NATIONAL BOARD OF EXAMINATIONS THESIS PROTOCOL

TITLE : Confocal Microscopy vs Histopathology In Diagnosis Of

Gastrointestinal Lesions.

DR MANSI CHAWLA

DNB PATHOLOGY TRAINEE

GUIDE : DR ENAM MURSHED KHAN

Senior Consultant and Chief of Department of Pathology

Apollo Gleneagles Hospital, Kolkata

CO-GUIDE – 1 : DR ASRA NAUSHEEN QUADRI

Consultant, Department of Pathology

Apollo Gleneagles Hospital, Kolkata

CO-GUIDE – 2 : DR MAHESH KUMAR GOENKA

Head and Director of Institute of Gastrosciences

Chief Gastroenterologist and Hepatologist

Apollo Gleneagles Hospital, Kolkata

PLACE

Apollo Gleneagles Hospital

58, Canal Circular Road, Kolkata - 54.

Phone – (033) 23203040

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  PROJECT SUMMARY

The value and unique aspects of Confocal Laser Endomicroscopy in the

diagnosis of conditions such as chronic gastritis, intestinal metaplasia,
precancerous lesions and early gastric cancer have been verified by some
researchers. But the mainstay for the diagnosis of gastrointestinal lesions still
remains biopsy and histopathology. But biopsy has complications like
haemorrhage, infection and increased stay in hospital. Moreover there is
always a risk of sampling error which can have a great impact on the patient
outcome.

Confocal Endomicroscopy on the other hand provides the capacity for direct
non invasive serial optical sectioning of intact, thick and living tissues with a
minimum sample preparation as well as marginal improvement in lateral
resolution.

 The objective of this study is:

 To determine the efficacy of Confocal Endomicroscopy in diagnosing
gastrointestinal lesions.

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  INTRODUCTION AND BACKGROUND

Confocal Endomicroscopy is a novel technology which allows surface

histological diagnosis at a cellular and subcellular level in vivo. It thereby
provides instantaneous histopathology during ongoing upper and lower
gastrointestinal endoscopy. This allows immediate diagnosis of neoplastic
and inflammatory lesions of gastrointestinal mucosa. Studies have
demonstrated the power of endomicroscopy in screening and surveillance
colonoscopy, ulcerative colitis, Barrett’s oesophagus, gastrointestinal polyps
and gastric cancer. In all the above lesions, biopsy and histopathology
confirms the diagnosis.

Carcinomas of upper and lower gastrointestinal tract have poor prognosis

and curative treatment is achievable only in local disease. Thus early
detection is of paramount importance. Management usually relies on
histopathological evaluation of a tissue specimen as the gold standard for
diagnosis.

However biopsy might be prone to sampling error and tissue preparation for
ex vivo analysis implies a time delay for definite diagnosis which is then not
available during endoscopic procedure. This potentially results in resection
of lesion that does not necessarily mandate invasive treatment (over
treatment) or in taking a biopsy instead of resection of the neoplastic lesion
(under treatment).

So the comparative study of Confocal Endomicroscopy vs Histopathology in

diagnosing gastrointestinal lesions plays an important role.

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  REVIEW OF LITERATURE AND LACUNAE

Kudo et al.,1996 stated in their well known Pit Pattern Classification that
“…the ability to establish an immediate endoscopic diagnosis has been the
ultimate objective of endoscopists since the very earliest phases of
development of endoscopy.”2 However they still had to rely on predicting
the histopathology of neoplastic lesions rather than being able to see the
histopathology at a cellular level in vivo. This has been possible by the novel
technique termed Confocal Laser Endomicroscopy.

In a study by Meining A et al., 2007 Confocal Endomicroscopy has been

mentioned to be a promising tool for in vivo histology. It was used to
evaluate known or suspected neoplasia in upper or lower Gastrointestinal
Tract. Total of 47 patients with known or suspected neoplasia in upper or
lower gastro intestinal tract were examined. Thereafter biopsies were taken
from same examined area. A total of 119 Confocal Endomicroscopic video
sequences were recorded of 85 benign and 34 neoplastic areas. For
Pathologist accuracy of Confocal Endomicroscopy detecting neoplasia was
92.6% and 73.9% (intention to diagnose). Agreement of Confocal
microscopy and Histopathology was excellent. Conclusion of the study was
that Confocal microscopy using mini probe has the potential to diagnose
neoplasia during ongoing endoscopy. The system had the advantage that it
could be used with standard endoscopes.3

