welcome to cap’s “ivm” webinar series sponsored by the · esophagus stomach 500 µm 1 cm 500...

© 2012 College of American Pathologists. All rights reserved. 1

Welcome to CAP’s “IVM” Webinar Series sponsored by the

Personalized Health Care Committee

This webinar on “In Vivo Microscopy” is presented by

Guillermo (Gary) Tearney, MD, PhD.

Your host is Jill Kaufman, PhD. For comments about this

webinar or suggestions for upcoming

webinars, please contact Jill Kaufman at

[email protected]

THE WEBINAR WILL BEGIN MOMENTARILY. ENJOY!

mailto:[email protected]

cap.org v. #

In Vivo Microscopy Guillermo (Gary) Tearney, MD, PhD

September 11, 2013

Place sub-brand

here

http://capnet/group1/communications-toolkit/cap-image-library/Laboratory Images/LAB_horizontal/LAB_H_computercellimages.png/image_view_fullscreen

3 © 2012 College of American Pathologists. All rights reserved.

Guillermo (Gary) Tearney, MD, PhD

• PhD in Electrical Engineering (MIT)

• MGH Pathologist

• Pioneer in IVM technology

development and clinical

validation

• Vice-chair of IVM Work Group

Disclaimer


The College does not permit reproduction of any substantial

portion of the material in this Webinar without its written

authorization. The College hereby authorizes attendees of the

CAP Webinar to use the PDF presentation solely for

educational purposes within their own institutions. The College

prohibits use of the material in the Webinar – and any

unauthorized use of the College’s name or logo – in

connection with promotional efforts by marketers of laboratory

equipment, reagents, materials, or services.

Opinions expressed by the speaker are the speaker’s own and

do not necessarily reflect an endorsement by CAP of any

organizations, equipment, reagents, materials or services used by participating laboratories.

Disclosure

• Dr. Tearney has the following financial relationships

with commercial interests to disclose:

• Consulting

- Ninepoint Medical, Samsung, Merck

• Sponsored research

- Canon, Ninepoint Medical, Samsung, iLumen, Air

Liquide, Merck

• Royalties

- Ninepoint Medical, Terumo, MIT


In Vivo Microscopy (IVM)

Definition of IVM:

• A new field where microscopic images are

obtained in real time from living patients

- Technologies currently use light

- Images may be rapidly acquired in 2D and 3D

- Images may be obtained using instrumentation

that can be inserted into endoscope accessory

ports or as standalone imaging tools

Goals of IVM

• Guide the acquisition of targeted and more

meaningful biopsies

• Screen entire organs for occult microscopic disease

• Obtain microscopic diagnoses when tissues cannot

be easily or safely excised

• Assess the efficacy of therapy

Technologies

Commercially available and FDA-approved

• Optical coherence tomography (OCT)

• Confocal microscopy

- Confocal laser endomicroscopy (CLE)

• Volume laser endomicroscopy (VLE)

Many other technologies used in research

Material costs (estimates)

• Equipment: ~$50K-$250K

• Endoluminal probes: ~$100-$1000/use

Optical Coherence Tomography (OCT)

• Enables visualization of microscopic tissue

architectural morphology

• Analogous to ultrasound, but uses light to achieve

higher resolution

• Provides cross-sectional and 3D images

• 10 µm resolution in depth

• 30-40 µm resolution in plane parallel to surface of

tissue

• Contrast arises from scattering within tissue

• Example: OCT cross-sectional OCT image of

entire esophagus Epithelium

Lamina propria

Submucosa

Muscularis

propria

Layered architecture

OCT

• Example: OCT image of Barrett’s esophagus with

high grade dysplasia

OCT (in vivo) Histology

• Arrows point to atypical glands in the mucosa


Capsule IVM

Capsule

Optics

Tether

esophagus

stomach

500 µm

1 cm

500 µm

Normal

Volunteer

• Examples: OCT images of

coronary arteries in vivo

In-stent restenosis

Thin-cap fibroatheroma

Plaque rupture

Confocal Microscopy

• Enables visualization of microscopic tissue

architectural and cellular morphology

• Provides 2D images in plane parallel to tissue

surface (en face)

• 1-2 µm resolution

• 10 µm resolution in depth

• Contrast arises from scattering within tissue or from

Fluorescein injected i.v.

