In Vivo Histology of Barrett’s Esophagus and Associated Neoplasia by Confocal Laser Endomicroscopy  Ralf Kiesslich, Liebwin Gossner, Martin Goetz, Alexandra Dahlmann, Michael Vieth, Manfred Stolte, Arthur Hoffman, Michael Jung, Bernhard Nafe, Peter R. Galle, Markus F. Neurath  Clinical Gastroenterology and Hepatology  Volume 4, Issue 8, Pages 979-987 (August 2006) DOI: 10.1016/j.cgh.2006.05.010 Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 1 Confocal laser endomicroscope. (A) Confocal laser endoscope. On the handpiece of the endoscope 2 additional buttons (arrows) allow modification of the infiltration depth of the scanning system (range, 0–250 μm within the mucosal layer). (B) The confocal endomicroscope is integrated in the distal tip of a conventional videoendoscope. The endomicroscopic window (arrow) allows the transmission of blue laser light, with a single optical fiber acting as both the illumination and detection confocal pinhole. The endomicroscope protrudes slightly at the distal end of the endoscope, allowing targeting of the endomicroscopic examination. Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 2 Confocal images of the Z-line and squamous-lined lower esophagus. (A) The white arrows show the squamous cell epithelium. A single Barrett gland can be identified (yellow arrows). The subepithelial capillaries are highlighted brightly because of the flow of fluorescein within the vessels (blue arrow). (B) Squamous cell–lined lower esophagus showing single cells with clear borders (white arrows). The capillaries within the papillae of the lamina propria directed toward the luminal surface can be seen in horizontal sectioning. Dark spots within the capillaries represent red blood cells. (C) The video endoscopic image is displayed simultaneously. A long segment of Barrett’s esophagus is present. The protruded tip is visible at the lower left corner of the image (arrow). The endomicroscope has to be targeted toward the Z-line to obtain images as shown in A. (D) The arrows within the squamous-lined esophagus show the areas where the confocal images were obtained. Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 3 In vivo histology of gastral epithelium from the cardia and antrum. (A) The foveolae gastricae are visible clearly as dark round glandular openings with regular basal borders (white arrows). The connective tissue between the glands shows bright cells with dark borders in a typical cobblestone pattern. (B) The glands at the antrum are rather long in shape (white arrows). The typical cobblestone also is present in the distal part of the stomach (blue arrows). Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 4 In vivo histology of Barrett’s epithelium without neoplastic changes. (A) In the upper part of the mucosal layer of Barrett’s epithelium endomicroscopic imaging allows recognition of mucin within goblet cells (white arrows). The arrangement of the Barrett’s epithelium shows a typical villiform shape. (B) Subepithelial capillaries with a regular shape can be identified (blue arrows). Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 5 In vivo and ex vivo histology of Barrett’s epithelium. (A) A typical villiform shape of Barrett’s epithelium is visible. In deeper parts of the mucosal layer the epithelial layer is displayed as a homogenous dark band with a clear apical and basal border (white arrows). (B) The subepithelial capillary network is easily identifiable and regular in shape. (C) Video endoscopic imaging shows a short Barrett’s esophagus. (D) Corresponding histologic specimen with typical goblet cells (black arrow) and capillaries (blue arrow). Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 6 Barrett’s epithelium with high-grade intraepithelial neoplasia. (A) Endomicroscopy is showing an enlarged and irregular Barrett gland with an irregular basal border (white arrows). (B) Conventional histology shows high-grade intraepithelial neoplasia with irregular nuclei (white arrows) and a similar shape of the glands, corresponding well with in vivo endomicroscopy. (C) In upper parts of the mucosa distinct black cells are seen that characterize malignancy (white arrows). Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 7 Barrett’s-associated neoplasia. (A) The epithelial layer is disarranged and the cells have an irregular orientation (white arrows). (B) Magnification of a single malignant gland showing a malignant invasion of the lamina propria (white arrows), which corresponds well with conventional histology (shown in D). (C) A small polypoid lesion (type IIa) is visible within a short Barrett’s esophagus. Endomicroscopy could be targeted toward the lesion. (D) Conventional histology shows an early carcinoma with drip-off malignant cells in the lamina propria of the mucosa (black arrows). Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 8 Barrett’s-associated neoplasia. (A) Distinct black irregular cells (white arrow) with irregular shape and size are visible within squamous cell epithelium (bright cells). (B) Histologic specimen shows high grade with intraepithelial neoplasia with similar cell disarrangement compared with the endomicroscopic image. (C) Video endoscopy shows a triangular reddish mucosa (arrow) representing Barrett’s-associated neoplasia surrounded by squamous cell epithelium. Endoscopic resection revealed early Barrett’s cancer. Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 9 Confocal Barrett classification to predict histopathology in the distal esophagus. Clinical Gastroenterology and Hepatology 2006 4, 979-987DOI: (10.1016/j.cgh.2006.05.010) Copyright © 2006 American Gastroenterological Association Terms and Conditions