Evaluation Of Pancreatic Cystic Lesions Research Articles

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

Macroscopic, endomicroscopic, and histologic findings and correlation are an integral part of the diagnostic evaluation of pancreatic cystic lesions (PCLs), as complementing morphologic features seen by different specialties are combined to contribute to a final diagnosis. However, malignancy risk stratification of PCLs with worrisome features can still be challenging even after endoscopic ultrasound guided-fine needle aspiration (EUS-FNA) with cytological evaluation. This review aims to summarize cyst clinicopathological features from the pathologists' perspective, coupled with knowledge from advanced diagnostics-confocal laser endomicroscopy and cyst fluid molecular analysis, to demonstrate the state-of-art risk stratification of PCLs. This review includes illustrative photos of surgical specimens, endomicroscopic and histologic images, and a summary of cyst fluid molecular markers.

Recent advances in the diagnostic evaluation of pancreatic cystic lesions.

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.

Diagnostic Yield of Transabdominal Ultrasonography for Evaluation of Pancreatic Cystic Lesions Compared with Endoscopic Ultrasonography.

Detection rates of pancreatic cystic lesions (PCLs) have increased, resulting in greater requirements for regular monitoring using imaging modalities. We aimed to evaluate the capability of ultrasonography (US) for morphological characterization of PCLs as a reference standard using endoscopic ultrasonography (EUS). A retrospective analysis was conducted of 102 PCLs from 92 patients who underwent US immediately prior to EUS between January 2014 and May 2017. The intermodality reliability and agreement of the PCL morphologic findings of the two techniques were analyzed and compared using the intraclass correlation coefficient and κ values. The success rates of US for delineating PCLs in the head, body, and tail of the pancreas were 77.8%, 91.8%, and 70.6%, respectively. The intraclass correlation coefficient for US and the corresponding EUS lesion size showed very good reliability (0.978; p < 0.001). The κ value between modalities was 0.882 for pancreatic duct dilation, indicating good agreement. The κ values for solid components and cystic wall and septal thickening were 0.481 and 0.395, respectively, indicating moderate agreement. US may be useful for monitoring PCL growth and changes in pancreatic duct dilation, but it has limited use in the diagnosis and surveillance of mural nodules or cystic wall thickness changes.

Mucinous Cystic Lesions of the Pancreas an EUS-FNA-based Study with ClinicoPathological Follow Up

Background: Mucinous cystic lesions of pancreas harbor a pre-malignant potential thus necessitating their distinction from the non-mucinous ones. To make this distinction, EUS-FNA cytology along with cyst fluid CEA and amylase levels are utilized in addition to endoscopic and radiological findings. Evaluation of K-ras mutations has emerged as a useful adjunct for the evaluation of mucinous cystic neoplasms of the pancreas. Aim: We aimed to study mucinous cystic lesions of the pancreas diagnosed on EUS-FNA cytology, in conjunction with cyst fluid CEA and amylase levels and the frequency of K-ras mutation in a cohort of patients seen at the largest cancer hospital in our country. Materials and Methods: After approval from the institutional review board, all the cases of mucinous cystic lesions of pancreas evaluated between July 2005 and August 2019 were reviewed. Patient data, including age, gender, endoscopic and radiological findings, cytological and/or histological diagnosis, cyst fluid CEA, and amylase levels were collected. Results: Twenty-three patients enrolled in the study demonstrated an equal gender distribution with a mean age of 67.4 years. The sensitivity of EUS-FNA for mucinous cystic lesions of the pancreas was 84.6%. Cyst fluid CEA levels were elevated in some MCNs but not IPMNs resulting in a sensitivity of 37.5%. The specificity of cyst fluid amylase was 90%. K-ras mutation was found to have a sensitivity and specificity of 50% and 100% respectively, for mucinous lesions of the pancreas. Conclusion: EUS-FNA is a useful technique for evaluation of pancreatic cystic lesions, especially since cytological diagnosis can be augmented by cyst fluid CEA and amylase levels. K-ras analysis can add further to the diagnostic utility of EUS-FNA

Needle-based Confocal Laser Endomicroscopy (nCLE) for Evaluation of Pancreatic Cystic Lesions: A Systematic Review and Meta-analysis.

