis of the gastrointestinal mucosa and its microvascularization during ongoing endoscopy by using topically or systemically administered contrast agents.Targeting markers of angiogenesis in association with confocal laser endomicroscopic examination(immunoendoscopy),as a future challenge,will add functional analysis to the morphological aspect of the neoplastic process.This review describes previous experience in endomicroscopic examination of the upper and lower digestive tract with emphasis on vascularization,resulting in a broad spectrum of potential clinical applications,and also preclinical research that could be translated to human studies.

Molecular confocal laser endomicroscopy:A novel technique for in vivo cellular characterization of gastrointestinal lesions

While flexible endoscopy is essential for macroscopic evaluation,confocal laser endomicroscopy(CLE)has recently emerged as an endoscopic method enabling visualization at a cellular level.Two systems are currently available,one based on miniprobes that can be inserted via a conventional endoscope or via a needle guided by endoscopic ultrasound.The second system has a confocal microscope integrated into the distal part of an endoscope.By adding molecular probes like fluorescein conjugated antibodies or fluorescent peptides to this procedure(either topically or systemically administered during on-going endoscopy),a novel world of molecular evaluation opens up.The method of molecular CLE could potentially be used for estimating the expression of important receptors in carcinomas,subsequently resulting in immediate individualization of treatment regimens,but also for improving the diagnostic accuracy of endoscopic procedures by identifying otherwise invisible mucosal lesions.Furthermore,studies have shown that fluorescein labelled drugs can be used to estimate the affinity of the drug to a target organ,which probably can be correlated to the efficacy of the drug.However,several of the studies in this research field have been conducted in animal facilities or in vitro,while only a limited number of trials have actually been carried out in vivo.Therefore,safety issues still needs further evaluations.This review will present an overview of the implications and pitfalls,as well as future challenges of molecular CLE in gastrointestinal diseases.

Clinical impact of confocal laser endomicroscopy in the management of gastrointestinal lesions with an uncertain diagnosis

To evaluate the clinical impact of confocal laser endomicroscopy (CLE) in the diagnosis and management of patients with an uncertain diagnosis. METHODSA retrospective chart review was performed. Patients who underwent CLE between November 2013 and October 2015 and exhibited a poor correlation between endoscopic and histological findings were included. Baseline characteristics, indications, previous diagnostic studies, findings at the time of CLE, clinical management and histological results were analyzed. Interventions based on CLE findings were also analyzed. We compared the diagnostic accuracy of CLE and target biopsies of surgical specimens. RESULTSA total of 144 patients were included. Of these, 51% (74/144) were female. The mean age was 51 years old. In all, 41/144 (28.4%) lesions were neoplastic (13 bile duct, 10 gastric, 8 esophageal, 6 colonic, 1 duodenal, 1 rectal, 1 ampulloma and 1 pancreatic). The sensitivity, specificity, positive predictive value, negative predictive value, and observed agreement when CLE was used to detect N-lesions were 85.37%, 87.38%, 72.92%, 93.75% and 86.81%, respectively. Cohen’s Kappa was 69.20%, thus indicating good agreement. Changes in management were observed in 54% of the cases. CONCLUSIONCLE is a new diagnostic tool that has a significant clinical impact on the diagnosis and treatment of patients with uncertain diagnosis.

Confocal laser endomicroscopy distinguishing benign and malignant gallbladder polyps during choledochoscopic gallbladderpreserving polypectomy:A case report

