Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review
Abstract
:1. Introduction
2. Indications to Perform EUS in the Evaluation of PCLs
3. EUS Imaging of PCLs
3.1. EUS Imaging and Morphology in the Differentiation of PCLs
3.1.1. Serous Cystadenomas (SCN)
3.1.2. Intraductal Papillary Mucinous Neoplasm
3.1.3. Mucinous Cystic Neoplasms (MCNs)
3.1.4. Pancreatic Neuroendocrine Tumor (pNET) and Solid Pseudopapillary Tumor (SPT)
3.1.5. Pancreatic Pseudocysts
3.1.6. Differentiation of PCLs Based on EUS Morphology
3.2. EUS Imaging and Detection of Malignancy in Mucinous PCLs
3.2.1. Advances in Endosonographic Imaging for Defining Cyst Morphology (Diagnosis and Risk Stratification)
Contrast-Harmonic Mode Endoscopic Ultrasound
EUS-Guided Needle-Based Confocal Laser Endomicroscopy (EUS-nCLE)
4. EUS-Fluid Acquisition
5. EUS-Tissue Acquisition
5.1. EUS-Fine Needle Aspiration (FNA)
5.2. Other EUS-TA Modalities
EUS and Artificial Intelligence
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Guideline | Indications |
---|---|
American Gastroenterological Association (AGA) (2015) | >2 high risk features: • PCL Size > 3 cm • Dilated main pancreatic duct • Presence of a solid component |
International Consensus Guidelines (2017) | With any of the below features: • PCL size > 3 cm • Thickened/enhanced PCL wall • MPD 5–9 mm • Abrupt change in MPD with distal pancreatic atrophy • Lymphadenopathy • Elevated CA 19-9 • Rapid growth (>5 mm/2 years) |
American College of Gastroenterology (2018) | With any of the below features: • MPD > 5 mm • IPMN or MCN > 3 cm • Change in MPD caliber with upstream atrophy • Size increase > 3 mm/year • Jaundice secondary to PCL • Pancreatitis secondary to PCL • Presence of mural nodule or solid component |
European (2018) | Radiologic or clinical features of concern for malignancy: Radiologic: • MPD ≥ 5mm • Size increase ≥ 5 mm/year • Presence of mural nodule or solid component Clinical: • Jaundice secondary to PCL • New onset diabetes • Increased CA 19-9 |
Assay | Pancreatic Lesion Association |
Carcinoembryonic Antigen (CEA) | Used to differentiate between mucinous and non-mucinous pancreatic cysts with varying accuracy depending on cutoff values. Generally agreed upon that CEA < 5 ng/mL is highly specific for non-mucinous PCL, with a specificity reaching 95%, and CEA > 800 ng/mL is highly specific for mucinous PCL, with a specificity of 98%. |
Cyst Fluid Glucose | Newer PCL fluid marker–cyst fluid glucose of <50 mg/dL indicates a mucinous cyst with a sensitivity of 91% and specificity of 75% vs. 67% and 80%, respectively, for CEA in the same study population. |
DNA Markers | Pancreatic Lesion Association |
VHL Gene Mutations | von Hippel–Lindau (VHL) mutations are correlated with serous cystadenomas. This loss of function mutation has been shown to have a sensitivity of 71% and specificity of 100% in determining serous cystadenomas when evaluating pancreatic cystic lesions. |
MEN1, LOH Gene Mutations | Multiple endocrine neoplasia 1 (MEN1) and loss of heterozygosity (LOH) genes are correlated with pancreatic neuroendocrine tumors. When evaluated together, these mutations have a sensitivity and specificity of 68% and 98%, respectively, in identifying a lesion as a pancreatic neuroendocrine tumor. |
MAPK, GNAS Mutations | MAPK and GNAS mutations are used to identify a pancreatic cystic lesion as mucinous with a sensitivity of 90% and specificity of 100%. |
TP53, SMAD4, CTNNB1, mTOR | When combined with MAPK/GNAS mutation in a sequencing panel, the addition of TP53/SMAD4/CTNNB1/mTOR was able to identify advanced neoplasia with a sensitivity and specificity of 88% and 98%, respectively. |
Guideline | Indications |
---|---|
American Gastroenterological Association (AGA) (2015) | EUS-FNA if >2 high risk features: • Cyst size > 3 cm • Dilated main pancreatic duct • Presence of a solid component |
International Consensus Guidelines (2017) | EUS-FNA if PCL with any of the below worrisome features: • Cyst size > 3 cm • Thickened/enhanced cyst walls • MPD 5–9 mm • Abrupt change in MPD with distal pancreatic atrophy • Lymphadenopathy • Elevated CA 19-9 • Rapid growth (>5 mm/2 years) |
American College of Gastroenterology (2018) | EUS-FNA if PCL with any of the below features: • MPD > 5 mm • IPMN or MCN > 3 cm • Change in MPD caliber with upstream atrophy • Size increase > 3 mm/year • Jaundice secondary to cyst • Pancreatitis secondary to cyst • Presence of mural nodule or solid component |
European (2018) | For cysts when the diagnosis is unclear and the results are expected to change clinical management. EUS-FNA is not to be performed if the diagnosis is available or if there is a clear indication for surgery. |
American Society for Gastrointestinal Endoscopy | EUS-FNA recommended for PCLs > 3 cm, presence of an epithelial nodule, dilated MPD, or suspicious mass lesion. In the absence of these features, EUS-FNA is considered optional. |
Technique | Description |
---|---|
Endoscopic Ultrasound- Fine Needle Aspiration (EUS-FNA) | Low sensitivity of 54%, but when positive, has a specificity of 93%. Targeted cyst wall puncture after aspiration of cyst fluid was shown to improve the yield and provide an adequate specimen in 77% of cases. |
Endoscopic Ultrasound Throught-the-Needle Biopsy (EUS-TTNB) | Introduction of microforceps through a 19-gauge needle, allowing for maintainence of cellular structure and potentially a higher yield. Pooled analysis showed a diagnostic yield of 74% and a diagnostic performance of 80%. |
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Rangwani, S.; Juakiem, W.; Krishna, S.G.; El-Dika, S. Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review. Diagnostics 2023, 13, 705. https://doi.org/10.3390/diagnostics13040705
Rangwani S, Juakiem W, Krishna SG, El-Dika S. Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review. Diagnostics. 2023; 13(4):705. https://doi.org/10.3390/diagnostics13040705
Chicago/Turabian StyleRangwani, Shiva, Wasseem Juakiem, Somashekar G. Krishna, and Samer El-Dika. 2023. "Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review" Diagnostics 13, no. 4: 705. https://doi.org/10.3390/diagnostics13040705