Given the variable diagnostic yield of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions (PCLs), novel imaging techniques including needle-based confocal laser endomicroscopy (nCLE) have been devised. The aim of this study was to perform a structured systematic review and meta-analysis to evaluate the diagnostic performance and safety of nCLE for the diagnosis of PCLs. Individualized search strategies were developed in accordance with PRISMA and MOOSE guidelines and meta-analysis analyzed according to the Cochrane Diagnostic Test Accuracy working group methodology. Measured outcomes included diagnostic characteristics and procedure-associated adverse events. A bivariate model was used to compute combined weighted sensitivity, specificity, positive/negative likelihood ratio (LR), diagnostic odds ratio, and summary receiver operating characteristic curve with corresponding 95% confidence intervals (CIs). Seven studies (n=324; mean age: 63.99±5.36 y; 52.47% female) were included. The pooled sensitivity, specificity, positive LR, and negative LR of nCLE was 85% (95% CI, 71-93; I2=74.20%), 99% (95% CI, 90-100; I2=72.60%), 78.66 (95% CI, 7.99-774.68; I2=26.86%), and 0.15 (95% CI, 0.07-0.31; I2=75.84%), respectively. Diagnostic accuracy as measured by summary receiver operating characteristic curve was 99% (95% CI, 98-100). The pooled diagnostic odds ratio was 534 (95% CI, 50-5664; I2=58.00%). Postprocedure pancreatitis developed in 1% (95% CI, 0-3; I2=5.64%) of cases. On the basis of this meta-analysis, nCLE appears to be an effective and safe technique for the diagnostic evaluation of PCLs. Although moderate-to-high amounts of heterogeneity were present, our results demonstrated that nCLE has a diagnostic accuracy of 99% with a low rate of adverse events.

Confocal endomicroscopy for evaluation of pancreatic cystic lesions: a systematic review and international Delphi consensus report.

Background and study aims The aim of thi systematic review and consensus report is to standardize the practice of endoscopic ultrasound (EUS-guided needle-based confocal laser endomicroscopy (nCLE) for pancreatic cystic lesion (PCL) evaluation. Methods We performed an international, systematic, evidence-based review of the applications, outcomes, procedural processes, indications, training, and credentialing of EUS-nCLE in management of PCLs. Based on available clinical evidence, preliminary nCLE consensus statements (nCLE-CS) were developed by an international panel of 15 experts in pancreatic diseases. These statements were then voted and edited by using a modified Delphi approach. An a priori threshold of 80 % agreement was used to establish consensus for each statement. Results Sixteen nCLE-CS were discussed. Thirteen (81 %) nCLE-CS reached consensus addressing indications (non-communication PCL meeting criteria for EUS-FNA or with prior non-diagnostic EUS-FNA), diagnostic outcomes (improved accuracy for mucinous PCLs and serous cystadenomas with substantial interobserver agreement of image patterns), low incidence of adverse events (fluorescein-associated and pancreatitis), procedural processes (nCLE duration, manipulation of needle with probe), and training (physician knowledge and competence). Conclusion Based on a high level of agreement pertaining to expert consensus statements, this report standardizes the practice of EUS-nCLE. EUS-nCLE should be systematically considered when EUS-FNA is indicated for PCL evaluation.

Radiomics for the Diagnosis and Differentiation of Pancreatic Cystic Lesions.

