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Application of OCT in the Gastrointestinal Tract

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Application of OCT in the Gastrointestinal Tract applied sciences Review Application of OCT in the Gastrointestinal Tract Nicholas S. Samel 1 and Hiroshi Mashimo 2,* 1 Dartmouth College, Hanover, NH 02090, USA 2 VA Boston Healthcare System, Harvard Medical School, West Roxbury, MA 02132, USA * Correspondence: [email protected] Received: 12 July 2019; Accepted: 22 July 2019; Published: 25 July 2019 Abstract: Optical coherence tomography (OCT) is uniquely poised for advanced imaging in the gastrointestinal (GI) tract as it allows real-time, subsurface and wide-field evaluation at near-microscopic resolution, which may improve the current limitations or even obviate the need of superficial random biopsies in the surveillance of early neoplasias in the near future. OCT’s greatest impact so far in the GI tract has been in the study of the tubular esophagus owing to its accessibility, less bends and folds and allowance of balloon employment with optimal contact to aid circumferential imaging. Moreover, given the alarming rise in the incidence of Barrett’s esophagus and its progression to adenocarcinoma in the U.S., OCT has helped identify pathological features that may guide future therapy and follow-up strategy. This review will explore the current uses of OCT in the gastrointestinal tract and future directions, particularly with non-endoscopic office-based capsule OCT and the use of artificial intelligence to aid in diagnoses. Keywords: gastrointestinal imaging; optical coherence tomography; Barrett’s esophagus; artificial intelligence 1. Introduction Diagnostic imaging of the gastrointestinal (GI) tract has long relied on white-light endoscopy (WLE) for the detection of mucosal abnormalities such as neoplasias, vascular deformities, and inflammatory conditions. While WLE is a clinical standard for GI imaging and cancer detection, it remains far from ideal. A standard colonoscopy can miss up to 40% of adenomas [1,2] and despite improvements to increase mucosal visualization [3], miss rates are still concerning, especially for flat lesions such as sessile serrated adenomas [4]. While part of the suboptimal detection can be attributed to patients’ inadequate preparatory colonic lavage, WLE’s limited field of view (FOV) and time-consuming mucosal inspection during endoscope withdrawal are additional limiting factors [3]. Since the survival rate from GI cancers can be improved by 5 to 10-fold if diagnosed at an early stage [5], there is an obvious need to improve detection of early GI neoplasias. Advanced imaging in the GI tract can be broadly divided into surface and subsurface modalities. Surface imaging includes chromoendoscopy [6], virtual chromoendoscopy [7], magnification endoscopy and endocytoscopy [8], and autofluorescence imaging [9]. There have been tremendous improvements in the resolution, field of view (FOV), and methods of surface imaging, such as improving contrast in magnification endoscopy and using selected wavelengths (Narrow Band Imaging, NBI) or digital enhancements such as flexible spectral imaging color enhancement (FICE; Fujinon Inc, Saitama, Japan). However, these modalities are limited to superficial lesions and improved magnification generally comes at the cost of restricted FOV, which makes screening and surveillance for multi-focal lesions more difficult. On the other hand, subsurface imaging, which includes endoscopic ultrasonography [10], confocal endomicroscopy [11], and OCT, allows for visualization of structures not feasible with most endoscopes. Appl. Sci. 2019, 9, 2991; doi:10.3390/app9152991 www.mdpi.com/journal/applsci Appl. Sci. 2019, 9, 2991 2 of 16 Appl. Sci. 2019, 9, x FOR PEER REVIEW 2 of 16 Ofmicroscopic these technologies, resolution OCTwith isvolumetric a uniquely and poised subsurface imaging real-time modality, imaging combining capabilities nearly microscopic [12]. These resolutioncharacteristics with position volumetric OCT and to subsurface solve many real-time of the imaging weaknesses capabilities of the [ 12other]. These GI characteristicstract imaging positiontechniques. OCT This tosolve review many will of explore the weaknesses some of ofthe the recent other advances GI tract imaging of OCT techniques.in GI applications This review and willdescribe explore the somefuture of potential the recent for advances OCT to of incorp OCTorate in GI applicationspurpose-build and probe describe designs the futureand computer- potential foraided OCT diagnosis to incorporate techniques purpose-build [12]. probe designs and computer-aided diagnosis techniques [12]. 