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CC BY 4.0 · Endoscopy 2025; 57(S 01): E555-E556
DOI: 10.1055/a-2598-4188
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Confocal endomicroscopy: an additional approach in the watch-and-wait strategy for advanced rectal tumors

Authors

  • Ana Victória Martins Lima 

    1   Endoscopy Fellowship, Instituto do Câncer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil

  • Fernanda Carvalho Franco

    1   Endoscopy Fellowship, Instituto do Câncer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil

  • Guilherme Cutait de Castro Cotti

    2   Colorectal Surgery Division, Instituto do Câncer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil

  • Carlos Frederico Sparapan Marques

    2   Colorectal Surgery Division, Instituto do Câncer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil

  • Evandro Sobroza de Mello

    3   Department of Pathology, Instituto do Câncer do Estado de São Paulo, University of São Paulo, Sao Paulo, Brazil

  • Fauze Maluf-Filho

    4   Endoscopy Division, Instituto do Câncer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil

  • Adriana Vaz Safatle-Ribeiro 

    4   Endoscopy Division, Instituto do Câncer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil
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A 73-year-old patient underwent a screening colonoscopy, which revealed an infiltrative lesion in the distal rectum. Histology confirmed the diagnosis of moderately differentiated infiltrative adenocarcinoma ([Fig. 1]).

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Fig. 1 Infiltrative lesion in the distal rectum confirmed it as moderately differentiated infiltrative adenocarcinoma.

Locally advanced adenocarcinomas of the mid and distal rectum are best managed with neoadjuvant chemoradiotherapy, followed by surgery [1]. However, patients who achieve a complete clinical response may undergo a ‘watch-and-wait’ strategy for organ preservation, with strict follow-up to allow early detection in the event of tumor regrowth [2] [3].

The patient underwent neoadjuvant chemoradiotherapy, and 10 weeks after treatment, restaging exams were performed. Rectoscopy revealed a scar, and chromoscopy with narrowband imaging (NBI) demonstrated only increased vessels ([Fig. 2]). Magnetic resonance imaging (MRI) revealed no residual lesion, suggestive of complete response.

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Fig. 2 Scar identified on rectoscopy after neoadjuvant chemoradiotherapy treatment evaluated using a white-light imaging combined with b narrow-band imaging.

As part of the investigation, the patient underwent probe-based confocal laser endomicroscopy (pCLE), which is a real-time, in vivo method allowing a 1.000 times magnification, providing cellular and microvascular examination [4], as demonstrated in [Video 1]. It has been suggested that pCLE might be used during a watch-and-wait strategy for rectal neoplasia, avoiding immediate surgical treatment [5].

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Confocal endomicroscopy: a useful complementary method for diagnosing residual lesions following neoadjuvant chemoradiotherapy for advanced rectal adenocarcinoma.Video 1

pCLE revealed epithelial and vascular abnormalities indicative of a residual neoplastic lesion ([Fig. 3]), and targeted biopsies confirmed the presence of adenocarcinoma. The patient underwent minimally invasive treatment by transanal endoscopic operation (TEO) ([Fig. 4]), which provided a curative resection.

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Fig. 3 Epithelial and vascular abnormalities suggestive of a residual neoplastic lesion were identified using pCLE. a Probe positioned over the scar. b Irregular crypts along with thick and dark epithelium. c Back-to-back glands. d Dilated and tortuous vessels. Abbreviation: pCLE, probe-based confocal laser endomicroscopy.
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Fig. 4 Specimen obtained through TEO confirmed a curative resection. Abbreviation: TEO, transanal endoscopic operation.

This case illustrates that pCLE could be a useful complementary method for diagnosing residual lesions following neoadjuvant chemoradiotherapy for advanced rectal adenocarcinoma.

Endoscopy_UCTN_Code_CCL_1AD_2AB

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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We extend our deepest gratitude to the medical team for their invaluable contributions to this study. Additionally, we are sincerely grateful to the service that facilitated the development of this research. The institutional support, provided infrastructure, and commitment to advancing scientific inquiry were essential to the successful completion of this work. Furthermore, we express our appreciation to the editorial team of the journal for considering this article for review. Your dedication to ensuring the quality and relevance of academic publications is greatly valued.

