Confocal chromolaser endomicroscopy: a supplemental diagnostic tool prior to transanal endoscopic microsurgery of rectal tumors?

  • Thomas BorschitzEmail author
  • Ralf Kiesslich
Original Article



Due to diagnostic advancements, preoperative staging of rectal tumors was significantly improved. However, difficulties in obtaining accurate results can sometimes be observed in the staging of adenomas and early rectal carcinomas (pT1/2). The aim of this study was to test if confocal chromolaser endomicroscopy (cCLEM) can help minimize this diagnostic gap.


cCLEM generates optical transversal sections at ×1,000 magnification and allows for evaluation of the mucosal microarchitecture and differentiation of normal mucosa from adenomas and carcinomas. Cases with conflicting preoperative findings (adenoma vs. ≥uT2 categories), undetectable tumors after inadequate (R1/RX) snare polypectomy of carcinomas, and extremely flat adenoma areas were studied.


By cCLEM, in ≥uT2 carcinomas with an adenoma histology, malignoma-suspicious areas were identified and selected biopsies were done. In addition, re-epithelialized polypectomy areas of carcinomas were visualized and targeted reoperations could be carried out. Furthermore, the dignity and extension of extremely flat adenomas were determined and marked by clips for additional therapy.


In cases with rectal tumors, conflicting or unclear findings, and flat extending adenomas, the utilization of cCLEM should be considered. Especially in cases with early rectal carcinomas, unnecessary second operations and also recurrences can be minimized or even avoided by selective usage of cCLEM.


