Impact of needle-based confocal laser endomicroscopy on the therapeutic management of single pancreatic cystic lesions

Abstract

Background and aim The diagnosis and therapeutic management of large single pancreatic cystic lesions (PCLs) represent major issues for clinicians and essentially rely on endoscopic ultrasound fine-needle aspiration (EUS-FNA) findings. Needlebased confocal laser endomicroscopy (nCLE) has high diagnostic performance for PCLs. This study aimed to evaluate the impact of nCLE on the therapeutic management of patients with single PCLs. Methods Retrospective and comparative study. Five independent pancreatic disease experts from tertiary hospitals independently reviewed data from a prospective database of 206 patients with single PCL, larger than 2 cm and who underwent EUS-FNA and nCLE. Two evaluations were performed. The first one included the sequential review of clinical information, EUS report and FNA results. The second one included the same data + nCLE report. Participants had to propose a therapeutic management for each case. Results The addition of nCLE to EUS-FNA led to significant changes in therapeutic management for 28% of the patients (p < 0.001). nCLE significantly increased the interobserver agreement of 0.28 (p < 0.0001), from 0.36 (CI 95% 0.33-0.49) to 0.64 (CI 95% 0.61-0.67). nCLE improved the rates of full agreement among the five experts of 24% (p < 0.0001), from 30 to 54%. With nCLE, the surveillance rate of benign SCAs fell by 35%, from 40 (28/70) to 5% (4/76). Conclusion The addition of nCLE to EUS-FNA significantly improves reliability of PCL diagnosis and could impact the therapeutic management of patients with single PCLs. ClinicalTrials.gov number, NCT01563133.Keywords EUS-FNA · Pancreatic cysts · Needle-based confocal laser endomicroscopy Abbreviations BD-IPMN Branch duct-intraductal papillary mucinous neoplasm CT Computed tomography CEA Carcinoembryonic antigen EUS-FNA Endoscopic ultrasound fine-needle aspiration IML Indeterminate mucinous lesion MCN Mucinous cystic neoplasm MRI Magnetic resonance imaging nCLE Needle-based confocal laser endomicroscopy NEN Neuroendocrine neoplasm PC Pseudocyst PCLs Pancreatic cystic lesions SCA Serous cystadenoma The therapeutic management of pancreatic cystic lesions (PCL) depends on the cyst type. Surveillance or surgical and Other Interventional TechniquesPublisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The Role of Needle-Based Confocal Laser Endomicroscopy in the Evaluation of Pancreatic Cystic Lesions: A Systematic Review

“…Palazzo et al [ 30 ] reported similar findings of a retrospective analysis of 209 cases. The addition of nCLE to EUS-FNA led to substantial changes in management for 28% of patients in the study ( p <0.001).…”

EUS-guided confocal laser endomicroscopy: Can we use thick and wide for diagnosis of early cancer?

“…They also reported that with nCLE, the surveillance rate of benign serous cystic adenomas fell by 35%, from 40%. 8 Further studies using a larger cohort of patients with PCLs to validate these findings are needed. Research and technologic developments involving nCLE probes compatible with a 22-gauge needle would provide a larger area of in vivo sampling and effectively permit an increase of the total PCL surface area visualized during the procedure.…”

Pancreatic cystic lesions: time to move to 19-gauge needle with EUS-guided microforceps biopsy or needle-based confocal laser endomicroscopy

“…The results of MFB, nCLE, or their combination changed management in 38.6%, 43.2%, and 52.3% of cases, respectively.EUS-guided microforceps biopsy and nCLE have been recently introduced to evaluate PCLs, such as large unilocular/oligocystic lesions apparently not communicating with the main pancreatic ductal system and intraductal papillary mucinous neoplasms with worrisome features, 2 where cystic fluid analysis has proven to be of limited value. 3 Recent studies have reported an excellent diagnostic performance for both techniques, 4,5 and the impact of nCLE on management has been pointed out. 5 Nevertheless, adverse events (AEs) and additional costs should be considered to select those patients who really need these investigations.…”

“…3 Recent studies have reported an excellent diagnostic performance for both techniques, 4,5 and the impact of nCLE on management has been pointed out. 5 Nevertheless, adverse events (AEs) and additional costs should be considered to select those patients who really need these investigations.…”

“…That is not in line with the largest prospective multicenter trials that reported higher risk of acute pancreatitis or bleeding, especially after MFB. 4,5 Because of the increased risk related to the performance of both MFB and nCLE, the selection of patients to undergo these tests should be accurate, thus excluding those in whom clinical history and/or imaging modalities strongly favor one diagnosis over the others. Indeed, in the present study, 7 patients had a history of acute or chronic pancreatitis, which, even thought to be remote, pointed toward a diagnosis of pseudocyst (6 identified by MFB).…”