Assessment of the diagnostic performance and interobserver variability of endocytoscopy in Barrett's esophagus: a pilot ex-vivo study

Abstract

Aim: To investigate a classification of endocytoscopy (ECS) images in Barrett's esophagus (BE) and evaluate its diagnostic performance and interobserver variability.

Methods: ECS was applied to surveillance endoscopic mucosal resection (EMR) specimens of BE ex-vivo. The mucosal surface of specimen was stained with 1% methylene blue and surveyed with a catheter-type endocytoscope. We selected still images that were most representative of the endoscopically suspect lesion and matched with the final histopathological diagnosis to accomplish accurate correlation. The diagnostic performance and inter-observer variability of the new classification scheme were assessed in a blinded fashion by physicians with expertise in both BE and ECS and inexperienced physicians with no prior exposure to ECS.

Results: Three staff physicians and 22 gastroenterology fellows classified eight randomly assigned unknown still ECS pictures (two images per each classification) into one of four histopathologic categories as follows: (1) BEC1-squamous epithelium; (2) BEC2-BE without dysplasia; (3) BEC3-BE with dysplasia; and (4) BEC4-esophageal adenocarcinoma (EAC) in BE. Accuracy of diagnosis in staff physicians and clinical fellows were, respectively, 100% and 99.4% for BEC1, 95.8% and 83.0% for BEC2, 91.7% and 83.0% for BEC3, and 95.8% and 98.3% for BEC4. Interobserver agreement of the faculty physicians and fellows in classifying each category were 0.932 and 0.897, respectively.

Conclusion: This is the first study to investigate classification system of ECS in BE. This ex-vivo pilot study demonstrated acceptable diagnostic accuracy and excellent interobserver agreement.

Keywords: Barrett’s esophagus; Dysplasia; Endocytoscopy; Esophageal adenocarcinoma; Interobserver agreement.

Figure 1

Classification of endocytoscopic images of Barrett’s esophagus. A: Squamous epithelium (BEC 1) Cytoplasm-rich, rhomboid cells in a regular pattern; B: Barrett’s esophagus without dysplasia (BEC 2) Increased cell number and different-sized nuclei/cells; C: Barrett’s esophagus with dysplasia (BEC 3) Increased nucleus-cytoplasm ratio, and dense chromatin and nuclear fission are prominent; D: Esophageal adenocarcinoma (BEC 4) Cells of various sizes, irregularly arranged, with blurred and enlarged nuclei (magnification × 1125).