Confocal Laser Endomicroscopy (CLE)

Endoscopic microscopy – microscopy through an

endoscope

Multiple forms:

• Probe-based CLE (pCLE)

• Endoscope-based CLE (eCLE)

• Needle-based CLE (nCLE)

- Probe inserted through the bore of a biopsy

needle

pCLE

Examples

Barrett’s No Dysplasia Barrett’s High-grade/IMC

eCLE

Histology image IVM image (in vivo)

Example

Kiesslich CGH,2006;4:979

Balloon Insertion 3D OCT IVM Dataset

Identify Suspect Areas

Mark Suspect Areas

Biopsy at Marks Histopathology

Guided Biopsy Paradigm

21

Organ System In Vivo Microscopy

Now 3–5 Years 7–10 years

GI Clinical

Procedures Standard of Care Standard of Care

Cardiovascular Clinical

Procedures Standard of Care Standard of Care

Lung Clinical Trials Clinical Procedures Standard of Care

Skin Clinical

Procedures Clinical Procedures Standard of Care

Breast Research Clinical Trials Clinical

Procedures

© 2012 College of American Pathologists. All rights reserved.

IVM Application Areas and Timeline

Some Potential Case Use

Scenarios

• In vivo

- Real-time diagnosis

• in the endoscopy or interventional suite (pathologist present during the procedure)

• at remote site (images transmitted to a pathologist viewing workstation)

- Regular signout

• pathologist views images off-line after procedure is performed

• Ex vivo • Adequacy of needle biopsy

• Pathologist uses equipment and renders diagnosis in real time as intraoperative consult

• Pathologist uses equipment to guide tissue section sampling in grossing room

CPT Codes and Reimbursement

• CPT 43206 Esophageal Optical Endomicroscopy

• CPT 43252 Upper GI Optical Endomicroscopy- Both of these codes for upper GI procedures have been assigned to APC 419 for Hospital Outpatient Facility Reimbursement.

• CPT 88375 Optical Endomicroscopy InterpretationThis code, intended for the pathologist, has been assigned to APC 0342 for Hospital Outpatient Facility Reimbursement.

• CPT 0291T, 0292T Intravascular OCT (carrier priced)

Pathologist

Interpretation

Getting Involved with IVM

• CAP Resource Guide

• CAP Atlas (coming soon)

• Multidisciplinary collaborations between

pathologists and medical subspecialists

- Contact local pathologists who are experts in

reading microscopic images and can help set up

and integrate these technologies into patient

care work flow

• This guide was created to assist pathologists who

are considering providing or developing in vivo

microscopy skills and services within the next 24

months.

• The In Vivo Microscopy Resource Guide is free for

members and is available via registration on the

Member tab of www.cap.org.

CAP’s Pathology IVM Resource Guide


http://www.cap.org/



Table of Contents

Section 1 In Vivo Microscopy: The Basics

1.1 Background (5)

1.2 In Vivo Microscopy and Pathology (4)

1.3 Hot Topics: IVM in the News (2)

Section 2 Understanding IVM Technology

2.1 In Vivo Microscopy Technologies (2)

2.2 Confocal Microscopy (4)

2.3 Optical Coherence Tomography (13)

2.4 Multiphoton Microscopy (5)

2.5 Optical Spectroscopy and Spectroscopic Imaging (3)

Section 3 Insights from Early Adopters

3.1 Guillermo (Gary) J. Tearney

3.2 Maryann Fitzmaurice

Section 4 Applications of Ex Vivo Microscopy (5)

