Endomicroscopy

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Endomicroscopy is a technique for obtaining histology-like images from inside the human body in real-time,[1][2][3] a process known as ‘optical biopsy’.[4][5] It generally refers to fluorescence confocal microscopy, although multi-photon microscopy and optical coherence tomography have also been adapted for endoscopic use.[6][7][8][9] Commercially available clinical endomicroscopes can achieve a resolution on the order of a micrometre, have a field-of-view of several hundred µm, and are compatible with fluorophores which are excitable using 488 nm laser light. The main applications are currently in imaging of the gastro-intestinal tract, particularly for the diagnosis and characterisation of Barrett’s Esophagus, pancreatic cysts and colorectal lesions.

Principles[edit]

Conventional, widefield microscopy is generally unsuitable for imaging thick tissue because the images are corrupted by a blurred, out-of-focus background signal.[10] Endomicroscopes achieve optical sectioning (removal of the background intensity) using the confocal principle - each image frame is assembled in a point-by-point fashion by scanning a laser spot rapidly over the tissue. In table-top confocal microscopes the scanning is usually performed using bulky galvanometer or resonant scanning mirrors. Endomicroscopes either have a miniaturised scanning head at the distal tip of the imaging probe, or perform the scanning outside of the patient and use an imaging fibre bundle to transfer the scan pattern to the tissue.[3]

Fibre Bundle Endomicroscopes[edit]

Fibre bundles were originally developed for use in flexible endoscopes.[11] and have since been adapted for use in endomicroscopy.[12][13][14] They consist of a large number (up to tens of thousands) of fibre cores inside a single shared cladding, are flexible, and have diameters on the order of a millimetre. In a coherent fibre bundle the relative positions of the cores are maintained along the fibre, meaning that an image projected onto one end of the bundle will be transferred to the other end without scrambling. Therefore, if one end of the bundle is placed at the focus of a table-top confocal microscope, the bundle will act as a flexible extension and allow endoscopic operation. Since only the cores, and not the cladding, transmit light, image processing must be applied to remove the resulting honeycomb-like appearance of the images.[15] Each core essentially acts as an image pixel, and so the spacing between fibre cores limits the resolution. The addition of micro-optics at the distal tip of the bundle allows for magnification and hence higher resolution imaging, but at the cost of reducing the field-of-view.

Distal Scanning Endomicroscopes[edit]

Distal scanning endomicroscopes incorporate a miniature 2D scanning apparatus into the imaging probe. The laser excitation and returning fluorescent emission are sent to and received from the scanning head using an optical fibre. Most experimental devices have either used MEMS scanning mirrors,[16] or direct translation of the fibre using electromagnetic actuation.[17]

Non-Confocal Endomicroscopes[edit]

Widefield endomicroscopes (i.e. non-depth sectioning microscopes) have been developed for select applications,[18] including the imaging of cells ex vivo.[19] Optical coherence tomography and multi-photon microscopy have both been demonstrated endoscopically.[20][21][22] Successful implementations have used distal scanning rather than fibre bundles due to problems with dispersion and light loss.

Commercial Products[edit]

Two endomicroscope products have been developed: the Pentax ISC-1000/EC3870CIK (Pentax/Hoya, Tokyo, Japan), now withdrawn from some markets, and Cellvizio (Mauna Kea Technologies, Paris, France). The Pentax Medical device is pre-packaged into an endoscope, and uses electromagnetic-controlled scanning of a fibre to perform the confocal scanning at the distal tip of the device. This provides sub-micrometre resolution across a large field of view and up to a million pixels per frame. The original Pentax instrument had variable frame rate up to 1.6 fps and dynamic adjustment of working distance by the user over a depth range from surface to 250um.[17] Mauna Kea’s Cellvizio device has an external laser scanning unit and offers a selection of fibre-bundle based probes with resolution, field of view and working distance optimised for different applications. These probes are compatible with standard endoscope instrument channels, and have a frame rate of 12 Hz.[14]

Applications[edit]

The majority of clinical trials have focused on applications in the gastro-intestinal (GI) tract, particularly the detection and characterisation of pre-cancerous lesions. Mauna Kea’s Cellvizio has US Food and Drug Administration (FDA) 510(k) clearance and a European CE Mark for use in the GI and pulmonary tracts.[3] Research studies have suggested a large range of potential applications, including in the urinary tract,[5] head and neck,[23] ovaries,[24] and lungs.[25] Confocal endomicroscopy has been utilized to describe in vivo mucosal morphology in dogs.[26] Commonly used fluorescent stains include topically applied acriflavine, and intravenously administered fluorescein sodium.[3][27]

References[edit]

