Original article
Pancreas, biliary tract, and liver
Endoscopic Ultrasound-Guided Confocal Laser Endomicroscopy Increases Accuracy of Differentiation of Pancreatic Cystic Lesions

https://doi.org/10.1016/j.cgh.2019.06.010Get rights and content

Background & Aims

Imaging patterns from endoscopic ultrasound (EUS)-guided needle-based confocal laser endomicroscopy (nCLE) have been associated with specific pancreatic cystic lesions (PCLs). We compared the accuracy of EUS with nCLE in differentiating mucinous from nonmucinous PCLs with that of measurement of carcinoembryonic antigen (CEA) and cytology analysis.

Methods

We performed a prospective study of 144 consecutive patients with a suspected PCL (≥20 mm) who underwent EUS with fine-needle aspiration of pancreatic cysts from June 2015 through December 2018 at a single center; 65 patients underwent surgical resection. Surgical samples were analyzed by histology (reference standard). During EUS, the needle with the miniprobe was placed in the cyst, which was analyzed by nCLE. Fluid was aspirated and analyzed for level of CEA and by cytology. We compared the accuracy of nCLE in differentiating mucinous from nonmucinous lesions with that of measurement of CEA and cytology analysis.

Results

The mean size of dominant cysts was 36.4 ± 15.7 mm and the mean duration of nCLE imaging was 7.3 ± 2.8 min. Among the 65 subjects with surgically resected cysts analyzed histologically, 86.1% had at least 1 worrisome feature based on the 2012 Fukuoka criteria. Measurement of CEA and cytology analysis identified mucinous PCLs with 74% sensitivity, 61% specificity, and 71% accuracy. EUS with nCLE identified mucinous PCLs with 98% sensitivity, 94% specificity, and 97% accuracy. nCLE was more accurate in classifying mucinous vs nonmucinous cysts than the standard method (P < .001). The overall incidence of postprocedure acute pancreatitis was 3.5% (5 of 144); all episodes were mild, based on the revised Atlanta criteria.

Conclusions

In a prospective study, we found that analysis of cysts by nCLE identified mucinous cysts with greater accuracy than measurement of CEA and cytology analysis. EUS with nCLE can be used to differentiate mucinous from nonmucinous PCLs. ClincialTrials.gov no: NCT02516488.

Section snippets

Methods

The Ohio State University Wexner Medical Center Institutional Review Board approved this prospective study. All authors had access to the study data and reviewed and approved the final manuscript.

Subjects were referred for EUS–fine-needle aspiration (FNA) based on the treating physician and current guidelines for managing PCLs.1 The Comparison of Confocal Laser Endomicroscopy IN vivo Diagnosis and EX vivo (INDEX) Study was performed during a 3.5-year study period from June 1, 2015, to December

Cohort Characteristics

As shown in Figure 1, EUS-nCLE was performed in 144 subjects. The mean age of all subjects who underwent EUS-nCLE was 60.2 years (SD, 14.3 y), the mean size of the dominant cyst was 36.4 mm (SD, 15.7 mm), and the mean duration of EUS-nCLE image acquisition was 7.3 minutes (SD, 2.8 min). Other characteristics of this cohort are shown in Supplementary Table 3.

Comparison of Mucinous and Nonmucinous Pancreatic Cystic Lesions

Among subjects with surgical histopathology (n = 65), univariate analysis (Table 1) showed that patients with mucinous PCLs were older,

Discussion

The management of PCLs is challenging with increasing incidental detection of PCLs, divergent management guidelines, and lack of optimal diagnostics used in the current standard of care. This is problematic for the accurate classification of mucinous vs nonmucinous PCLs. In this report of the INDEX study, which comprises a large number of subjects who underwent EUS-nCLE and surgical resection of PCLs, we show that specific endomicroscopy image patterns have higher diagnostic accuracy for

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    Conflicts of interest The authors disclose no conflicts.

    Funding This study was funded by an American College of Gastroenterology Clinical Research grant.

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