Original article
Clinical endoscopy
Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study

https://doi.org/10.1016/j.gie.2014.10.025Get rights and content

Background

The diagnosis of pancreatic cystic neoplasms (PCNs), which now depends on morphology, cytology, and fluid analysis, is still challenging. A novel confocal laser endomicroscopy probe that can be inserted through a 19-gauge FNA needle allows needle-based confocal laser endomicroscopy (nCLE), and the feasibility of nCLE has been reported in PCNs. The combination of cystoscopy by using a through-the-needle fiberoptic probe in combination with nCLE under EUS guidance may improve the diagnosis of PCNs.

Objective

To assess the feasibility, safety, and diagnostic yield of the combination of cystoscopy and nCLE in the clinical diagnosis of PCNs.

Design

A prospective feasibility study.

Setting

An academic tertiary referral center.

Patients

Thirty patients with PCNs.

Interventions

EUS-guided dual through-the-needle imaging (cystoscopy and nCLE) for PCNs.

Main Outcome Measurements

Technical feasibility and safety. Associations of cystoscopy and nCLE findings with clinical diagnosis of PCNs.

Results

The procedure was technically successful with the exception of 1 probe exchange failure. In 2 patients (7%), postprocedure pancreatitis developed. Specific features associated with the clinical diagnosis of mucinous cysts were identified: mucin on cystoscopy and papillary projections and dark rings on nCLE. The sensitivity of cystoscopy was 90% (9/10), and that of nCLE was 80% (8/10), and the combination was 100% (10/10) in 18 high-certainty patients.

Limitations

A single-center study and lack of complete pathologic correlation.

Conclusion

The combination of dual through-the-needle imaging (cystoscopy and nCLE) of pancreatic cysts appears to have strong concordance with the clinical diagnosis of PCN. (Clinical trial registration number: NCT01447238.)

Section snippets

Patients

Patients presenting at the University of California, Irvine Medical Center for EUS-guided FNA for the evaluation of pancreatic cysts were enrolled. Inclusion criteria included patients older than 18 years of age with a pancreatic cyst identified on previous imaging. Exclusion criteria included patients who have a contraindication to undergoing EUS-guided FNA such as medically unstable patients, severe coagulopathy, poor visualization on EUS for various reasons, pregnancy or breast-feeding,

Patient characteristics

Between October 2010 and May 2012, 30 patients were enrolled. Patient and cyst characteristics are shown in Table 1. The median cyst size was 30.1 mm. Thirteen of 30 patients had multiple cysts, but EUS-FNA with through-the-needle imaging was performed on the largest cyst. Clinical diagnoses were established with high certainty in 18 patients including 2 who underwent surgical resection with pathologic diagnosis of 1 IPMN and 1 MCN (Fig. 1). Clinical diagnosis in all 30 patients was IPMN (n =

Discussion

The accurate clinical diagnosis of PCN continues to be a conundrum. Our study showed that a combination of through-the needle cystoscopy and nCLE for pancreatic cysts under EUS was feasible, and specific features associated with the clinical diagnosis of mucinous cysts were identified. The sensitivity of cystoscopy in the clinical diagnosis of mucinous cysts was 90%, that of nCLE was 80%, and the combination was 100%.

One of our study limitations was the lack of a true criterion standard

Conclusion

The combination of EUS-guided dual through-the-needle imaging of pancreatic cysts appears to have strong concordance with the clinical diagnosis of PCN. With further confirmational studies, including more pathologic correlation, these modalities may increase our ability to accurately diagnose PCNs and ultimately to help better stratify these patients with respect to their individual risk of malignant progression.

Acknowledgments

We acknowledge Amy Tan, Herlinda Bergman, Mark Shimamoto, and Yuna Chun for their assistance in data collection.

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    DISCLOSURE: The following authors disclosed financial relationships relevant to this article: Dr Samarasena has received honoraria from Mauna Kea Technologies. Dr Lee has received honoraria from Cook Endoscopy and Novartis. Dr Chang is a consultant for Cook Medical and is on the Medical Advisory Board of Mauna Kea Technologies. All other authors disclosed no financial relationships relevant to this publication.

    See CME section; p. 1237.

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