BACKGROUND In the last decade, confocal laser endomicroscopy (CLE) has emerged as a newendoscopic imaging modality for real-time in vivo histological examination at themicroscopic level. CLE has been shown to be useful for distinguishing benign andmalignant lesions and has been widely used in many digestive diseases. In ourstudy, we used CLE for the first time to examine the morphology of cholesterolpolyps as well as the different parts of normal gallbladder mucosa.CASE SUMMARY A 57-year-old woman was diagnosed by ultrasound with a polyp of 21 mm in thegallbladder wall. She consented to polyp removal by laparoscopic choledochoscopy.During laparoscopic cholecystectomy combined with choledochoscopicpolyp resection, CLE was used to observe the morphology of the polyp surfacecells. The appearance of the mucosa and microvessels in various parts of thegallbladder were also observed under CLE. Through comparison betweenpostoperative pathology and intraoperative CLE diagnosis, the reliability ofintraoperative CLE diagnosis was confirmed. CLE is a reliable method to examineliving cell pathology during cholecystectomy. Based on our practice, CLE shouldbe prioritized in the diagnosis of gallbladder polyps.CONCLUSION Compared with traditional histological examination, CLE has several advantages.We believe that CLE has great potential in this field.

In-vivo characterization of DALM in ulcerative colitis with high-resolution probe-based confocal laser endomicroscopy

Recently,the use of confocal laser endomicroscopy(CLE) in the diagnosis of chronic ulcerative colitis(CUC) was reported.In this brief report we aimed to assess the application of probe-based CLE to characterize colonic mucosa and dysplasia in CUC.The study involved a patient presenting long-standing CUC.Confocal imaging of both the inflamed mucosa,a circumscribed lesion(dysplasiaassociated lesional mass),and adjacent colonic mucosa are demonstrated and the correlation between the CLE and histological images.Inflamed mucosa and dysplasia showed specific alteration of crypt architecture,cellular infiltration,and vessel architecture with an excellent correlation between CLE and standard histological examination.

Confocal Laser Scanning Microscope Evaluation of Early Bacterial Colonization on Zirconium Oxide and Titanium Surfaces:An in vivo Study

To investigate the bacterial colonization on zirconium oxide and titanium surfaces in vivo quantitatively using a confocal laser scanning microscope （CLSM）. Ten samples of zirconium oxide ceramic and commercially pure titanium were fabricated and polished using silicon carbide abrasive paper. One sample from each group was evaluated topographic pattern under a scanning electron microscope. One sample from each group was to evaluate roughness using a profilometer. Eight volunteers were selected. The samples were cemented at the buccal surfaces of upper first molars. All samples were removed after 48 hours, immersed in SYTO-9 and propidium iodide fluorescent to stain for adherent bacteria and obseIved with CLSM. Fewer bacteria were observed in zirconia group than titanium group. However, there was no statistical difference between two groups. The experimental results demonstrate that zirconium oxide may be considered as a promising material for dental implant abutments.

Neuroprotective effects of low-concentration alpha-tocopherol Confocal laser microscopy observations

BACKGROUND： Alpha-tocopherol （ α-tocopherol） can effectively relieve neuronal damage induced by oxygen-centered free radicals. However, the effective dose remains controversial. OBJECTIVE： To evaluate the protective effects of low-concentration α-tocopherol on neuronal membranes. DESIGN, TIME AND SETTING： Contrast observation and in vitro study, performed at Laboratory of Neurosurgery, Tianjin Huanhu Hospital between April and September 2006. MATERIALS： Fetal cortical neurons were derived from two 14-day pregnant SD rats, and α-tocopherol was provided by Sigma, USA. METHODS： The neurons were randomly assigned to six groups： （1） normal： neurons were cultured under normal conditions; （2） oxidative damage： oxidative free radicals was damaged using the Fenton reaction; （3） α-tocopherol： neurons were cultured in different concentrations of -tocopherol 10, 20, 40, and 80 mg/L for 2 hours, respectively. MAIN OUTCOME MEASURES： Neuronal membrane damage was observed using a confocal laser microscope, and malonaldehyde production was detected using the thiobarbituric acid method. RESULTS： At normal, biological concentrations （10 mg/L）, α-tocopherol induced no change in the damaged neurons （P 〉 0.05）. However, at a concentration of 80 mg/L, the number of damaged neurons was significantly reduced, compared with the damage group （P 〈 0.05）. Malonaldehyde levels following 80 mg/L α-tocopherol treatment were less than the oxygen free radical damage group （P 〈 0.05）, but greater than the control group （P 〈 0.01）. CONCLUSION： A concentration of 80 mg/L α-tocopherol can effectively protect the neuronal cell membrane from oxidative damage

