Abstract
Background
Histological analysis of surgical specimen is the gold standard for cancer classification. In particular, frozen histological diagnosis of vague peritoneal spots or uncertain excision of tumors plays a crucial role in the decision to proceed with or abandon an operation. Confocal laser microscopy (CLM) enables in-vivo and real-time high-resolution tissue analysis. This method has already been used during endoscopic assessments analyzing transformation of esophageal or colon mucosa. We examined whether a CLM device enables to distinguish between non-malignant and malignant tissue in vivo and real time and enables to assign peritoneal carcinomatosis spots to their primary tumor. In addition, we investigated whether the newly developed CLM camera device causes any tissue damage.
Methods
CC531 colon carcinoma cells were implanted on the serosa side of the colon and intraperitoneally in Wag/Rija rats via laparotomy. After 7 days of tumor growth, confocal laser microscopy in vivo was performed by re-laparotomy. Images of non-malignant and malignant tissue were characterized in terms of specific signal pattern. No fluorescent dye was used. Correlations to findings in conventional histology were systematically recorded and described. Potential tissue damage was examined by conventional histology.
Results
All animals survived the operative procedure and could be evaluated 7 days following surgery. No unexpected death occurred after surgery. Non-malignant colon is defined by small cycles of the microvilli of the colon. There is repetitive deregulated structure in colon carcinoma. Peritoneal carcinomatosis showed the same structural pattern as in primary colon carcinoma. In all examined cases, it was possible to differentiate between peritoneal carcinomatosis spots and non-malignant peritoneum. The CLM device did not cause any tissue damage.
Conclusions
The CLM camera device reported here is feasible to identify peritoneal carcinomatosis spots, assign these spots to the primary tumor, as well as distinguish between non-malignant and malignant tissue in without using any fluorescent dye.




Similar content being viewed by others
References
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A (2015) Global cancer statistics, 2012. CA Cancer J Clin 65(2):87–108. https://doi.org/10.3322/caac.21262
Franko J, Shi Q, Goldman CD, Pockaj BA, Nelson GD, Goldberg RM, Pitot HC, Grothey A, Alberts SR, Sargent DJ (2012) Treatment of colorectal peritoneal carcinomatosis with systemic chemotherapy: a pooled analysis of north central cancer treatment group phase III trials N9741 and N9841. J Clin Oncol 30(3):263–267. https://doi.org/10.1200/JCO.2011.37.1039
Cercek A, Cusack JC Jr, Ryan DP (2015) Treatment of peritoneal carcinomatosis of colorectal origin. Am Soc Clin Oncol Educ Book. https://doi.org/10.14694/EdBook_AM.2015.35.e208
Ishigami S, Uenosono Y, Arigami T, Yanagita S, Okumura H, Uchikado Y, Kita Y, Kurahara H, Kijima Y, Nakajo A, Maemura K, Natsugoe S (2014) Clinical utility of perioperative staging laparoscopy for advanced gastric cancer. World J Surg Oncol 12:350. https://doi.org/10.1186/1477-7819-12-350
Fugazza A, Gaiani F, Carra MC, Brunetti F, Levy M, Sobhani I, Azoulay D, Catena F, de’ Angelis GL, de’ Angelis N (2016) Confocal laser endomicroscopy in gastrointestinal and pancreatobiliary diseases: a systematic review and meta-analysis. BioMed Res Int 2016:4638683. https://doi.org/10.1155/2016/4638683
Kiesslich R, Gossner L, Goetz M, Dahlmann A, Vieth M, Stolte M, Hoffman A, Jung M, Nafe B, Galle PR, Neurath MF (2006) In vivo histology of Barrett’s esophagus and associated neoplasia by confocal laser endomicroscopy. Clin Gastroenterol Hepatol 4(8):979–987. https://doi.org/10.1016/j.cgh.2006.05.010
Lim LG, Neumann J, Hansen T, Goetz M, Hoffman A, Neurath MF, Galle PR, Chan YH, Kiesslich R, Watson AJ (2014) Confocal endomicroscopy identifies loss of local barrier function in the duodenum of patients with Crohn’s disease and ulcerative colitis. Inflamm Bowel Dis 20(5):892–900. https://doi.org/10.1097/MIB.0000000000000027
