Essential Is Not Always Visible to the Eyes, Volumetric Laser Endoscopy Revealing Adenocarcinoma Beneath Squamous Mucosa on a Background of Barrettʼs Esophagus

Abstract

Barett's esophagus is a major risk factor for esophageal adenocarcinoma. Surveillance of Barrett's esophagus has been achieved through protocols involving random biopsies. New diagnostic modalities have been developed in order to ensure a more targeted sampling, reducing this unpredictability. We present the following case that illustrates the importance of using new modalities for detecting underlying lesions that can go unseen by utilizing white light endoscopy alone. This is the case of a 50 year-old female patient who had a chronic history of gastroesophageal acid reflux. She was an active smoker and occasional alcohol consumer. An upper endoscopy was performed and revealed a hiatal hernia. Random biopsies from the Gastroesophageal junction were taken and revealed intestinal metaplasia with low grade dysplasia. Consequently, the patient was referred for Radiofrequency ablation. During an esophagogastroduodenoscopy, high definition white light endoscopy showed an area of endoscopic Barrett's esophagus. This area was without visible lesion, nodule, or ulcerations except for an elevated squamous epithelium at the gastroesophageal junction. The entire distal esophagus was examined using Volumetric Laser Endomicroscopy (VLE) and revealed a disrupted layering and glandular distortion in one area buried under the squamous epithelium. The area was removed enbloc using endoscopic mucosal resection (EMR). Pathology of the resected area revealed a high-grade dysplasia (carcinoma in situ) with intramucosal adenocarcinoma invading the lamina propria pT1a, pNx underneath an intact squamous epithelium. The patient had a follow up EGD with no evidence of recurrence. Subsequently, the patient had circumferential Radiofrequency Ablation (RFA). VLE is an enhanced form of optical coherence tomography. Studies have shown its role where white light endoscopy and Narrow Band Imaging fail to detect dysplasia. It allows a more targeted sampling of areas at higher probability of dysplasia and can reveal underlying adenocarcinoma beneath squamous mucosa that is not superficially visible.1710_A Figure 1. Endoscopic view of the GE junction showing the elevated mucosa1710_B Figure 2. Volumetric Laser endomicroscopy image showing the underlying glandular distortion.1710_C Figure 3. Histo-pathology showing intramucosal adenocarcinoma