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Su1352 Supplementing American Gastroenterological Association Guidelines With Confocal Laser Endomicroscopy in the Evaluation of Asymptomatic Pancreatic Cystic Lesions
Abstracts
whether it prevented resection. Results: A total 282 lesions were reviewed. EUS-guided FNA and FNB were performed in 222 and 45 of those were sent to surgery. Clinical pancreatitis developed in one patient (1/222;0.004%) that was candidate for surgery. In another patient pancreatic inflammation that precluded resection was found but the patient was asymptomatic. None of them had a prior ERCP. Both cases were related to a novel front-end biopsy needle accounting for a 16% of the patients that required surgery but only 2.32%(1/43) of the total sampled with that needle if we consider symptomatic cases or 4.65% (2/43) if we consider also de asymptomatic case. Conclusions: Although the rate of clinical pancreatitis was low the presence of subclinical pancreatitis preventing resection has to be taken into account when sampling a potentially resectable lesion. The risk of subclinical pancreatitis represents an important problem that could be increased with the use of needles designed to obtain core biopsies.
Su1351 Our Experience With Pancreatic Cyst Surveillance and Retrospective Application of the New Aga Guidelines Edward Belkin*, Wahid Wassef University of Massachusetts, Newton, MA Background: Pancreatic cysts are often incidental findings discovered on cross-sectional imaging. Surveillance of these cysts is frequently undertaken for lesions deemed to be low-risk. However, which lesions require surveillance, its frequency, and modality remain uncertain. Recent AGA guidelines, published in 2015, attempt to give further guidance on the subject; however all of the recommendations are based on “very low quality of evidence.” In this study, we evaluate our experience with surveillance of pancreatic cysts and retrospectively apply the new guidelines to these cases. Methods: After IRB approval, we previously created a database of patients at our institution who underwent an endoscopic ultrasound (EUS) and/or had surgical pathology from October 2003 to August 2014 as part of management of their pancreatic cysts. For the purpose of the current study, we utilized that database and extracted all patients who underwent at least two evaluations (cross-sectional imaging or EUS) at least 6 months apart for incidentally found pancreatic cysts (not pseudocysts) as part of surveillance measures. Results: 64 patients met inclusion criteria with an average follow-up period of 3.2 years, during which an average of 1.98 EUS procedures, 1.67 MRIs, and 0.9 CTs were performed for each patient. These investigations led to discovery of 75 new clinical findings in 39 patients (Figure 1). Four patients underwent surgical resection (Table 1), of which 3 had dysplastic lesions, and none had invasive cancer. Discussion: In our cohort of 64 patients who were monitored over an average of 3.2 years for incidentally found pancreatic cysts, 39 patients developed 75 new findings, which we used to further risk-stratify each individual case. Notably, 79% of these findings required an EUS with fine needle aspiration (FNA) to obtain the results (KRAS, CEA, cytology), but according to the new AGA guidelines, none of these cases would have met criteria for EUS/FNA evaluation. Three of the four patients who underwent surgical resection of the cyst were found to have dysplastic cysts. Only one of these patients would have met criteria, during their surveillance period, according to the new guidelines to undergo an EUS evaluation. This patient had a benign lesion (serous cystadenoma). The other three lesions did not meet criteria for EUS evaluation, but were all found to have worrisome features on EUS/FNA, which helped lead to surgery. These patients’ surgical pathology identified mucinous cysts with dysplastic components. Conclusion: In this retrospective analysis, if the 2015 AGA guidelines were followed, none of the three patients with dysplastic mucinous cysts would have fit criteria for EUS/FNA during the time their surveillance period. Evaluation of pancreatic cysts with EUS/FNA may provide clinically useful information, which may help guide management strategy.