  1. ^ Paull, P.E., et al., Confocal laser endomicroscopy: a primer for pathologists. Archives of pathology & laboratory medicine, 2011. 135: p. 1343-8.
  2. ^ Liu, J.T.C., et al., Review Article : Modern Trends in Imaging II Point-of-care pathology with miniature microscopes. Pathology, 2011. 34: p. 81-98.
  3. ^ a b c d Jabbour, J.M., et al., Confocal Endomicroscopy: Instrumentation and Medical Applications. Annals of biomedical engineering, 2011.
  4. ^ Newton, R.C., et al., Progress toward optical biopsy: bringing the microscope to the patient. Lung, 2011. 189: p. 111-9.
  5. ^ a b Sonn, G.a., et al., Optical biopsy of human bladder neoplasia with in vivo confocal laser endomicroscopy. The Journal of urology, 2009. 182: p. 1299-305.
  6. ^ Tearney, G.J., et al., In Vivo Endoscopic Optical Biopsy with Optical Coherence Tomography. Science, 1997. 276: p. 2037-2039.
  7. ^ Zysk, A.M., et al., Optical coherence tomography: a review of clinical development from bench to bedside. Journal of biomedical optics, 2012. 12: p. 051403.
  8. ^ Jung, J.C., et al., In vivo mammalian brain imaging using one- and two-photon fluorescence microendoscopy. Journal of neurophysiology, 2004. 92: p. 3121-33.
  9. ^ Myaing, M.T., et al., Fiber-optic scanning two-photon fluorescence endoscope. Optics Letetrs, 2006. 31: p. 1076-78.
  10. ^ Wilson, T., Optical sectioning in fluorescence microscopy. Journal of microscopy, 2011. 242: p. 111-6.
  11. ^ H.H.Hopkins and N.S.Kapany, A flexible fibrescope, using static scanning. Nature, 1954. 187: p. 39-40.
  12. ^ Gmitro, A.F. and D. Aziz, Confocal microscopy through a fiber-optic imaging bundle. Optics Letters, 1993. 18: p. 565-567.
  13. ^ Makhlouf, H., et al., Multispectral confocal microendoscope for in vivo and in situ imaging. Journal of biomedical optics, 2008. 13: p. 044016.
  14. ^ a b Goualher, G.L., et al. Towards Optical Biopsies with an Integrated Fibered Confocal Fluorescence Microscope. in MICCAI 2004. 2004.
  15. ^ Perchant, A., G.L. Goualher, and F. Berier, Method for Processing an image acquired through a guide consisting of a plurality of optical fibers. 2011.
  16. ^ Dickensheets, D.L., G.S. Kino, and L. Fellow, Silicon-Micromachined Scanning Confocal Optical Microscope. Scanning, 1998. 7: p. 38-47.
  17. ^ a b Polglase, A.L., W.J. Mclaren, and S.A. Skinner, A fluorescence confocal endomicroscope for in vivo microscopy of the upper- and the lower-GI tract. Gastrointestinal Endoscopy, 2005. 62.
  18. ^ Pierce, M.C., et al., Low-cost endomicroscopy in the esophagus and colon. Am J Gastroenterol, 2012. 2011: p. 1722-1724.
  19. ^ Pierce, M., D. Yu, and R. Richards-Kortum, High-resolution fiber-optic microendoscopy for in situ cellular imaging. Journal of visualized experiments : JoVE, 2011: p. 8-11.
  20. ^ Huo, L., et al., Forward-viewing resonant fiber-optic scanning endoscope of appropriate scanning speed for 3D OCT imaging. Optics express, 2010. 18: p. 14375-84.
  21. ^ Zhang, Y.Y., et al., A compact fiber-optic SHG scanning endomicroscope and its application to visualize cervical remodeling during pregnancy. Proceedings of the National Academy of Sciences, 2012. 109: P. 12878-83.
  22. ^ Xi, J.F., et al., Integrated multimodal endomicroscopy platform for simultaneous en face optical coherence and two-photon fluorescence imaging. Optics Letters, 2012. 37: p. 362-44.
  23. ^ Haxel, B.R., et al., Confocal endomicroscopy: a novel application for imaging of oral and oropharyngeal mucosa in human. European archives of oto-rhino-laryngology - Head and Neck Surgery, 2010. 267: p. 443-8.
  24. ^ Tanbakuchi, A.a., et al., In vivo imaging of ovarian tissue using a novel confocal microlaparoscope. American journal of obstetrics and gynecology, 2010. 202: p. 90.e1-9.
  25. ^ Mufti, N., et al., Fiber optic microendoscopy for preclinical study of bacterial infection dynamics. Biomedical optics express, 2011. 2: p. 1121-34.
  26. ^ Sharman MJ et al. In vivo confocal endomicroscopy of small intestinal mucosal morphology in dogs. Journal of Veterinary Internal Medicine, 2013 (In Press)
  27. ^ Sharman MJ et al. The exogenous fluorophore, fluorescein, enables in vivo assessment of the gastrointestinal mucosa via confocal endomicroscopy: optimization of intravenous dosing in the dog model. Journal of Veterinary Pharmacology and Therapeutics, 2012. DOI: 10.1111/jvp.12031