2. Evolving OCT Technology Briefly,Briefly, the working principle principle of of OCT OCT is is analogous analogous to to that that of of an an ultrasound, ultrasound, with with analysis analysis of ofreflected reflected light light rather rather than than sound sound waves. waves. An An optical optical ranging ranging technique technique called called low coherencecoherence interferometryinterferometry [[13,14]13,14] usesuses aa MichelsonMichelson interferometerinterferometer to measuremeasure thethe timetime delaydelay andand subsequentsubsequent signal intensityintensity ofof lightlight reflected reflected from from a a tissue tissue sample. sample. Since Since its firstits first publication publication in the in earlythe early 1990s 1990s [15], endoscopic[15], endoscopic OCT OCT techniques techniques [16] and [16] applications and applications have have become become major major areas areas of research of research [17–20 [17–20].]. OCT cancan bebe broadlybroadly divideddivided intointo twotwo types:types: time-domaintime-domain OCTOCT (TD-OCT)(TD-OCT) andand Fourier-domainFourier-domain OCT (FD-OCT). (FD-OCT). They They differ differ in inthat that TD-OCT TD-OCT considers considers each each scan scanindividually individually with a with moving a moving mirror mirror(Figure (Figure1a) [21–23],1a) [ while21–23 ],FD-OCT while FD-OCTapplies a appliesFourier atransform Fourier transformon the detected on the spectrum detected (Figure spectrum 1b) (Figure[24–26].1 b)FD-OCT’s [24–26]. introductionFD-OCT’s introduction in the early in 2000s theearly generated 2000s a generated great increase a great in increaseimaging inspeed imaging and speedsensitivity and of sensitivity OCT [23–26]. of FD-OCT OCT [23 can–26 ].be furthe FD-OCTr divided can beinto further subcategories, divided spectral-domain into subcategories, OCT spectral-domain(SD-OCT) and swept-source OCT (SD-OCT) OCT and (SS-OCT) swept-source [21]. SD-OCT OCT (SS-OCT) uses a spectrometer [21]. SD-OCT with uses a broadband a spectrometer light withsource a broadbandand typically light operates source andat shorter typically wavelength operates ats [27,28]. shorter wavelengthsSS-OCT measures [27,28 interference]. SS-OCT measures spectra interferenceusing a wavelength-swept spectra using a light wavelength-swept source and a photodetector, light source and operating a photodetector, at longer operating wavelengths at longer and wavelengthswith a high imaging and with frequency, a high imaging sometimes frequency, reaching sometimes the MHz reaching region the [29–31]. MHz region Due to [29 its–31 improved]. Due to itstissue improved depth penetration tissue depth at penetration longer wavelengths, at longer wavelengths, SS-OCT is the SS-OCT technology is the of technology choice for of endoscopic choice for endoscopicapplications applications [32,33]. [32,33]. (a) (b) Figure 1.1.(a )( Time-domaina) Time-domain optical optical coherence coherence tomography tomogr (TD-OCT)aphy (TD-OCT) uses low coherence uses low interferometry. coherence Theinterferometry. light source The is split light and source the backscattered is split and the light ba isckscattered captured by light the is detector. captured The by depth the detector. information The isdepth provided information by the is scanned provided reference by the scanned path. Adapted reference from path. Tsai Adapted et al. 2014.from Tsai (b). et Swept-source al. 2014. (b). opticalSwept-source coherence optical tomography coherence (SS-OCT)tomography allows (SS-OCT) 10–200-fold allows faster10–200-fold imaging faster compared imaging to compared TD-OCT. (A)to TD-OCT. Interferometer (A) Interferometer with swept laserwith sourceswept laser and beamsource splitter and beam and splitter path di ffanderence pathD differenceL. (B) Time Δ delayL. (B) ofTime light delay from of sample light (dotted)from sample and reference(dotted) lightand (dashed).reference light (C) Interference (dashed). (C signal) Interference proportional signal to delay.proportional (D) Fourier to delay. transform (D) Fourier of the interference transform signalof the measuresinterferenceDL. signal Figure measures and caption ΔL. adapted Figure fromand Tsaicaption et al. adapted 2014. from Tsai et al. 2014. DiDifferentfferent imagingimaging probe designs allow didifferentfferent perspectives for acquisition of OCT images. Side-viewing probesprobes areare thethe most common inin endoscopicendoscopic OCT applications duedue to their large luminal surface area coverage [[12].12]. Different Different forms of side-viewingside-viewing probe delivery includeinclude the small diameter flexibleflexible sheathsheath [ 16[16],], large large diameter diameter inflatable inflatable balloon balloon [34 ][34] and and rigid rigid housing housing [35]. An[35]. introductory An introductory video video demonstrating imaging in the gastrointestinal tract using a probe-based OCT is available [36]. Small diameter flexible sheath, also called “optical biopsy,” is excellent for obtaining high-speed Appl. Sci. 2019, 9, 2991 3 of 16 demonstrating
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