Radiomics, also known as quantitative imaging or texture analysis, involves extracting a large number of features traditionally unmeasured in conventional radiological cross-sectional images and converting them into mathematical models. This review describes this approach and its use in the evaluation of pancreatic cystic lesions (PCLs). This discipline has the potential of more accurately assessing, classifying, risk stratifying, and guiding the management of PCLs. Existing studies have provided important insight into the role of radiomics in managing PCLs. Although these studies are limited by the use of retrospective design, single center data, and small sample sizes, radiomic features in combination with clinical data appear to be superior to the current standard of care in differentiating cyst type and in identifying mucinous PCLs with high-grade dysplasia. Combining radiomic features with other novel endoscopic diagnostics, including cyst fluid molecular analysis and confocal endomicroscopy, can potentially optimize the predictive accuracy of these models. There is a need for multicenter prospective studies to elucidate the role of radiomics in the management of PCLs.

The Role of Needle-Based Confocal Laser Endomicroscopy in the Evaluation of Pancreatic Cystic Lesions: A Systematic Review.

The prevalence of pancreatic cystic lesions (PCLs) has increased recently due to the increased use of cross-sectional abdominal imaging and the ageing global population. Current diagnostic techniques are inadequate to distinguish between PCLs that require surgery, close surveillance, or expectant management. This has resulted in increased morbidity from both inappropriately aggressive and conservative management strategies. Needle-based confocal laser endomicroscopy (nCLE) has allowed microscopic examination and visual delineation of the surface epithelium of PCLs. Landmark studies in this decade have correlated nCLE and histological findings and identified characteristics differentiating various types of PCLs. Subsequent studies have confirmed the high diagnostic yield of nCLE and its diagnostic utility in PCLs with an equivocal diagnosis. Moreover, nCLE has been shown to improve the diagnostic yield of PCLs. This will help avoid unnecessary pancreatic surgery, which carries significant morbidity and mortality risks. The early detection of high-grade dysplasia in PCLs will provide early surgical treatment and improve outcomes for pancreatic cancer. Despite the high upfront cost of nCLE, the improved diagnostic accuracy and resultant appropriate management have resulted in improved cost effectiveness. Refining the procedure technique and limiting the procedure length have significantly improved the safety of nCLE. A structured training program and device improvements to allow more complete mapping of the pancreatic cyst epithelium will be crucial for the widespread adoption of this promising technology.

Response to letter: Endoscopic ultrasound-guided confocal endomicroscopy requires high-quality imaging and interpretation for diagnostic evaluation of pancreatic cystic lesions.

Response to letter: Endoscopic ultrasound-guided confocal endomicroscopy requires high-quality imaging and interpretation for diagnostic evaluation of pancreatic cystic lesions.

Endoscopic ultrasound-guided confocal endomicroscopy requires high-quality imaging and interpretation for diagnostic evaluation of pancreatic cystic lesions.

The needle-based confocal endomicroscopy (nCLE) probe was first approved by the Food and Drug Administration (FDA) in 2013. In a “white paper” published by the American Gastroenterology Association, competency-based training of novel endoscopic imaging techniques was emphasized compared to the traditional volume-based model of procedures [1]. We define competency as the ability to recognize diagnostic image patterns in nCLE. Only with familiarity of these patterns, can the endoscopist acquire them during the procedure. While competency needs to be achieved before physicians start enrolling patients in a prospective study, image acquisition quality also needs to be continually monitored during the study process to evaluate the learning curve and detect any potential deficiencies.

Diagnostic accuracy of 18 FDG PET/CT in the evaluation of suspicious pancreatic cysts

