Real-time probe-based confocal laser endomicroscopy visualization of dual differentiation features in mixed-type gastric adenocarcinoma

Probe-based confocal laser endomicroscopy (pCLE) has emerged as a revolutionary endoscopic tool, offering real-time, in vivo histological imaging that transforms our understating of complex gastric malignancies [1] [2]. We present a case of mixed-type gastric adenocarcinoma in which pCLE played a pivotal role in precise visualization and diagnosis during endoscopic assessment ([Video 1]).

Probe-based confocal laser endomicroscopy (pCLE) scan of the lesion.Video 1

A 40-year-old woman with Helicobacter pylori infection underwent esophagogastroduodenoscopy. White-light endoscopy (WLE) with indigo carmine chromoendoscopy revealed a 3.5×4 cm erythematous lesion at the gastric angle, featuring a superficial flat-elevated morphology with well-demarcated margins ([Fig. 1]). It was considered a cancerous lesion according to diagnosis criteria under WLE: 1) well-demarcated border; and 2) irregularity in color/ surface pattern [3]. To further evaluate the lesion, pCLE (1000×magnification, BIOPSEE, Viestar Medical Technology, Wuhan, China) was employed, which revealed distinct microarchitectural patterns: elevated areas showed distorted glands with thickened epithelia ([Fig. 2] a), whereas flat regions exhibited chaotic branching glands and stenosed lumens ([Fig. 2] b). Dedifferentiation was characterized by complete glandular disorganization with dense neovascular networks ([Fig. 2] c). Based on the Miami classification [4] and discriminable glandular structures [5], mixed adenocarcinoma with dual differentiation was confirmed. Following informed consent, endoscopic submucosal dissection was performed. Real-time pCLE findings correlated perfectly with histopathology: microscopy confirmed both differentiated and undifferentiated components ([Fig. 2] d, [Fig. 2] e).

Fig. 1 WLE images showed a 3.5×4 cm superficial flat and elevated lesion in the gastric antrum.

Fig. 2 Microstructural imaging characteristics of distinct differentiation components under pCLE. a Chaotic glandular arrangement with increased branching and stenosed lumens. b Disordered cell arrangement in which normal glandular structure was almost unrecognizable. c Development of a dense network of neovascularization. d Histopathology showed well-differentiated adenocarcinoma, e moderately differentiated adenocarcinoma, and f poorly differentiated adenocarcinoma.

This case highlights pCLE's capacity to eliminate diagnostic ambiguity through immediate microscopic pattern recognition, reducing reliance on multiple biopsies. The technology's real-time delineation of heterogeneous tumor components represents a significant advancement toward optical biopsy-driven precision diagnostics for complex malignancies. This case report underscores pCLE's potential to transform endoscopic practice by enabling instant, high-resolution characterization of neoplastic lesions, thereby optimizing therapeutic decision-making.

• References

• 1 Wallace M, Lauwers GY, Chen Y. et al. Miami classification for probe-based confocal laser endomicroscopy. Endoscopy 2011; 43: 882-891
• 2 Zuo XL, Li Z, Li CQ. et al. Probe-based endomicroscopy for in vivo detection of gastric intestinal metaplasia and neoplasia: a multicenter randomized controlled trial. Endoscopy 2017; 49: 1033-1042
• 3 Yao K. The endoscopic diagnosis of early gastric cancer. Ann Gastroenterol 2013; 26: 11-22
• 4 Wallace M, Lauwers GY, Chen Y. et al. Miami classification for probe-based confocal laser endomicroscopy. Endoscopy 2011; 43: 882-891
• 5 Jeon SR, Cho WY, Jin SY. et al. Optical biopsies by confocal endomicroscopy prevent additive endoscopic biopsies before endoscopic submucosal dissection in gastric epithelial neoplasias: a prospective, comparative study. Gastrointest Endosc 2011; 74: 772-780