| Background and aimsGastric cancer is still one of the most common types of cancer, and one of the most common causes of cancer-related mortality in China. It is widely accepted that gastric mucosal dysplasia or intraepithelial neoplasia, is defined as precancerous lesions. Individuals with high-grade intraepithelial neoplasia (HGIN) are at high risk of gastric cancer, which need aggressive intervention in time; while low-grade intraepithelial neoplasia (LGIN) has less possibility to progress to cancer, and might reverse to benign lesions, for which a follow-up visit is recommended. Conventional white-light endoscopy (WLE) and endoscopic biopsy remain the major diagnostic method for gastric cancer and precancerous lesions. However, it has many limitations, and is sometimes challenging for a definite diagnosis.Confocal laser endomicroscopy (CLE) allows in vivo histological evaluation during endoscopy. The aim of this study was to investigate the ability of CLE in the diagnosis of gastric mucosal lesions by comparing the results of CLE and endoscopic biopsies with the postoperative histopathology of specimens by endoscopic submucosal dissection (ESD) or surgery as the reference standard.Patients and methodsConsecutive patients from December 2013 to February 2016, with definite or suspected gastric intraepithelial neoplasia and gastric cancer (a proportion of indefinite gastric mucosal lesions also included) based on WLE and endoscopic biopsies in the Department of Gastroenterology, the First Affiliated Hospital of Zhejiang University were enrolled in the study. After signing informed consents, CLE was performed before ESD or gastrectomy. Postoperative histopathology was considered as the golden standard; the validity and reliability of endoscopic biopsies and CLE were assessed.The CLE imaging criteria for the diagnosis of gastric mucosal lesions were as follows:LGIN:mature glands with differed sizes and mildly impaired polarity, normal appearance of capillaries; HGIN:naive glands with differed sizes and abnormal polarity, dilated and distorted appearance of capillaries; Cancer:loss of normal structure of gastric pit, loss of cell and gland polarity, destroyed appearance of capillaries.ResultsA total of 110 patients with 118 gastric mucosal lesions were involved. The final postoperative histopathology proved 58 gastric cancers,19 HGIN lesions,29 LGIN lesions, and 12 lesions with gastritis. The diagnostic consistency of CLE with golden standard was 60.2%, higher than that of endoscopic biopsy (42.4%, P= 0.002). The accuracy of CLE to diagnose LGIN, HGIN and gastric cancer was 88.1%,67.8% and 72.9%, versus 76.3%(P= 0.016),59.3%(P= 0.143) and 61.9%(P= 0.015) for endoscopic biopsies.Gastric HGIN/cancer could be identified by CLE with a significantly higher accuracy (93.2% versus 78.8%) (P< 0.001), sensitivity (97.4% versus 77.9%) (P< 0.001) than that by endoscopic biopsies, and a similar specificity (85.4% versus 80.5%) (P=0.687).There were 35 LGIN lesions identified by endoscopic biopsy. Compared to the golden standard, endoscopic biopsy underestimated 14 lesions (7 HGIN lesions and 7 gastric cancers). However, only 1 HGIN lesion was underestimated as LGIN by CLE, and another 5 gastric cancers were underestimated as HGIN by CLE.ConclusionsCLE was superior to endoscopic biopsies for the diagnosis of gastric intraepithelial neoplasia and gastric cancer. Especially, gastric HGIN/cancer could be identified by CLE with high validity and reliability. For LGIN lesions based on forceps biopsies, CLE can avoid underestimation and delayed diagnosis of disease. |
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