A Review of the Diagnosis and Management of Premalignant Pancreatic Cystic Lesions

Pancreatic cystic lesions are an increasingly common clinical finding. They represent a heterogeneous group of lesions that include two of the three known precursors of pancreatic cancer, intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN). Given that approximately 8% of pancreatic cancers arise from these lesions, careful surveillance and timely surgery offers an opportunity for early curative resection in a disease with a dismal prognosis. This review summarizes the current evidence and guidelines for the diagnosis and management of IPMN/MCN. Current pre-operative diagnostic tests in pancreatic cysts are imperfect and a proportion of patients continue to undergo unnecessary surgical resection annually. Balancing cancer prevention while preventing surgical overtreatment, continues to be challenging when managing pancreatic cysts. Cyst fluid molecular markers, such as KRAS, GNAS, VHL, PIK3CA, SMAD4 and TP53, as well as emerging endoscopic technologies such as needle-based confocal laser endomicroscopy and through the needle microbiopsy forceps demonstrate improved diagnostic accuracy. Differences in management and areas of uncertainty between the guidelines are also discussed, including indications for surgery, surveillance protocols and if and when surveillance can be discontinued.

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The Role of Confocal Endomicroscopy in the Diagnosis and Management of Pancreatic Cysts

European Medical Journal ◽

10.33590/emj/20-00182 ◽

2021 ◽

pp. 41-49

Author(s):

Margaret G Keane ◽

Stephen P Pereira

Keyword(s):

Diagnostic Accuracy ◽

Needle Aspiration ◽

Diagnostic Techniques ◽

Confocal Laser Endomicroscopy ◽

Confocal Laser ◽

Pancreatic Cysts ◽

Cystic Lesions ◽

Cystic Neoplasms ◽

Common Clinical Finding

Pancreatic cystic lesions are an increasingly common clinical finding. Current diagnostic techniques cannot reliably differentiate patients with high-risk lesions requiring surgical resection from those that can be safely surveyed or discharged. As a result, some patients may undergo unnecessary surgery with associated morbidity while others enter long-term surveillance with associated healthcare costs. Needle-based confocal laser endomicroscopy enables real time microscopic examination of the epithelial lining of a cyst wall at the time of a standard endoscopic ultrasound examination. The procedure is associated with low rates of adverse events, especially when the probe is loaded into the fine-needle aspiration needle before the procedure and examination times are limited. Needle-based confocal laser endomicroscopy has consistently been shown to have better diagnostic accuracy than cytology, which is often paucicellular and non-diagnostic in pancreatic cystic lesions. Studies have shown that diagnostic accuracy in needle-based confocal laser endomicroscopy is 84–95% in mucinous lesions and 39–99% in serous lesions. However, this technology is expensive and its place in diagnostic algorithms remains uncertain. Despite this, health economic analyses in certain health systems have been favourable, largely because of its potential to be able to discharge patients with benign lesions, such as serous cystic neoplasms, from long-term surveillance. Widespread adoption of this technology is unlikely but it has the potential to have an important role in indeterminate pancreatic cystic lesions.

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184 - Needle Based Confocal Laser Endomicroscopy: The Impact on Diagnosis and Management of Pancreatic Cystic Lesions

Gastroenterology ◽

10.1016/s0016-5085(18)30627-9 ◽

2018 ◽

Vol 154 (6) ◽

pp. S-47-S-48 ◽

Cited By ~ 1

Author(s):

Maxime Palazzo ◽

Geoffroy Vanbiervliet ◽

Ivan Borbath ◽

Alain Sauvanet ◽

Rodica Gincul ◽

...