4.1 Surgical Margins for Resection

4.2 Sentinel Lymph Nodes

4.3 Surgical Specimen Sampling

4.4 Virtual Histology


Section 5 Applications of In Vivo Microscopy

5.1 Gastrointestinal Tract (28) 5.1.1 Pancreas/Biliary

5.1.2 Other

5.2 Breast

5.3 Dermatology 5.4 Cardiovascular

5.5 Lung

5.6 Genitourinary

5.7 Gynecologic 5.8 Neurology

5.9 Eye

Section 6 Current Standards of Validation

Section 7 IVM Billing/Reimbursement


Table of Contents Continued


Table of Contents Continued


Section 8 Industry Education Resources

8.1 Industry Conferences

8.2 Biomedical Optics Education Resources

Section 9 CAP In Vivo Microscopy Education Resources

9.1 Webinars

9.1.1 Upcoming Webinars

9.1.2 Archived IVM Webinars

9.2 CAP Annual Conference

9.3 Pathologists Speaking on IVM at Other Conferences

9.3.1 Upcoming Conferences

9.3.2 Prior conferences in 2013

9.4 CAP IVM Information Flyers

9.4.1 Why IVM?

9.4.2 Barrettes 9.4.3 Other if more 9.5 IVM POET Report

Save the Date for These Upcoming

FREE IVM Webinars or Listen to past Webinars


• Upcoming Webinars

o Ex Vivo

Date To Be Determined (November)

o Richard M. Levenson, MD

• Archived Webinars

o Chapter 7 from CAP eBook: New Paths...New Choices: Pathology in

an Era of Advancing Science and Disruptive Health Economics

https://www1.gotomeeting.com/register/215812001

Register for upcoming or the archived webinars by going to

cap.org/webinars

https://www1.gotomeeting.com/register/215812001

http://www.cap.org/webinars

The CAP has created the Pathology Resource Guides, a new tool to

assist pathologists in understanding key emerging technologies. These

Resource Guides are a new CAP member benefit available at no

charge.

Molecular Diagnostic (single gene, small panel)

Genomic Analysis (large panels, exome, genome)

Digital Pathology

Register through the CAP member tab. You will receive periodic

updates for two years.

Questions? Contact [email protected].

Other CAP’s Pathology Resource Guides


https://www.cap.org/apps/cap.portal?_nfpb=true&_pageLabel=membership


• Pathology SPECs are:

o Prewritten PowerPoint presentation on emerging topics where molecular testing

plays a key role in patient management.

o Designed for pathologists to customize and use for educating other physicians and health care leaders in their communities; e.g. tumor boards, grand rounds

o Focused on molecular tests that are actionable to patient care today.

• Now Available:

― New- Emerging Concepts in Molecular Testing in Breast Cancer

― Emerging Concepts in the Workup of Colorectal Cancer

― Emerging Concepts in Therapeutic Guidance for Metastatic Melanoma

― Emerging Concepts in the Diagnosis and Workup of Thyroid Cancer

― Emerging Concepts in Colorectal Cancer Hereditary Non-Polyposis Cancer (Lynch Syndrome)

― Emerging Concepts in the Workup of Polycythemia and Thrombocythemia: JAK2

• To register, go to the CAP Member tab on cap.org. You do not need to be a member to utilize this free tool.

A CAP Tool- Short Presentations On Emerging

Concepts (SPECs)




• CAPconnect is a professional community for CAP

members. It offers:

o Networking

o Getting insights and feedback from peers

o Accessing CAP resources

o Keeping informed on professional issues

o ** NOTE there is a discussion group on IVM!

Join the community now by going to

capconnect.cap.org and signing up! © 2013 College of American Pathologists. All rights reserved. 32

http://community.cap.org/wp-login.php?redirect_to=http://community.cap.org/

THANK YOU!

Thank you for attending our webinar

“IVM” by

Guillermo (Gary) Tearney, MD, PhD.

For comments about this webinar

or suggestions for upcoming

webinars, please contact

Jill Kaufman, PhD,

Director of Personalized Health Care at [email protected]

NOTE: There is no CME/CE credit available for

today’s free webinar.

34


welcome to cap’s “ivm” webinar series sponsored by the · esophagus stomach 500 µm 1 cm 500...

Documents