  • References

  • 1 Habr-Gama A, Perez RO, Nadalin W. et al. Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg 2005; 9: 90-99
    CrossrefPubMedSearch in Google Scholar
  • 2 Cotti GC, Pandini RV, Braghiroli OFM. et al. Outcomes of Patients With Local Regrowth After Nonoperative Management of Rectal Cancer After Neoadjuvant Chemoradiotherapy. Dis Colon Rectum 2022; 65: 333-339
    CrossrefPubMedSearch in Google Scholar
  • 3 Nahas SC, Nahas CSR, Cama GM. et al. Diagnostic performance of magnetic resonance to assess treatment response after neoadjuvant therapy in patients with locally advanced rectal cancer. Abdom Radiol (NY) 2019; 44: 3632-3640
    CrossrefPubMedSearch in Google Scholar
  • 4 Cannizzaro R, Mongiat M, Canzonieri V. et al. Endomicroscopy and cancer: a new approach to the visualization of neoangiogenesis. Gastroenterol Res Pract 2012; 2012: 537170
    CrossrefPubMedSearch in Google Scholar
  • 5 Safatle-Ribeiro AV, Ribeiro Jr, Lata J. et al. The Role of Probe-Based Confocal Laser Endomicroscopy (pCLE) in the Diagnosis of Sustained Clinical Complete Response Under Watch-and-Wait Strategy After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Adenocarcinoma: a Score Validation. J Gastrointest Surg 2023; 27: 357-368
    CrossrefPubMedSearch in Google Scholar

Correspondence

Ana Victória Martins Lima, MD, PhD
Endoscopy Fellowship, Instituto do Câncer do Estado de São Paulo, University of São Paulo
Avenida Dr. Arnaldo, 251
01219-010 São Paulo
Brazil   

Publication History

Article published online:
13 June 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

  • References

  • 1 Habr-Gama A, Perez RO, Nadalin W. et al. Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg 2005; 9: 90-99
    CrossrefPubMedSearch in Google Scholar
  • 2 Cotti GC, Pandini RV, Braghiroli OFM. et al. Outcomes of Patients With Local Regrowth After Nonoperative Management of Rectal Cancer After Neoadjuvant Chemoradiotherapy. Dis Colon Rectum 2022; 65: 333-339
    CrossrefPubMedSearch in Google Scholar
  • 3 Nahas SC, Nahas CSR, Cama GM. et al. Diagnostic performance of magnetic resonance to assess treatment response after neoadjuvant therapy in patients with locally advanced rectal cancer. Abdom Radiol (NY) 2019; 44: 3632-3640
    CrossrefPubMedSearch in Google Scholar
  • 4 Cannizzaro R, Mongiat M, Canzonieri V. et al. Endomicroscopy and cancer: a new approach to the visualization of neoangiogenesis. Gastroenterol Res Pract 2012; 2012: 537170
    CrossrefPubMedSearch in Google Scholar
  • 5 Safatle-Ribeiro AV, Ribeiro Jr, Lata J. et al. The Role of Probe-Based Confocal Laser Endomicroscopy (pCLE) in the Diagnosis of Sustained Clinical Complete Response Under Watch-and-Wait Strategy After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Adenocarcinoma: a Score Validation. J Gastrointest Surg 2023; 27: 357-368
    CrossrefPubMedSearch in Google Scholar

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Zoom
Fig. 1 Infiltrative lesion in the distal rectum confirmed it as moderately differentiated infiltrative adenocarcinoma.
Zoom
Fig. 2 Scar identified on rectoscopy after neoadjuvant chemoradiotherapy treatment evaluated using a white-light imaging combined with b narrow-band imaging.
Zoom
Fig. 3 Epithelial and vascular abnormalities suggestive of a residual neoplastic lesion were identified using pCLE. a Probe positioned over the scar. b Irregular crypts along with thick and dark epithelium. c Back-to-back glands. d Dilated and tortuous vessels. Abbreviation: pCLE, probe-based confocal laser endomicroscopy.
Zoom
Fig. 4 Specimen obtained through TEO confirmed a curative resection. Abbreviation: TEO, transanal endoscopic operation.