Keyword(s):

Confocal Laser Endomicroscopy ◽

Confocal Laser ◽

Cystic Lesions ◽

Diagnosis And Management ◽

The Impact

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Pancreatic Cysts: Pathologic Classification, Differential Diagnosis, and Clinical Implications

Archives of Pathology & Laboratory Medicine ◽

10.5858/133.3.423 ◽

2009 ◽

Vol 133 (3) ◽

pp. 423-438 ◽

Cited By ~ 26

Author(s):

Olca Basturk ◽

Ipek Coban ◽

N. Volkan Adsay

Keyword(s):

Differential Diagnosis ◽

Malignant Potential ◽

Common Finding ◽

Pancreatic Cysts ◽

Pancreatic Ducts ◽

Low Grade ◽

Cystic Lesions ◽

Dismal Prognosis ◽

Cystic Tumors ◽

Pathologic Classification

Abstract Context.—Cystic lesions of the pancreas are being recognized with increasing frequency and have become a more common finding in clinical practice because of the widespread use of advanced imaging modalities and the sharp drop in the mortality rate of pancreatic surgery. Consequently, in the past 2 decades, the nature of many cystic tumors in this organ has been better characterized, and significant developments have taken place in the classification and in our understanding of pancreatic cystic lesions. Objective.—To provide an overview of the current concepts in classification, differential diagnosis, and clinical/biologic behavior of pancreatic cystic tumors. Data Sources.—The authors' personal experience, based on institutional and consultation materials, combined with an analysis of the literature. Conclusions.—In contrast to solid tumors, most of which are invasive ductal adenocarcinomas with dismal prognosis, cystic lesions of the pancreas are often either benign or low-grade indolent neoplasia. However, those that are mucinous, namely, intraductal papillary mucinous neoplasms and mucinous cystic neoplasms, constitute an important category because they have well-established malignant potential, representing an adenoma-carcinoma sequence. Those that are nonmucinous such as serous tumors, congenital cysts, lymphoepithelial cysts, and squamoid cyst of pancreatic ducts have no malignant potential. Only rare nonmucinous cystic tumors that occur as a result of degenerative/necrotic changes in otherwise solid neoplasia, such as cystic ductal adenocarcinomas, cystic pancreatic endocrine neoplasia, and solid-pseudopapillary neoplasm, are also malignant and have variable degrees of aggressiveness.

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Needle-based confocal laser endomicroscopy of pancreatic cystic lesions: a prospective multicenter validation study in patients with definite diagnosis

Endoscopy ◽

10.1055/a-0732-5356 ◽

2018 ◽

Vol 51 (09) ◽

pp. 825-835 ◽

Cited By ~ 21

Author(s):

Bertrand Napoleon ◽

Maxime Palazzo ◽

Anne-Isabelle Lemaistre ◽

Fabrice Caillol ◽

Laurent Palazzo ◽

...

Keyword(s):

Diagnostic Performance ◽

Needle Aspiration ◽

Serous Cystadenoma ◽

Confocal Laser Endomicroscopy ◽

Confocal Laser ◽

Cystic Lesions ◽

Ultrasound Guided ◽

Cystic Fluid ◽

Post Procedure ◽

Mean Size

Abstract Background Needle-based confocal laser endomicroscopy (nCLE) enables observation of the inner wall of pancreatic cystic lesions (PCLs) during an endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). This study prospectively evaluated the diagnostic performance of nCLE for large, single, noncommunicating PCLs using surgical histopathology or EUS-FNA cytohistopathology as a reference diagnosis. Methods From April 2013 to March 2016, consecutive patients referred for EUS-FNA of indeterminate PCLs without evidence of malignancy or chronic pancreatitis were prospectively enrolled at five centers. EUS-FNA and nCLE were performed and cystic fluid was aspirated for cytohistopathological and carcinoembryonic antigen (CEA) analysis. The diagnostic performance of nCLE was assessed against the reference standard and compared with that of EUS and CEA. This study was registered on ClinicalTrials.gov (NCT01563133). Results 206 patients underwent nCLE and 78 PCLs (mean size 40 mm, range 20 – 110 mm) had reference diagnoses (53 premalignant and 25 benign PCLs). Post-procedure pancreatitis occurred in 1.3 % of the patients. nCLE was conclusive in 71 of the 78 cases (91 %). The sensitivies and specifities of nCLE for the diagnosis of serous cystadenoma, mucinous PCL, and premalignant PCL were all ≥ 0.95 (with 95 % confidence interval from 0.85 to 1.0). The AUROC was significantly larger for nCLE than for CEA or EUS. Conclusions nCLE had excellent diagnostic performance that surpassed that of CEA and EUS for the diagnosis of large, single, noncommunicating PCLs. The nCLE procedure should be considered in patients with indeterminate PCLs to ensure a more specific diagnosis.

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