Rectal cancer Local excision Confocal chromolaser endomicroscopy 


  1. 1.
    Borschitz T, Heintz A, Junginger T (2006) The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum 49:1492–1506CrossRefPubMedGoogle Scholar
  2. 2.
    Borschitz T, Junginger T (2003) Value of local surgical therapy of rectal cancer. A literature analysis. Zentralbl Chir 128:1066–1074CrossRefPubMedGoogle Scholar
  3. 3.
    Middleton PF, Sutherland LM, Maddern GJ (2005) Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum 48:270–284CrossRefPubMedGoogle Scholar
  4. 4.
    Sengupta S, Tjandra JJ (2001) Local excision of rectal cancer: what is the evidence? Dis Colon Rectum 44:1345–1361CrossRefPubMedGoogle Scholar
  5. 5.
    Sharma A, Hartley J, Monson JRT (2003) Local excision of rectal tumours. Surg Oncol 12:51–61CrossRefPubMedGoogle Scholar
  6. 6.
    Ganai S, Kanumuri P, Rao RS, Alexander AI (2006) Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers. Ann Surg Oncol 13:547–556CrossRefPubMedGoogle Scholar
  7. 7.
    Maeda K, Maruta M, Sato H, Hanai T, Masumori K, Matumoto M, Koide Y, Matuoka H, Katuno H (2006) Local excision of stratified T1 rectal cancer. Am J Surg 191:410–412CrossRefGoogle Scholar
  8. 8.
    Tytherleigh MG, Warren BF, Mortensen NJ (2008) Management of early rectal cancer. Br J Surg 95:409–423CrossRefPubMedGoogle Scholar
  9. 9.
    Borschitz T, Heintz A, Junginger T (2007) Transanal endoscopic microsurgical excision of pT2 rectal cancer: results and possible indications. Dis Colon Rectum 50:292–301CrossRefPubMedGoogle Scholar
  10. 10.
    American Joint Committee on Cancer (AJCC) (2002) In: Greene FL, Page DL, Fleming ID, Fritz AG, Balch ChM, Haller DG, Morrow M (eds) Cancer staging manual, 6th edn. Springer, New YorkGoogle Scholar
  11. 11.
    Schmiegel W, Reinacher-Schick A, Arnold D, Graeven U, Heinemann V, Porschen R, Riemann J, Rödel C, Sauer R, Wieser M, Schmitt W, Schmoll HJ, Seufferlein T, Kopp I, Pox C (2008) Update S3-guideline "colorectal cancer" 2008. Z Gastroenterol 46:799–840CrossRefPubMedGoogle Scholar
  12. 12.
    Ueno H, Mochizuki H, Shinto E, Hashiguchi Y, Hase K, Talbot IC (2002) Histologic indices in biopsy specimens for estimating the probability of extended local spread in patients with rectal carcinoma. Cancer 94:2882–2891CrossRefPubMedGoogle Scholar
  13. 13.
    UICC (2002) In: Sobin LH, Wittekind CH (eds) TNM classification of malignant tumours, 6th edn. Wiley, New YorkGoogle Scholar
  14. 14.
    Delaney PM, Harris MR (1995) Fiberoptics in confocal microscopy. In: Pawley JB (ed) Handbook of biological confocal microscopy. Plenum, New York, pp 515–523Google Scholar
  15. 15.
    Kiesslich R, Burg J, Vieth M, Gnaendiger J, Enders M, Delaney P, Polglase A, McLaren W, Janell D, Thomas S, Nafe B, Galle PR, Neurath MF (2004) Confocal laser endoscopy for diagnosing intraepithelial neoplasias and colorectal cancer in vivo. Gastroenterology 127:706–713CrossRefPubMedGoogle Scholar
  16. 16.
    Hurlstone DP, Kiesslich R, Thomson M, Atkinson R, Cross SS (2008) Confocal chromoscopic endomicroscopy is superior to chromoscopy alone for the detection and characterisation of intraepithelial neoplasia in chronic ulcerative colitis. Gut 57:196–204CrossRefPubMedGoogle Scholar
  17. 17.
    Kiesslich R, Goetz M, Lammersdorf K, Schneider C, Burg J, Stolte M, Vieth M, Nafe B, Galle PR, Neurath MF (2007) Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis. Gastroenterology 132:874–882CrossRefPubMedGoogle Scholar
  18. 18.
    Yoshida S, Tanaka S, Hirata M, Mouri R, Kaneko I, Oka S, Yoshihara M, Chayama K (2007) Optical biopsy of GI lesions by reflectance-type laser-scanning confocal microscopy. Gastrointest Endosc 66:144–149CrossRefPubMedGoogle Scholar
  19. 19.
    Kakeji Y, Yamaguchi S, Yoshida D, Tanoue K, Ueda M, Masunari A, Utsunomiya T, Imamura M, Honda H, Maehara Y, Hashizume M (2006) Development and assessment of morphologic criteria for diagnosing gastric cancer using confocal endomicroscopy: an ex vivo and in vivo study. Endoscopy 38:886–890CrossRefPubMedGoogle Scholar
  20. 20.
    Kitabatake S, Niwa Y, Miyahara R, Ohashi A, Matsuura T, Iguchi Y, Shimoyama Y, Nagasaka T, Maeda O, Ando T, Ohmiya N, Itoh A, Hirooka Y, Goto H (2006) Confocal endomicroscopy for the diagnosis of gastric cancer in vivo. Endoscopy 38:1110–1114CrossRefPubMedGoogle Scholar
  21. 21.
    East JE, Suzuki N, Saunders BP (2007) Comparison of magnified pit pattern interpretation with narrow band imaging versus chromoendoscopy for diminutive colonic polyps: a pilot study. Gastrointest Endosc 66:310–316CrossRefPubMedGoogle Scholar
  22. 22.
    Nicholls RJ, Galloway DJ, Mason AY, Boyle P (1985) Clinical staging of rectal cancer. Br J Surg 72:51–52CrossRefGoogle Scholar
  23. 23.
    Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J (2004) Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging—a meta-analysis. Radiology 232:773–783CrossRefPubMedGoogle Scholar
  24. 24.
    Beets-Tan RG, Beets GL (2004) Rectal cancer review with emphasis on MR imaging. Radiology 232:335–346CrossRefPubMedGoogle Scholar
  25. 25.
