Use of High-Definition Narrow Band Imaging With Magnification to Successfully Identify Early Esophageal Squamous Cancer, Predict Depth of Invasion, and Guide Endoscopic Therapy

Abstract

Figure: A. NBI without magnification B. NBI with magnification C. Post EMR D. H&E stain of mucosectomy specimen.Purpose: Esophageal squamous cell cancers (ESCCs) that are confined to mucosa are amenable to endoscopic therapy. We present a case of early detection of ESCC and prediction of invasion depth based on superficial microvasculature changes using high definition narrow band imaging (NBI) with integrated dual focus magnification endoscope. A 78-year-old male with history of Barrett's esophagus with high grade dysplasia (HGD) status post Barrett's eradication was noted to have an area of discolored mucosa with texture change in the upper esophagus during surveillance endoscopy. Pathology by endoscopic biopsy showed high-grade squamous dysplasia. NBI with magnifi cation using Olympus GIF-HQ190 dual focus endoscope showed a well-demarcated area with intraepithelial papillary capillary loop (IPCL) dilatation, elongation (Inoue IPCL type V2, Arima's type 3) and background color change. Lugol chromoendoscopy of this lesion was positive. Margins of the lesion were marked with APC and lesion was lifted using saline injection. 270-degree endoscopic mucosal resection was performed using cap and snare. Mucosectomy pathology revealed m1 ESCC with negative margins. Follow-up endoscopy at 3 months was normal and no dysplasia was seen on histology. Early detection of ESCC may be amenable to endoscopic therapy and has better survival. Lugol chromoendoscopy is commonly used for detecting ESCC but has low specificity and PPV. NBI with magnification can help identify dysplasia by detecting early changes in the superficial microvasculature. Though there are no well-defined guidelines, two classification systems for IPCL changes have been proposed by Inoue et al and Arima et al. Characteristics in IPCL such as tortuosity, dilatation, caliber change and variation in shape of multiple IPCLs have been associated with neoplasia. The depth of invasion may be associated with the pattern of IPCL as well as changes in background color (Inoue) and presence of avascular areas (Arima). We were able to apply this information in our patient and make a decision to pursue endoscopic therapy for treatment of superficial ESCC. Consensus and validation of the IPCL patterns will be helpful in evaluation and treatment of early ESCC.