In vivo endomicroscopy improves detection of Barrett's esophagus-related neoplasia: a multicenter international randomized controlled trial (with video)

Abstract

Background: Confocal laser endomicroscopy (CLE) enables in vivo microscopic imaging of the GI tract mucosa. However, there are limited data on endoscope-based CLE (eCLE) for imaging Barrett's esophagus (BE).

Objective: To compare high-definition white-light endoscopy (HDWLE) alone with random biopsy (RB) and HDWLE + eCLE and targeted biopsy (TB) for diagnosis of BE neoplasia.

Design: Multicenter, randomized, controlled trial.

Setting: Academic medical centers.

Patients: Adult patients with BE undergoing routine surveillance or referred for early neoplasia.

Intervention: Patients were randomized to HDWLE + RB (group 1) or HDWLE + eCLE + TB (group 2). Real-time diagnoses and management plans were recorded after HDWLE in both groups and after eCLE in group 2. Blinded expert pathology diagnosis was the reference standard.

Main outcome measurements: Diagnostic yield, performance characteristics, clinical impact.

Results: A total of 192 patients with BE were studied. HDWLE + eCLE + TB led to a lower number of mucosal biopsies and higher diagnostic yield for neoplasia (34% vs 7%; P < .0001), compared with HDWLE + RB but with comparable accuracy. HDWLE + eCLE + TB tripled the diagnostic yield for neoplasia (22% vs 6%; P = .002) and would have obviated the need for any biopsy in 65% of patients. The addition of eCLE to HDWLE increased the sensitivity for neoplasia detection to 96% from 40% (P < .0001) without significant reduction in specificity. In vivo CLE changed the treatment plan in 36% of patients.

Limitations: Tertiary-care referral centers and expert endoscopists limit generalizability.

Conclusion: Real-time eCLE and TB after HDWLE can improve the diagnostic yield and accuracy for neoplasia and significantly impact in vivo decision making by altering the diagnosis and guiding therapy. (

Clinical trial registration number: NCT01124214.).

Keywords: BE; Barrett's esophagus; CLE; CPT; Current Procedural Terminology; ECA; HDWLE; HGD; NBI; RB; TB; WLE; confocal laser endomicroscopy; eCLE; endoscope-based CLE; esophageal adenocarcinoma; high-definition white-light endoscopy; high-grade dysplasia; narrow-band imaging; pCLE; probe-based CLE; random biopsy; targeted biopsy; white-light endoscopy.