Tumor neoangiogenesis detection by confocal laser endomicroscopy and anti-CD105 antibody:Pilot study

AIM: To evaluate neoangiogenesis in patients with colon cancer by two fluorescently labeled antibodies on fresh biopsy samples imaged with confocal laser endomicroscopy(CLE).METHODS: CLE is an imaging technique for gastrointestinal endoscopy providing in vivo microscopy at subcellular resolution.An important question in validating tumor angiogenesis is what proportion of the tumor vascular network is represented by preexisting parent tissue vessels and newly formed vessels.CD105(endoglin) represents a proliferation-associated endothelial cell adhesion molecule.In contrast to panendothelial markers,such as CD31,CD105 is preferentially expressed in activated endothelial cells that participate in neovascularization.Thus,we evaluated CD105 and CD31 expression from samples of ten patients with primary rectal adenocarcinoma,using a dedicated endomicroscopy system.A imaging software was used to obtain the Z projection of the confocal serial images from each biopsy sample previously combined into stacks.Vascular density and vessel diameters were measured within two 50 μm x 475 μm rectangular regions of interest centered in the middle of each image in the horizontal and vertical direction.The results were averaged over all the patients and were expressed as the mean ± SE.RESULTS: The use of an anti-CD105 antibody was found to be suitable for the detection of blood vessels in colon cancer.Whereas anti-CD31 antibodies stained blood vessels in both normal and pathologic colon equally,CD105 expression was observed primarily in malignant lesions,with little or no expression in the vessels of the normal mucosa(244.21 ± 130.7 vessels/mm3 in only four patients).The average diameter of antiCD105 stained vessels was 10.97 ± 0.6 μm in tumor tissue,and the vessel density was 2787.40 ± 134.8 vessels/mm3.When using the anti-CD31 antibody,the average diameter of vessels in the normal colon tissue was 7.67 ± 0.5 μm and the vessel density was 3191.60 ± 387.8 vessels/mm3,while in the tumors we obtained an average diameter of 10.88 ± 0.8 μm and a vessel density of 4707.30 ± 448.85 vessels/mm3.Thus,there were more vessels stained with CD31 than CD105(P < 0.05).The average vessel diameter was similar for both CD31 and CD105 staining.A qualitative comparison between CLE vs immunohistochemistry lead to similar results.CONCLUSION: Specific imaging and quantification of tumor microvessels are feasible in human rectal cancer using CLE examination and CD105 immunostaining of fresh tissue samples.

Uses of probe-based confocal laser endomicroscopy:Responses to a question to practitioners

Confocal laser endomicroscopy is a novel imaging technology,which allows realtime visualization and inter-pretation of microscopic details in live tissues. Although several potential uses have been identified for this technology,no data are available regarding its real-worlduses. We report the results of an email-based survey of experts in North America regarding their use of the technology.

Real-time in vivo distal margin selection using confocal laser endomicroscopy in transanal total mesorectal excision for rectal cancer