Background: The incidence of diagnostic inaccuracy remain high with the conventional approach in the evaluation of pancreatic cystic lesions. The purpose of this study was to examine the added value of 18Fluorodeoxyglucose positron emission computed tomography (18FDG PET/CT) over the standardised diagnostic work up in the evaluation of suspicious pancreatic cysts. Material & Methods: Patients with a primary diagnosis of a pancreatic cystic lesion who were recruited in a multicentre prospective diagnostic accuracy and clinical value trial for the use of 18FDG PET/CT in the diagnosis and management of patients with suspected pancreatic cancer (PET-PANC trial) were identified. All of the included patients underwent imaging with multidetector CT scan in addition to the selective use of MRI and endoscopic ultrasound. Patients underwent 18FDG PET/CT within two weeks from registration into the trial. Statistical parameters of pre18FDG PET/CT based diagnosis vs post 18FDG PET/CT diagnosis were calculated and compared. Results: The study included 74 patients with a suspicion of a malignant pancreatic cyst (ultimately 67 benign, 7 malignant). The sensitivity, specificity and the overall accuracy of the MDT panel in the diagnosis of malignant pancreatic cysts based on pre 18FDG PET/CT diagnostic workup vs post 18FDG PET/CT based diagnosis were 85.7%, 61.2%, 63.5% vs 100%, 86.6%, 87.8% respectively. Almost 40% of patients who were diagnosed with a malignant pancreatic cyst based on pre 18FDG PET/CT workup were in fact benign. Moreover,18FDG PET/CT diagnosed new malignancies not identified on MDCT (n=2), led to a non-therapeutic lung lobectomy (n=1), showed areas of increased 18FDG uptake that warranted further evaluation (n=13). Conclusion: 18FDG PET/CT provides an additive value to the current multidisciplinary team diagnostic strategy of malignant pancreatic cysts, its use is likely to influence management decisions and could potentially be utilised to decide on the appropriateness of surgery over continued surveillance.

Differentiating benign from malignant pancreatic cysts on computed tomography

PurposeIt is important to identify features on computed tomography (CT) that can distinguish between benign and premalignant or malignant pancreatic cysts to avoid unnecessary surgeries. This study investigated the preoperative diagnostic evaluation of cystic pancreatic lesions to determine how advanced imaging and clinical factors should guide management. MethodsIn total, 53 patients with 27 benign and 26 premalignant or malignant cysts were enrolled. CT features of the cysts were compared using univariate and multivariate analyses. ResultsOn univariate analysis, a solid component (p < 0.01), septation (p < 0.01), location (p < 0.01), border (p < 0.01), wall enhancement (p = 0.01), lesion margins (p < 0.01), pancreatic atrophy (p = 0.04), and a cystic wall (p < 0.01) were all significantly different between benign and premalignant or malignant cysts. On multivariate analysis, only a solid component (p < 0.01) and septation (p < 0.01) were significant. ConclusionA thin cystic wall, uniform homogeneity, a clear border, the presence of septation, pancreatic atrophy, and the absence of both wall enhancements and solid components were more frequently seen in benign cysts. A thick wall, lack of homogeneity, the presence of wall enhancements and solid components, absence of septation, only a small degree of pancreatic atrophy, and unclear borders were more frequent among premalignant or malignant cysts. The only CT features to differentiate benign from premalignant or malignant cysts were a solid component and septation.

Impact of EUS-guided microforceps biopsy sampling and needle-based confocal laser endomicroscopy on the diagnostic yield and clinical management of pancreatic cystic lesions

