Diagnosis of Pancreatic Cystic Lesions by Virtual Slicing: Comparison of Diagnostic Potential of Needle-Based Confocal Laser Endomicroscopy versus Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Abstract

Background:Pancreatic cystic lesions are often challenging entities for diagnosis and management. EUS-FNA diagnostic accuracy is limited by paucicellularity of cytology specimens and sampling errors. Needle-based confocal laser endomicroscopy (nCLE) provides real-time imaging of the microscopic structure of the cystic lesion and could result in a more accurate diagnosis.Aims and Objectives:To determine the diagnostic utility of in vivo nCLE and EUS-FNA in the diagnosis and histologic characterization of pancreatic cystic lesions (PCL).Materials and Methods:All patients diagnosed with PCL who had undergone nCLE and FNA over a 10-year period within a major urban teaching hospital were included in this study. All gastroenterology reports of the nCLE images and corresponding pathologist findings from the EUS-FNA were collected and compared with, a final diagnosis prospectively collected from clinicopathological and imaging data.Results:A total of n=32 patients were included in this study, which consisted of n=13 serous cystadenoma (SCA), n=7 intraductal papillary mucinous neoplasms (IPMN), n=2 mucinous cystic neoplasms (MCN), n=3 well-differentiated neuroendocrine tumors, n=2 cysts, n=2 benign pancreatic lesions, n=1 adenocarcinoma, n=1 gastrointestinal stromal tumor (GIST) and n=1 lymphangioma. The overall diagnostic rate was higher in nCLE (87.5%) vs. EUS-FNA (71.9%) While the diagnostic accuracy of nCLE and EUS-FNA were comparable in characterization of benign vs. malignant lesions, the nCLE diagnosis demonstrated higher accuracy rate in identifying mucinous cystic neoplasms compared to EUS-FNA.Conclusion:nCLE is a useful companion diagnostic tool for pancreatic cystic lesions and could assist the cytopathologist to better triage the sample for required ancillary testing and treatment planning. The combination of nCLE and EUS-FNA may be especially helpful in reducing the proportion of cases categorized as non-diagnostic.

The diagnostic role of endoscopic ultrasonography, magnetic resonance imaging and computed tomography in the assessment of pancreatic cystic lesions

“…In the present study, the most common location of PCs was the pancreatic head (32.6%). Similarly as in most studies, the most common localization was the pancreatic head which this rate reaches up to 63% [6,10,14] .…”

Efficacy of EUS-guided needle-based confocal laser endomicroscopy in the diagnosis of pancreatic lesions: A systematic review and meta-analysis

“…There were two studies which evaluated SPLs,[ 25 37 ] whereas the other studies evaluated PCLs. [ 20 21 24 26 27 28 29 30 38 ] EUS FNA has had high rates of false-negative or inadequate specimens reported in some studies; nCLE can aid in improving sensitivity and specificity for the diagnosis of pancreatic lesions. [ 46 47 48 ] However, high cost, the necessity of physician training for nCLE interpretation and variable interobserver agreement limit the use of this technology.…”

“…Future studies should evaluate nCLE as an adjunct with EUS FNA or some other modality such as through the needle microforceps biopsy or cystoscopy as a few studies have demonstrated with promising results. [ 21 28 30 38 ]…”

Risk Stratification of Pancreatic Cysts With Confocal Laser Endomicroscopy

“…The combination of nCLE with EUS-FNA provides an almost perfect diagnostic test for PC with sensitivity, specificity, and positive and negative predictive values approaching 100%. 40 Two retrospective studies have looked at the impact of nCLE in the management of PC. Both studied solitary cysts, and the overall change in management of patients was 28% and 43%.…”