BACKGROUND Transanal total mesorectal excision(TaTME)allows patients with ultralow rectal cancer to be treated with sphincter-saving surgery.However,accurate delineation of the distal resection margin(DRM),which is essential to achieve R0 resection for low rectal cancer in TaTME,is technically demanding.AIM To assess the feasibility of optical biopsy using probe-based confocal laser endomicroscopy(pCLE)to select the DRM during TaTME for low rectal cancer.METHODS A total of 43 consecutive patients who were diagnosed with low rectal cancer and scheduled for TaTME were prospectively enrolled from January 2019 to January 2021.pCLE was used to determine the distal edge of the tumor as well as the DRM during surgery.The final pathological report was used as the gold standard.The diagnostic accuracy of pCLE examination was calculated.RESULTS A total of 86 pCLE videos of 43 patients were included in the analyses.The sensitivity,specificity and accuracy of real-time pCLE examination were 90.00%[95%confidence interval(CI):76.34%-97.21%],86.96%(95%CI:73.74%-95.06%)and 88.37%(95%CI:79.65%-94.28%),respectively.The accuracy of blinded pCLE reinterpretation was 86.05%(95%CI:76.89%-92.58%).Furthermore,our results show satisfactory interobserver agreement(κ=0.767,standard error=0.069)for the detection of cancer tissue by pCLE.There were no positive DRMs(≤1 mm)in this study.The median DRM was 7 mm[interquartile range(IQR)=5-10 mm].The median Wexner score was 5(IQR=3-6)at 6 mo after stoma closure.CONCLUSION Real-time in vivo pCLE examination is feasible and safe for selecting the DRM during TaTME for low rectal cancer(clinical trial registration number:NCT04016948).

In situ observation of the dissolution kinetics of Al_(2)O_(3) particles in CaO–Al_(2)O_(3)–SiO_(2) slags using laser confocal scanning microscopy

The dissolution kinetics of Al_(2)O_(3) in CaO-Al_(2)O_(3) SiOslags was studied using a high-temperature confocal scanning laser microscope at 1773 to 1873 K.The results show that the controlling step during the Al_(2)O_(3) dissolution was the diffusionin molten slag.It was found that the dissolution curves of Al_(2)O_(3) particles were hardly agreed with the traditional boundary layer diffusion model with the increase of the CaO/Al_(2)O_(3) ratio of slag.A modified diffusion equation considering slag viscosity was developed to study the dissolution mechanism of Al_(2)O_(3) in slag.Diffusion coefficients of Al_(2)O_(3) in slag were calculated as 2.8×10to 4.1×10m~2/s at the temperature of 1773-1873 K.The dissolution rate of Al_(2)O_(3) increased with higher temperature,CaO/Al_(2)O_(3),and particle size.A new model was shown to be v_(Al_(2)O_(3))=0.16×r_(0)^(1.58)×x^(3.52)×(T-T_(mp))^(1.11)to predict the dissolution rate and the total dissolution time of Al_(2)O_(3) inclusions with various sizes,where vAl_(2)O_(3) is the dissolution rate of Al_(2)O_(3) in volume,μm^(3)/s;x is the value of CaO/Al_(2)O_(3) mass ratio;R_(0) is the initial radius of Al_(2)O_(3),μm;T is the temperature,K;T_(mp) is the melting point of slag,K.

Solidification process of conventional superalloy by confocal scanning laser microscope

The solidification process of a conventional superalloy, IN718, was investigated by confocal scanning laser microscope （CSLM）. The liquid fraction during solidification was obtained as a function of real time and temperature in reference with the in-situ observation. The characteristics of L→γ transformation were analyzed and the γ growing rate of each stage was also calculated. Scheil equation was employed to predict the segregation behavior, and the predict results are in consistence with the experimental results. As a result, the confocal scanning laser microscope shows a great potential for solidification process research.

Single Particle-Based Confocal Laser Scanning Microscopy for Visual Detection of Copper Ions in Confined Space

Main observation and conclusion A single particle-based confocal laser scanning microscopy was developed for the visual detection of copper ions in confined space.A fluorescence microparticle,named AuNCs/ZIF-8,was synthesized by coating gold nanoclusters(AuNCs)onto the outer surface of zeolitic imidazolate framework-8(ZIF-8).

The Experiment and Design of Confocal Laser Scanner for Biochip

In this article ,we chiefly discuss optical part and photoelectrical part, and analyze the result data to make out the relationship between pinhole and special resolution and the influence of PMT on the result data.