EUS-guided microforceps biopsy sampling (MFB) and needle-based confocal laser endomicroscopy (nCLE) are emerging diagnostic tools for pancreatic cystic lesions (PCLs). There is a paucity of data regarding their performance and impact. The aim of this study was to compare diagnostic outcomes and changes in clinical management resulting from MFB and nCLE use in PCLs. This was a single-center retrospective study of patients with PCLs who underwent combined EUS-guided FNA, MFB, and nCLE. Primary outcomes included diagnostic yield (specific PCL type) and change in clinical management for each modality compared with the current "composite standard" (CS) obtained by combining clinical, morphologic, cyst fluid cytology, and chemical analysis. Forty-four cysts were studied in 44 patients. Technical success was 100% for EUS-FNA, 88.6% for MFB, and 97.7% for nCLE. Of 44 procedures, there was 1 adverse event (2.3%, an infected pseudocyst). Diagnostic yield for each individual modality was 34.1% for CS, 75.0% for MFB (P< .05 vs CS), and 84.1% for nCLE (P< .05 vs CS). Diagnostic yield for combined tests was 79.5% for CS/MFB, 88.6% for CS/nCLE, and 93.2% for CS/MFB/nCLE (P= not significant). Compared with the CS, the use of MFB, nCLE, and their combination led to overall change in clinical management in 38.6%, 43.2%, and 52.3% of cases, respectively. MFB and nCLE led to an overall increase in discontinuation of surveillance (MFB, 34.1% [P< .05]; nCLE, 31.8% [P< .05]), led by a reduction in the indication for follow-up radiologic or endoscopic studies (MFB, 34.1% [P< .05]; nCLE, 38.6% [P< .05]). Based on MFB and nCLE, 2 of 28 (7.1%) and 3 of 28 (10.7%) patients who would have undergone further surveillance were referred for surgery. In the evaluation of PCLs, the use of combined EUS-guided FNA, MFB, and nCLE is safe. MFB and nCLE led to significant improvements in specific PCL diagnosis, which in turn has major impacts in clinical management.

Endoscopic ultrasonography for the evaluation of pancreatic cystic neoplasms.

Endoscopic ultrasonography (EUS) is a modality with high spatial resolution that enables comprehensive observation of the entire pancreas and plays an important role in the diagnosis of pancreatic lesions. Recent advances in diagnostic imaging methods such as ultrasound, computed tomography, and magnetic resonance imaging have increased the incidental detection of pancreatic cystic lesions (PCLs). EUS has been recognized as an essential diagnostic method for the detection and evaluation of PCLs. EUS has two important roles: as a detailed (high-resolution) imaging diagnostic method and as an approach for collecting cyst fluid content by EUS-guided fine needle aspiration for pathological diagnosis or biomarker evaluation. Furthermore, in recent years, the usefulness of contrast-enhanced EUS for the differential diagnosis of PCLs or evaluation of grade of malignancy, and a novel imaging technique called needle-based confocal laser endomicroscopy to observe intraductal structures through a needle, has been reported. An understanding of the morphological characteristics of PCLs depicted by ultrasound imaging and of the benefits and limitations of EUS diagnosis in daily practice is needed.

Interobserver agreement among expert pathologists on through-the-needle microforceps biopsy samples for evaluation of pancreatic cystic lesions

The recent development of microforceps for EUS through-the-needle biopsy (TTNB) sampling of the wall of pancreatic cystic lesions (PCLs) allows the collection of histologic specimens never handled and evaluated before by pathologists. We aimed to estimate the interobserver agreement among pathologists in evaluating such samples. TTNB specimen slides from 40 PCLs with worrisome features were retrieved and independently evaluated for specimen adequacy, presence of lining epithelium, grade of epithelial dysplasia, presence of ovarian type stroma, and specific diagnosis by 6 expert pathologists from 6 different tertiary care centers. The Gwet's AC1 was used to assess interobserver agreement. An almost perfect agreement was observed for specimen adequacy (AC1, .82; 95% confidence interval [CI], .79-.98), presence of lesional epithelium (AC1, .90; 95% CI, .86-.92), epithelial dysplasia (AC1, .97; 95% CI, .95-.99), and ovarian-like stroma (AC1, .90; 95% CI, .86-.93). When considering all diagnoses separately, a moderate to substantial agreement was observed (AC1, .62; 95% CI, .57-.67), similarly to mucinous cysts versus serous adenoma versus other diagnoses (AC1, .65; 95% CI, .59-.70) and for mucinous cysts versus all other diagnoses (AC1,.74; 95% CI, .68-.84). The agreement for diagnosis of mucinous cystic neoplasm versus intraductal mucinous papillary neoplasm was almost perfect (AC1, .88; 95% CI, .81-.95). Interobserver agreement between expert pathologists in the evaluation of TTNB samples from PCLs with worrisome features was close to perfection for all evaluated parameters, except definitive diagnosis. When mucinous cystic lesions were compared versus all other diagnoses, the agreement became substantial, thus indicating that TTNB specimens can provide important information for PCL management decisions.