    Brown G, Kirkham A, Williams GT, Bourne M, Radcliffe AG, Sayman J, Newell R, Sinnatamby C, Heald RJ (2004) High-resolution MRI of the anatomy important in total mesorectal excision of the rectum. AJR Am J Roentgenol 182:431–439PubMedGoogle Scholar
  26. 26.
    Rao SX, Zeng MS, Xu JM, Qin XY, Chen CZ, Li RC, Hou YY (2007) Assessment of T staging and mesorectal fascia status using high-resolution MRI in rectal cancer with rectal distention. World J Gastroenterol 13:4141–4146PubMedGoogle Scholar
  27. 27.
    Assenat E, Thézenas S, Samalin E, Bibeau F, Portales F, Azria D, Quenet F, Rouanet P, Saint Aubert B, Senesse P (2007) The value of endoscopic rectal ultrasound in predicting the lateral clearance and outcome in patients with lower-third rectal adenocarcinoma. Endoscopy 39:309–313CrossRefPubMedGoogle Scholar
  28. 28.
    Badger SA, Devlin PB, Neilly PJ, Gilliland R (2007) Preoperative staging of rectal carcinoma by endorectal ultrasound: is there a learning curve? Int J Colorectal Dis 22:1261–1268CrossRefPubMedGoogle Scholar
  29. 29.
    Garcia-Aguilar J, Pollack J, Lee SH, Hernandez de Anda E, Mellgren A, Wong WD, Finne CO, Rothenberger DA, Madoff RD (2002) Accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. Dis Colon Rectum 45:10–15CrossRefPubMedGoogle Scholar
  30. 30.
    Giovannini M, Bories E, Pesenti C, Moutardier V, Lelong B, Delpéro JR (2006) Three-dimensional endorectal ultrasound using a new freehand software program: results in 35 patients with rectal cancer. Endoscopy 38:339–343CrossRefPubMedGoogle Scholar
  31. 31.
    Warmath JR, Bao P, Clements LW, Herline AJ, Galloway RL (2005) Development of a three-dimensional freehand endorectal ultrasound system for use in rectal cancer imaging. Med Phys 32:1757–1766CrossRefPubMedGoogle Scholar
  32. 32.
    Pikarsky A, Wexner S, Lebensart P, Efron J, Weiss E, Nogueras J, Reissman P (2000) The use of rectal ultrasound for the correct diagnosis and treatment of rectal villous tumors. Am J Surg 179:261–265CrossRefPubMedGoogle Scholar
  33. 33.
    Renzulli P, Maurer CA, Netzer P, Büchler MW (2004) Surgical management of large sessile villous and tubulovillous adenomas of the lower rectum. Dig Surg 21:287–292CrossRefPubMedGoogle Scholar
  34. 34.
    Worrell S, Horvath K, Blakemore T, Flum D (2004) Endorectal ultrasound detection of focal carcinoma within rectal adenomas. Am J Surg 187:625–629CrossRefPubMedGoogle Scholar
  35. 35.
    Kneist W, Terzic A, Burghardt J, Heintz A, Junginger T (2004) Selection of patients with rectal tumors for local excision based on preoperative diagnosis. Results of a consecutive evaluation study of 552 patients. Chirurg 75:168–175CrossRefPubMedGoogle Scholar
  36. 36.
    Hurlstone DP, Sanders DS, Lobo AJ, McAlindon ME, Cross SS (2005) Indigo carmine assisted high-magnification chromoscopic colonoscopy for the detection and characterisation of intraepithelial neoplasia in ulcerative colitis: a prospective evaluation. Endoscopy 37:1186–1192CrossRefPubMedGoogle Scholar
  37. 37.
    Rutter MD, Saunders BP, Wilkinson KH, Rumbles S, Schofield G, Kamm MA, Williams CB, Price AB, Talbot IC, Forbes A (2004) Pancolonic indigo carmine dye spraying for the detection of dysplasia in ulcerative colitis. Gut 53:256–260CrossRefPubMedGoogle Scholar
  38. 38.
    Kiesslich R, Fritsch J, Holtmann M, Koehler HH, Stolte M, Kanzler S, Nafe B, Jung M, Galle PR, Neurath MF (2003) Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis. Gastroenterology 124:880–888CrossRefPubMedGoogle Scholar
  39. 39.
    Dekker E, van den Broek FJ, Reitsma JB, Hardwick JC, Offerhaus GJ, van Deventer SJ, Hommes DW, Fockens P (2007) Narrow-band imaging compared with conventional colonoscopy for the detection of dysplasia in patients with longstanding ulcerative colitis. Endoscopy 39:216–221CrossRefPubMedGoogle Scholar
  40. 40.
    Pohl J, Nguyen-Tat M, Pech O, May A, Rabenstein T, Ell C (2008) Computed virtual chromoendoscopy for classification of small colorectal lesions: a prospective comparative study. Am J Gastroenterol 103:562–569CrossRefPubMedGoogle Scholar
  41. 41.
    Schäfer HH, Vivaldi C, Hölscher AH (2006) Local excision with transanal endoscopic microsurgery (TEM) after endoscopic R1/R2-polypectomy of pT1 "low-risk" carcinomas of the rectum. Z Gastroenterol 44:647–650CrossRefPubMedGoogle Scholar
  42. 42.
    Hershman MJ, Myint AS, Makin CA (2003) Multi-modality approach in curative local treatment of early rectal carcinomas. Colorectal Dis 5:445–450CrossRefPubMedGoogle Scholar
  43. 43.
    Lee W, Lee D, Choi S, Chun H (2003) Related transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc 17:1283–1287CrossRefPubMedGoogle Scholar
  44. 44.
    Tao S, Lu Q, Jiang B (2007) The clinical significance of colorectal flat lesions under endoscopy. Zhonghua Yi Xue Za Zhi 87:1417–1419PubMedGoogle Scholar
  45. 45.
    Teixeira CR, Tanaka S, Haruma K, Yoshihara M, Sumii K, Kajiyama G, Shimamoto F (1996) Flat-elevated colorectal neoplasms exhibit a high malignant potential. Oncology 53:89–93CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  1. 1.Clinic of General and Abdominal SurgeryJohannes Gutenberg University HospitalMainzGermany
  2. 2.First Department of Internal MedicineJohannes Gutenberg University HospitalMainzGermany

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