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(3):706–713
Fottner C, Mettler E, Goetz M, Schirrmacher E, Anlauf M, Strand D, Schirrmacher R, Kloppel G, Delaney P, Schreckenberger M, Galle PR, Neurath MF, Kiesslich R, Weber MM (2010) In vivo molecular imaging of somatostatin receptors in pancreatic islet cells and neuroendocrine tumors by miniaturized confocal laser-scanning fluorescence microscopy. Endocrinology 151(5):2179–2188. https://doi.org/10.1210/en.2009-1313
De Palma GD (2009) Confocal laser endomicroscopy in the “in vivo” histological diagnosis of the gastrointestinal tract. World J Gastroenterol 15(46):5770–5775
Becker V, von Delius S, Bajbouj M, Karagianni A, Schmid RM, Meining A (2008) Intravenous application of fluorescein for confocal laser scanning microscopy: evaluation of contrast dynamics and image quality with increasing injection-to-imaging time. Gastrointest Endosc 68(2):319–323. https://doi.org/10.1016/j.gie.2008.01.033
Coda S, Thillainayagam AV (2014) State of the art in advanced endoscopic imaging for the detection and evaluation of dysplasia and early cancer of the gastrointestinal tract. Clin Exp Gastroenterol 7:133–150. https://doi.org/10.2147/CEG.S58157
Ellebrecht DB, Gebhard MP, Horn M, Keck T, Kleemann M (2016) Laparoscopic confocal laser microscopy without fluorescent injection: A pilot ex vivo study in colon cancer. Surg Innov. https://doi.org/10.1177/1553350616637690
Marquet RL, Westbroek DL, Jeekel J (1984) Interferon treatment of a transplantable rat colon adenocarcinoma: importance of tumor site. International journal of cancer Journal international du cancer 33(5):689–692
Lopes Cardozo AM, Gupta A, Koppe MJ, Meijer S, van Leeuwen PA, Beelen RJ, Bleichrodt RP (2001) Metastatic pattern of CC531 colon carcinoma cells in the abdominal cavity: an experimental model of peritoneal carcinomatosis in rats. Eur J Surg Oncol 27(4):359–363. https://doi.org/10.1053/ejso.2001.1117
Pelz JO, Doerfer J, Hohenberger W, Meyer T (2005) A new survival model for hyperthermic intraperitoneal chemotherapy (HIPEC) in tumor-bearing rats in the treatment of peritoneal carcinomatosis. BMC Cancer 5:56. https://doi.org/10.1186/1471-2407-5-56
Becker V, Wallace MB, Fockens P, von Delius S, Woodward TA, Raimondo M, Voermans RP, Meining A (2010) Needle-based confocal endomicroscopy for in vivo histology of intra-abdominal organs: first results in a porcine model (with videos). Gastrointest Endosc 71(7):1260–1266. https://doi.org/10.1016/j.gie.2010.01.010
Pierangelo A, Fuks D, Benali A, Validire P, Gayet B (2017) Diagnostic accuracy of confocal laser endomicroscopy for the ex vivo characterization of peritoneal nodules during laparoscopic surgery. Surg Endosc 31(4):1974–1981. https://doi.org/10.1007/s00464-016-5172-7
Hara H, Takahashi T, Nakatsuka R, Higashi S, Naka T, Sumiyama K, Miyazaki Y, Makino T, Kurokawa Y, Yamasaki M, Takiguchi S, Mori M, Doki Y, Nakajima K (2016) A novel approach of optical biopsy using probe-based confocal laser endomicroscopy for peritoneal metastasis. Surg Endosc 30(8):3437–3446. https://doi.org/10.1007/s00464-015-4626-7
White SB, Procissi D, Chen J, Gogineni VR, Tyler P, Yang Y, Omary RA, Larson AC (2016) Characterization of CC-531 as a rat model of colorectal liver metastases. PLoS ONE 11(5):e0155334. https://doi.org/10.1371/journal.pone.0155334
Acknowledgements
We thank KARL STORZ SE & Co. KG for their support with the laparoscopic CLM device.
Funding
This study was supported by the junior research Grant of the University of Lübeck (J02-2015).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Drs. David Benjamin Ellebrecht, Christiane Kuempers, Marco Horn, Prof. Dr. Tobias Keck, and Prof. Dr. Markus Kleemann have no conflicts of interest or financial ties to disclose.
Rights and permissions
About this article
Cite this article
Ellebrecht, D.B., Kuempers, C., Horn, M. et al. Confocal laser microscopy as novel approach for real-time and in-vivo tissue examination during minimal-invasive surgery in colon cancer. Surg Endosc 33, 1811–1817 (2019). https://doi.org/10.1007/s00464-018-6457-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-018-6457-9