Association between macroscopically visible tissue samples and diagnostic accuracy of EUS-guided through-the-needle microforceps biopsy sampling of pancreatic cystic lesions

EUS-guided through-the-needle biopsy (TTNB) sampling has been reported to improve diagnostic yield compared with cytology for the evaluation of pancreatic cystic lesions (PCLs). The number of macroscopically visible tissue samples needed to reach an adequate diagnosis is still unknown. This is a retrospective, single-center study on consecutive patients with PCLs with risk features (cyst >3 cm, thickened wall, cyst growth during follow-up, and mural nodules) who underwent TTNB sampling. The capability of differentiating mucinous versus nonmucinous cysts, ability to obtain a cyst-lining epithelium, definition of the grade of dysplasia, and specific diagnosis of cyst histotype were evaluated for 1, 2, or 3 TTNB macroscopically visible specimens. Sixty-one patients were evaluated. A 100% histologic adequacy was reached by 2 samples (P= .05 versus 1). Compared with cytology, 1 TTNB specimen improved the possibility of defining cyst histotype (P< .0001), whereas 2 specimens increased all 4 diagnostic categories (P< .003). Two specimens also increased diagnostic yield compared with 1 sample (P< .085). The collection of a third sample did not improve the value of any diagnostic categories. A specific diagnosis was reached in 74% of patients with 2 histologic samples. The diagnostic reliability of TTNB sampling compared with surgical histology was 90%, with a 22.9% rate of adverse events. Two TTNB macroscopically visible specimens reached 100% histologic adequacy and a specific diagnosis in 74% of patients. The collection of a third specimen did not add any additional information and should be avoided to possibly decrease the risk of adverse events.

An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions.

Background and Objectives:Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field.Methods:A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized.Results:Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year.Conclusion:Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.

Systematic review of the utility of 18-FDG PET in the preoperative evaluation of IPMNs and cystic lesions of the pancreas

The aim of this systematic review is to assess the role of 18-fluorodeoxyglucose positron emission tomography in the preoperative evaluation of intraductal papillary mucinous neoplasms and cystic lesions of the pancreas. A computerized PubMed search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies evaluating positron emission tomography in the preoperative evaluation of pancreatic cystic lesions. A total of 14 studies evaluated the role of 18-fluorodeoxyglucose positron emission tomography/positron emission tomography-computed tomography, 9 of which evaluated only intraductal papillary mucinous neoplasms and 5 evaluated all pancreatic cystic lesions, including intraductal papillary mucinous neoplasms. Pooled analysis was carried out for studies evaluating intraductal papillary mucinous neoplasms only and studies evaluating all cystic lesions. Imaging with 18-fluorodeoxyblucose positron emission tomography had a positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of 90%, 91%, 85%, 95%, and 91% in identifying malignancy (defined as either invasive and/or high-grade dysplasia) in intraductal papillary mucinous neoplasms and a positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of 85%, 81%, 79%, 86%, and 88% in identifying malignancy in other cystic lesions. Pooled analysis reported the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of Sendai consensus guidelines (SCG) criteria as 69%, 69%, 68%, 55%, and 58%. The Fukuoka consensus guidelines (FCG) only had sensitivity, specificity, and accuracy reported as 61%, 52%, and 52%, respectively. The 18-fluorodeoxyblucose positron emission tomography had a high degree of accuracy of detecting malignancy in intraductal papillary mucinous neoplasm and cystic lesion of the pancreas. Comparison of the utility of positron emission tomography with the Fukuoka consensus guidelines and the Sendai consensus guidelines suggest that positron emission tomography is superior to present guidelines in detecting malignant intraductal papillary mucinous neoplasm and cystic lesion of the pancreas. Further studies in larger patient cohorts may be required to corroborate these findings and to determine the place of positron emission tomography in the management of intraductal papillary mucinous neoplasm and cystic lesions of the pancreas.

