Abstract
Background
The differential diagnosis of pancreatic cystic lesions (PCLs) is an increasingly common clinical challenge. Confocal laser endomicroscopy (CLE) may differentiate PCLs by imaging of the cyst wall. However, clinical experience is still limited, and better image definition and characterization of the cyst wall in a spectrum of cysts are needed. This experimental study aimed to expose detailed imaging characteristics of PCLs by CLE.
Methods
Patients who underwent surgery of a PCL were enrolled. During surgery, intravenous fluorescein (2.5 ml of 10%) was injected just prior to the ligation of blood vessels supplying the pancreas. The freshly excised specimens were transected along the long axis to fully expose the luminal surface. A Gastroflex-UHD CLE probe (pCLE) was used manually to acquire images directly from the surface of cyst wall. The specimen subsequently underwent cross-sectional histology. All recorded data were analyzed by two investigators for predefined and original image findings of PCLs.
Results
Ten cases were recruited into the study. All patients underwent surgery because of a mucinous cyst with worrisome features or a symptomatic PCL. Imaging was successful in all patients and differently shaped papillary projections (PP) were visualized in eight patients. Pathological examination of those patients confirmed 6 cases with Intraductal Papillary Mucinous Neoplasm (IPMN) and 2 cases with Mucinous Cystic Neoplasm (MCN). In two patients with serous cystadenoma, typical vascular network was visualized in one patient, and microcystic structures in the other. Three of the IPMNs were malignant. The loss of papillary margin integrity and significant fragmentation together with irregularity was detected in malignant IPMNs by CLE.
Conclusions
Pancreatic cyst epithelial wall can be visualized successfully by pCLE in ex vivo surgical specimens. Different papillary projections have been seen in all cases of IPMNs and MCNs. CLE has potential for identifying IPMN subtypes and for grading dysplasia.
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References
Cooper CL, O’Toole SA, Kench JG (2013) Classification, morphology and molecular pathology of premalignant lesions of the pancreas. Pathology 45:286–304
Farrell JJ, Fernandez-del Castillo C (2013) Pancreatic cystic neoplasms: management and unanswered questions. Gastroenterology 144:1303–1315
Ferrone CR, Correa-Gallego C, Warshaw AL, Brugge WR, Forcione DG, Thayer SP et al (2009) Current trends in pancreatic cystic neoplasms. Arch Surg 144:448–454
Brugge WR, Lauwers GY, Sahani D, Fernandez-del Castillo C, Warshaw AL (2004) Cystic neoplasms of the pancreas. N Engl J Med 351:1218–1226
Konstantinou F, Syrigos KN, Saif MW (2013) Intraductal papillary mucinous neoplasms of the pancreas (IPMNs): epidemiology, diagnosis and future aspects. JOP 14:141–144
Brugge WR (2013) Endoscopic approach to the diagnosis and treatment of pancreatic disease. Curr Opin Gastroenterol 29:559–565
Hutchins GF, Draganov PV (2009) Cystic neoplasms of the pancreas: a diagnostic challenge. World J Gastroenterol 15:48–54
Brugge WR, Lewandrowski K, Lee-Lewandrowski E, Centeno BA, Szydlo T, Regan S et al (2004) Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 126:1330–1336
Morris-Stiff G, Lentz G, Chalikonda S, Johnson M, Biscotti C, Stevens T et al (2010) Pancreatic cyst aspiration analysis for cystic neoplasms: mucin or carcinoembryonic antigen–which is better? Surgery 148:638–644
Polglase AL, McLaren WJ, Skinner SA, Kiesslich R, Neurath MF, Delaney PM (2005) A fluorescence confocal endomicroscope for in vivo microscopy of the upper- and the lower-GI tract. Gastrointest Endosc 62:686–695
Konda VJ, Aslanian HR, Wallace MB, Siddiqui UD, Hart J, Waxman I (2011) First assessment of needle-based confocal laser endomicroscopy during EUS-FNA procedures of the pancreas (with videos). Gastrointest Endosc 74:1049–1060
Konda VJ, Meining A, Jamil LH, Giovannini M, Hwang JH, Wallace MB et al (2013) A pilot study of in vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy under endosonographic guidance. Endoscopy 45:1006–1013
Napoleon B, Lemaistre AI, Pujol B, Caillol F, Lucidarme D, Bourdariat R et al (2015) A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy. Endoscopy 47:26–32
Nakai Y, Iwashita T, Park DH, Samarasena JB, Lee JG, Chang KJ (2015) Diagnosis of pancreatic cysts: eUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study. Gastrointest Endosc 81:1204–1214
Furukawa T, Kloppel G, Volkan Adsay N, Albores-Saavedra J, Fukushima N, Horii A et al (2005) Classification of types of intraductal papillary-mucinous neoplasm of the pancreas: a consensus study. Virchows Arch 447:794–799
Bosman F (2010) WHO classification of tumours of the digestive system. IARC Press, Lyon
Kadayifci A, Atar M, Basar O, Forcione DG, Brugge WR (2017) Needle-based confocal laser endomicroscopy for evaluation of cystic neoplasms of the pancreas. Dig Dis Sci 62:1346–1353
Koh YX, Zheng HL, Chok AY, Tan CS, Wyone W, Lim TK et al (2015) Systematic review and meta-analysis of the spectrum and outcomes of different histologic subtypes of noninvasive and invasive intraductal papillary mucinous neoplasms. Surgery 157:496–509
Andrejevic-Blant S, Kosmahl M, Sipos B, Kloppel G (2007) Pancreatic intraductal papillary-mucinous neoplasms: a new and evolving entity. Virchows Arch 451:863–869
Rezaee N, Barbon C, Zaki A, He J, Salman B, Hruban RH et al (2016) Intraductal papillary mucinous neoplasm (IPMN) with high-grade dysplasia is a risk factor for the subsequent development of pancreatic ductal adenocarcinoma. HPB 18:236–246
Krishna SG, Lee JH (2016) Appraisal of needle-based confocal laser endomicroscopy in the diagnosis of pancreatic cysts. World J Gastroenterol 22:1701–1710
Napoleon B, Lemaistre AI, Pujol B, Caillol F, Lucidarme D, Bourdariat R et al (2016) In vivo characterization of pancreatic cystic lesions by needle-based confocal laser endomicroscopy (nCLE): proposition of a comprehensive nCLE classification confirmed by an external retrospective evaluation. Surg Endosc 30:2603–2612
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Abdurrahman Kadayifci, Mustafa Atar, Michelle Yang, Carlos Fernandez-del Castillo, Mari Mino-Kenudson and William R. Brugge have no conflict of interest or financial ties to disclose.
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Kadayifci, A., Atar, M., Yang, M. et al. Imaging of pancreatic cystic lesions with confocal laser endomicroscopy: an ex vivo pilot study. Surg Endosc 31, 5119–5126 (2017). https://doi.org/10.1007/s00464-017-5577-y
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DOI: https://doi.org/10.1007/s00464-017-5577-y