Recent advances in the diagnostic evaluation of pancreatic cystic lesions

Abstract

Pancreatic cystic lesions (PCLs) are becoming more prevalent due to more frequent abdominal imaging and the increasing age of the general population. It has become crucial to identify these PCLs and subsequently risk stratify them to guide management. Given the high morbidity associated with pancreatic surgery, only those PCLs at high risk for malignancy should undergo such treatment. However, current diagnostic testing is suboptimal at accurately diagnosing and risk stratifying PCLs. Therefore, research has focused on developing new techniques for differentiating mucinous from non-mucinous PCLs and identifying high risk lesions for malignancy. Cross sectional imaging radiomics can potentially improve the predictive accuracy of primary risk stratification of PCLs at the time of detection to guide invasive testing. While cyst fluid glucose has reemerged as a potential biomarker, cyst fluid molecular markers have improved accuracy for identifying specific types of PCLs. Endoscopic ultrasound guided approaches such as confocal laser endomicroscopy and through the needle microforceps biopsy have shown a good correlation with histopathological findings and are evolving techniques for identifying and risk stratifying PCLs. While most of these recent diagnostics are only practiced at selective tertiary care centers, they hold a promise that management of PCLs will only get better in the future.

Needle Tract Seeding after Endoscopic Ultrasound Tissue Acquisition of Pancreatic Lesions: A Systematic Review and Meta-Analysis

“…While EUS-FNA may still play a competitive role as compared to EUS-FNB when rapid-on-site cytological evaluation (ROSE) is available, EUS-FNB was found to overperform standard FNA for tissue sampling of several solid lesions in the absence of a pathologist in the endoscopic room [ 3 , 4 , 5 , 6 ]. Moreover, in spite of the favorable diagnostic outcomes of EUS through-the-needle biopsy (TTNB) and confocal laser endomicroscopy (CLE), EUS-FNA is still frequently used in the diagnostic algorithm of cystic pancreatic lesions (PCLs) [ 7 , 8 , 9 ]. Although uncommon, one potential and serious complication of EUS-TA is needle tract seeding (NTS) [ 10 ].…”

Pancreatic Cystic Lesions: A Focused Review on Cyst Clinicopathological Features and Advanced Diagnostics

“…Standard of care analysis of the cyst fluid (CEA, amylase, glucose, and cytology) improve the differentiation of PCLs. EUS-FNA of cyst fluid with molecular analysis and nCLE for in vivo endomicroscopy, when indicated (generally PCLs ≥ 2 cm diameter), collectively approach a high (>90%) accuracy for the diagnosis and risk stratification of PCLs [2][3][4][5]9,23]. Data sources [1,3,9,13,14,52,66,72].…”

“…In this review, we have described features observed in specific PCLs using two advanced diagnostics (nCLE and cyst fluid NGS). Both techniques can enhance the diagnostic accuracy of cyst type and advanced neoplasia significantly [108], and they may be considered when radiomics and EUS cyst morphology are indicative of a high-risk PCL [2]. However, these advanced diagnostics are only available in limited centers currently, and large prospective studies are needed before incorporation into guidelines.…”

“…Our knowledge of different types of PCLs has grown dramatically in recent years. A multidisciplinary approach using a combination of radiological imaging, endoscopic ultrasound (EUS), cytology, cyst fluid analysis, and molecular profiling is most helpful in diagnosing and risk stratifying PCLs [2][3][4][5]. Despite these advancements, challenges still exist in the appropriate classification of PCLs as benign versus precancerous and accurate risk-stratification of intraductal papillary mucinous neoplasm (IPMNs).…”

Application of Artificial Intelligence in the Management of Pancreatic Cystic Lesions

“…Currently, the two major applications of this technique are diagnosis of cyst type and malignant risk-stratification. Positive cyst fluid cytology is a surgical indication amongst all current guidelines because it is highly specific for lesions harboring advanced neoplasia, although it is of limited sensitivity [ 71 , 72 ] Genomic analysis via NGS of cyst fluid is a well-studied method that lends to improved sensitivity while maintaining high specificity for the diagnosis of mucinous neoplasm and advanced neoplasia. Specifically, the presence of KRAS and GNAS mutations in cyst fluid has enhanced sensitivity and specificity for classifying mucinous lesions when compared with CEA and cytology [ 73 , 74 ].…”