Endoscopic ultrasound-guided through-the-needle microforceps biopsy in the evaluation of pancreatic cystic lesions: a multicenter study.

Background and study aims Accurate diagnosis and classification of pancreatic cysts (PCs) remains a challenge. The aims of this study were to: (1) evaluate the safety and technical success of a novel microforceps for EUS-guided through-the-needle biopsy (TTNB) of PCs; and (2) assess its diagnostic yield for mucinous PCs when compared to FNA cyst fluid analysis and cytology. Patients and methods This was a multicenter retrospective analysis of 47 patients who underwent EUS-FNA and TTNB for PCs between January 2014 and June 2017. Technical success was defined as acquisition of a specimen adequate for cytologic or histological evaluation. Cyst fluid carcinoembryonic antigen (CEA) was used to initially categorize cysts as non-mucinous (CEA < 192 ng/mL) or mucinous (CEA ≥ 192 ng/mL). Final diagnosis was based on identifiable mucinous pancreatic cystic epithelium on cytology, microforceps histology and/or surgical histology when available. Results Forty-seven patients with PCs (mean size 30.7 mm) were included. TTNB was successfully performed in 46 of 47 (97.9 %). Technical success was significantly lower with FNA (48.9 %) compared to TTNB (85.1 %) ( P < .001). For cysts with insufficient amount of fluid for CEA (n = 19) or CEA < 192 ng/mL, the cumulative incremental diagnostic yield of a mucinous PC was significantly higher with TTNB vs. FNA (52.6 % vs 18.4 %; P = .004). TTNB alone (34.4 %) diagnosed more mucinous PCs than either CEA ≥ 192 ng/mL alone (6.3 %) or when combined with FNA cytology (9.4 %). One episode of self-limited bleeding (2.1 %) and one of pancreatitis (2.1 %) occurred. Conclusions EUS-TTNB is safe and effective for evaluating PCs. TTNB may help increase the diagnostic yield of mucinous PCs.

Application of compressed sensing to 3D magnetic resonance cholangiopancreatography for the evaluation of pancreatic cystic lesions

The aim of this study was to assess changes in acquisition time, image quality and evaluation of pancreatic cysts when applying CS to a 3D MRCP sequence. Thirty subjects (17F; 13M) undergoing MRCP for evaluation of pancreatic cyst(s) were prospectively recruited and underwent 3D MRCP and CS 3D MRCP (CS factor = 2) on a 3T scanner. The acquisition time was recorded. Two experienced radiologists independently recorded quality of the images, presence of artifacts, visualization of the main pancreatic duct, bile ducts and index pancreatic cyst using a five-point scale. Presence of mural nodules and septations in the cyst, size of the cyst and caliber of the main pancreatic duct were also recorded. A paired sample t-test was used to compare the acquisition time of 3D MRCP and CS 3D MRCP. Image quality metrics and visualization of cyst features were compared with Wilcoxon signed-rank test and McNemar test.The mean acquisition time of CS-3D-MRCP (150 ± 63 s) was significantly lower than that of 3D-MRCP (317 ± 104 s; P < 0.001). The median score of overall quality (reader 1, 3.7 ± 1.0 vs. 3.4 ± 1.1, P = 0.11; reader 2, 3.8 ± 1.0 vs. 3.7 ± 1.1, P = 0.36), artifacts and visualization of the bile ducts were not significantly different between 3D-MRCP and CS-3D-MRCP. There was no significant difference in the visualization score of the index pancreatic cyst (reader 1, 4.2 ± 0.9 vs. 4.1 ± 0.9, P = 0.42; reader 2, 4.2 ± 0.4 vs. 4.0 ± 0.7, P = 0.27) and no difference in the assessment of cyst features. Applying CS to 3D-MRCP yields a two-fold reduction in acquisition time with comparable image quality and visualization of key pancreatic cyst features.