In another study by Ralf Kiesslich and colleagues, Johannes Gutenberg

University, Mainz, 55131, Mainz, Germany in2007, Confocal
Endomicroscopy was prospectively evaluated for diagnosis of specialised
intestinal metaplasia and Barrett’s epithelium was diagnosed in vivo by
presence of villiform or glandular epithelium, microscopic diagnosis of
intrapapillary capillary loops and by presence of Goblet cells, which are
pathognomic of Barrett’s epithelium and easily recognised by dark staining
mucin inclusion. With conventional Histopathology from targeted specimens
serving as Gold Standard, prediction of specialised intestinal epithelium was
possible with an accuracy of 96.8% by Confocal Endomicroscopy.4

In a study by Kiesslich et al., 2004 it has been shown for the first time that
diagnosis of dysplasia /neoplasia in Ulcerative Colitis could be done by

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 Confocal Laser Endomicroscopy with high values of diagnostic accuracy
(sensitivity 94% and specificity 98%).5

In a recent trial in 2005, Yeoh and colleagues used Confocal

Endomicroscopy for diagnosis of gastric cancer and precursor lesion.
Confocal Endomicroscopy was used ex vivo after acriflavine application on
biopsy specimens typical features of gastric cancer were architectural atypia
and increased nuclear to cytoplasmic ratio and chromatin condensation was
found. This allowed a prediction of cancer with sensitivity and specificity of
84% and 95% respectively and an inter observer agreement of 0.63. In
addition Confocal Endomicroscopy has also been shown to visualise
precursor lesions such as intestinal metaplasia. By Confocal
Endomicroscopy larger areas of intestinal metaplasia were screened in vivo
by taking multiple optical biopsies to target the biopsy towards most
suspicious area.6

Although less remarkable diagnostic values were found by Van den Broek et
al in 2011, who reported a diagnostic accuracy of 81% with confocal Laser
Endomicroscopy.7

So the question lies,”Can Confocal Endomicroscopy match the efficacy of

conventional biopsy and histopathology for diagnosis of gastrointestinal
lesions?”

Ralf Kiesslich et al., 2005 concluded from their case report that confocal
endomicroscopy helps in the immediate diagnosis of Helicobacter pylori in
vivo during standard video endoscopy thus allowing the endoscopist to
generate “smart” biopsy samples rather than random biopsy samples.
Therefore, confocal laser endoscopy allows identification of patients in
whom the diagnosis of H pylori has been missed by urease testing because of
nonrepresentative untargeted biopsy samples.11

Xie at al., 2011 concluded from their study that Endoscope integrated CLE
with fluorescein staining can reliably help in the real-time identification of
colonic adenomas and among three diagnostic categories, goblet cell
depletion can be used to distinguish adenomas and hyperplastic polyps.10

Ralf Kiesslich et al., 2006 concluded from their study that endomicroscopy
allowsthe diagnosis of Barrett’s epithelium with high accuracy and offers a

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 better possibility for screening larger surface areas of the mucosa in patients
at higher risk for the development of Barrett’s esophagus and esophageal
cancer.9

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  RESEARCH QUESTION

 Can Confocal Microscopy match the diagnostic accuracy of Biopsy and

Histopathology in diagnosis of gastro intestinal lesions?
 What will be the effect in management if confocal microscopy is
combined with histopathology for diagnosis of gastrointestinal lesions?

 AIMS AND OBJECTIVES

 To determine the efficacy of Confocal Endomicroscopy in diagnosis of

gastrointestinal lesions.
 To compare Confocal Endomicroscopy with Histopathology for diagnosis
of gastrointestinal lesions .
 In case of discordance predictive value to be determined.

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  MATERIALS AND METHODS

o Study Area : Apollo Gleneagles Hospital, Kolkata.

o Study population :
 Inclusion criteria : Cases of gastrointestinal lesions undergoing confocal
microscopy and histopathological examination as a routine investigation
will be included.
 Exclusion criteria : Inadequate and error in sampling will be excluded.

o Sample size : The sample size will be limited to 50 which is comparable

to other prospective study done by Antonio Rispo et al (51 cases).8

o Study design : Time framed Prospective study of Observational

Analytical Design.

o Study duration : All cases will be taken between June 2015 to December
2016 (1 year and 7 months).

o Method of measurement of outcome of interest :

 Sensitivity and Specificity of Confocal Microscopy.
 Degree of Concordance between results obtained by two procedures.

o Data collection methods :

 Confocal microscopy will give ‘optical biopsy’ inside gastrointestinal
tract in real time. It is direct, non invasive and will give serial optical
sectioning of intact, thick and living specimens as histology like images.
 For histopathology, the biopsy material will be fixed with 10% formalin
and stained with Haematoxylin-Eosin and seen under microscope.
 To make the study unbiased, the diagnosis based on histopathology
should be made without knowing the confocal microscopy findings and
vice versa.
 STATISTICAL METHODS
 Analysis will be done by chi-square test.

