Targeting neoplasia using volumetric laser endomicroscopy with laser marking.

Volumetric laser endomicroscopy (VLE) is a recent advanced imaging technology that allows high resolution microstructure imaging of the esophagus and gastric cardia; it has been increasingly used in Europe and the USA [1–3]. The system has been recently upgraded to include a laser marking device that places cautery marks on the mucosa to provide targets for histology. We report a case of an incidental finding of focal high grade dysplasia targeted using this new technology. A 69-year-old man was referred for advanced imaging and removal of a gastroesophageal junction polyp. The polyp was visualized, using high definition resolution white-light endoscopy (HDR-WLE), on the cardia side of the gastroesophageal junction (▶Fig. 1; ▶Video1). It was a mobile pedunculated polyp with its base at the gastric cardia (Paris classification 0–1p). It is our practice to use VLE for high resolution imaging of mucosal pathology in the esophagus and gastroesophageal junction. We used a 20-mm balloon containing the VLE probe (▶Fig. 2). VLE showed that the polyp of interest did not contain any of the VLE characteristics that have been associated with neoplasia [4, 5]. No atypical glands or abnormal signal intensity were seen. There was however an area at the gastroesophageal junction just proximal to the polyp that contained a cluster of atypical glands that were suspicious for neoplasia (▶Fig. 3). This area appeared normal on HDR-WLE and narrow-band imaging (NBI) so laser marks were placed at the site to mark it for targeting (▶Fig. 4). Endoscopic mucosal resection of the polyp and the VLE-targeted area was performed. Histology of the polyp showed an inflammatory polyp and the VLE-targeted area was consistent with focal high grade dysplasia (▶Fig. 5; ▶Video1). This case demonstrates the capability of VLE to obtain high resolution microstructure imaging of the esophagus and gastroesophageal junction that can aid in the diagnosis of neoplasia.