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  WAIVER OF CONSENT FORM AND PATIENT INFORMATION
SHEET

 As the study is about anonymous data analysis of the routine

investigation in the management of disease condition and no other special
investigation or procedures are part of the study; there is no need to seek
additional patient’s consent.

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  REFERENCES :
1) Kiesslich R, Goetz M, Lammersdorf K, Schneider C, Burg J, Stolte M, et
al. Chromoscopy-guided endomicroscopy increases the diagnostic yield
of intraepithelial neoplasia in ulcerative colitis. Gastroenterol. 2007
March; 132(3): 874-882.
2) Kudo S, Tamura S, Nakajima T, Yamano H, Kusaka H, Watanabe H, et
al. Diagnosis of colorectal tumour lesions by magnifying endoscopy.
Gastrointest Endosc. 1996 July; 44(1): 8-14.
3) Meining A, Saur D, Baiboui M, Becker V, Peltier E, Hofler H, et al. In
vivo histopathology for detection of gastrointestinal neoplasia with a
portable, confocal mini probe: An examiner blinded analysis. Clin
Gastroenterol Hepatol. 2007 November; 5(11): 1261-1267.
4) Dienert K, Kiesslich R, Vieth M, Neurath MF, Neuhaus H. In vivo
microvascular imaging of early squamous cell cancer of esophagus by
confocal laser endomicroscopy. Endoscopy. 2007 April; 39(4): 366-368.
5) Kiesslich R, Burg J, Vieth M, Gnaendiger J, Enders M, Delaney P, et al.
Confocal laser endoscopy for diagnosing intraepithelial neoplasias and
colorectal cancer in vivo. Gastroenterology. 2004 September; 127(3):
706-713.
6) Yeoh KG, Salto-Tellez M and Khor CJ. Confocal laser endoscopy is
useful for in vivo rapid diagnosis of gastric neoplasia and preneoplasia.
Gastroenterology. 2005; 128: A27-A27.
7) van den Broek FJ, van Es JA, van Eeden S, Stokkers PC, Ponsioen CY,
Reitsma JB, et al. Pilot study of probe-based confocal laser
endomicroscopy during colonoscopic surveillance of patients with
longstanding ulcerative colitis. Endoscopy. 2011 Feb; 43(2): 116-122
8) Rispo A, Castiglione F, Staibano S, Esposito D, Maione F, Siano M, et al.
Diagnostic accuracy of confocal laser endomicroscopy in diagnosing
dysplasia in patients affected by long-standing ulcerative colitis. World J
Gastrointest Endosc. 2012 September 16; 4(9): 414-420
9) Kiesslich R, Gossner L, Goetz M, Dahlmann A, Vieth M, Stolte M, et al.
In vivo histology of Barrett’s esophagus and associated neoplasia by
confocal laser endomicroscopy. Clin Gastroenterol Hepatol. 2006
August; 4(8): 979–987
10) Xie XJ, Li CQ, Zuo XL, Yu T, Gu XM, Li Z, et al. Differentiation
of colonic polyps by confocal laser endomicroscopy. Endoscopy. 2011
Feb; 43(2): 87-93.
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 11) Kiesslich R, Goetz M, Burg J, Stolte M, Siegel E, Maeurer M J, et
al. Diagnosing Helicobacter pylori in vivo by confocal laser endoscopy.
Gastroenterology 2005 June; 128(7): 2119–2123

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  DATA COLLECTION FORM

 TITLE : Confocal Microscopy Vs Histopathology In Diagnosis Of

Gastrointestinal Lesions

1) Serial Number :

2) Age :

3) Sex :

4) Site of confocal microscopy / biopsy done :

5) Confocal microscopy findings :

6) Histopathology findings :

 ANALYSIS :

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  Approval of Ethical Committee and its composition :

 Approval of Scientific Committee and its composition :

(Signature of the Candidate) (Signature of Guide)

(Signature of the Head of (Signature of the Head

the department) of the institution)

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