Su1352 Supplementing American Gastroenterological Association Guidelines With Confocal Laser Endomicroscopy in the Evaluation of Asymptomatic Pancreatic Cystic Lesions Rohan Modi*1, Samer El-Dika2, Jon Walker2, Sean T. McCarthy2, Phil A. Hart2, Darwin L. Conwell2, Somashekar G. Krishna2 1 Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH Objective: Due to suboptimal diagnostic accuracy of the current standard of care (cyst fluid CEA and cytology) in differentiating mucinous versus non-mucinous pancreatic cystic lesions (PCLs), the 2015 American Gastroenterological Association (AGA) guidelines for asymptomatic pancreatic cystic lesions (PCLs) recommend endoscopic ultrasound (EUS) when two high-risk features including size 3 cm, dilated main pancreatic duct, or presence of an associated solid component are identified. EUS-guided needle based confocal laser endomicroscopy (nCLE) is a novel technology with specific patterns for mucinous PCLs having been described and validated among independent external observers. The aim of this study was to assess the impact of EUS-nCLE on AGA guidelines in the management of PCLs. Methods: Subjects with PCLs were prospectively enrolled in a study evaluating EUSnCLE. Diagnostic parameters of different investigative modalities were computed for all subjects. Results: Forty-nine subjects with incidental PCLs underwent EUS-nCLE. Only 3 of 49 (6.1%) subjects met the criteria for EUS as per AGA guidelines. 18 subjects underwent surgical resection (mean cyst size 32. 3 11 mm), including 10 subjects with mucinous PCLs (Table 1). EUS-nCLE revealed diagnostic ‘epithelial bands or papillae’ in all 10 mucinous PCLs (sensitivity, specificity, and diagnostic accuracy of 100%), where as a combination of cyst fluid CEA 192 ng/mL or ‘mucin’ on cytology was observed in 7 of 10 mucinous PCLs (sensitivity 70%, specificity 50%, accuracy 61%). Among subjects with mucinous PCLs, 3 were intraductal papillary mucinous neoplasms with high-grade dysplasia (2 of 3 met AGA criteria for EUS) and 3 were mucinous cystic neoplasms (0/3 patients met AGA guidelines). Conclusions: The AGA guidelines dictate similar management of all incidental asymptomatic neoplastic PCLs not meeting criteria for EUS. These preliminary results suggest incorporating EUS-nCLE within AGA guidelines can improve diagnostic accuracy in identifying mucinous PCLs. Further validation in a larger, multi-center studies may result in a lower threshold to perform EUS for asymptomatic cysts.
Table 1: Surgical resection of pancreatic cystic lesions after undergoing endoscopic ultrasound guided needle-based confocal laser endomicroscopy Final Diagnosis IPMN MCN CNET SCA LE Cyst Others Total
AB346 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Frequency
Percentage (%)
7 3 2 1 1 4 18
38.9 16.7 11.1 5.6 5.6 22.2 100.0
www.giejournal.org
whether it prevented resection. Results: A total 282 lesions were reviewed. EUS-guided FNA and FNB were performed in 222 and 45 of those were sent to surgery. Clinical pancreatitis developed in one patient (1/222;0.004%) that was candidate for surgery. In another patient pancreatic inflammation that precluded resection was found but the patient was asymptomatic. None of them had a prior ERCP. Both cases were related to a novel front-end biopsy needle accounting for a 16% of the patients that required surgery but only 2.32%(1/43) of the total sampled with that needle if we consider symptomatic cases or 4.65% (2/43) if we consider also de asymptomatic case. Conclusions: Although the rate of clinical pancreatitis was low the presence of subclinical pancreatitis preventing resection has to be taken into account when sampling a potentially resectable lesion. The risk of subclinical pancreatitis represents an important problem that could be increased with the use of needles designed to obtain core biopsies.
Su1351 Our Experience With Pancreatic Cyst Surveillance and Retrospective Application of the New Aga Guidelines Edward Belkin*, Wahid Wassef University of Massachusetts, Newton, MA Background: Pancreatic cysts are often incidental findings discovered on cross-sectional imaging. Surveillance of these cysts is frequently undertaken for lesions deemed to be low-risk. However, which lesions require surveillance, its frequency, and modality remain uncertain. Recent AGA guidelines, published in 2015, attempt to give further guidance on the subject; however all of the recommendations are based on “very low quality of evidence.” In this study, we evaluate our experience with surveillance of pancreatic cysts and retrospectively apply the new guidelines to these cases. Methods: After IRB approval, we previously created a database of patients at our institution who underwent an endoscopic ultrasound (EUS) and/or had surgical pathology from October 2003 to August 2014 as part of management of their pancreatic cysts. For the purpose of the current study, we utilized that database and extracted all patients who underwent at least two evaluations (cross-sectional imaging or EUS) at least 6 months apart for incidentally found pancreatic cysts (not pseudocysts) as part of surveillance measures. Results: 64 patients met inclusion criteria with an average follow-up period of 3.2 years, during which an average of 1.98 EUS procedures, 1.67 MRIs, and 0.9 CTs were performed for each patient. These investigations led to discovery of 75 new clinical findings in 39 patients (Figure 1). Four patients underwent surgical resection (Table 1), of which 3 had dysplastic lesions, and none had invasive cancer. Discussion: In our cohort of 64 patients who were monitored over an average of 3.2 years for incidentally found pancreatic cysts, 39 patients developed 75 new findings, which we used to further risk-stratify each individual case. Notably, 79% of these findings required an EUS with fine needle aspiration (FNA) to obtain the results (KRAS, CEA, cytology), but according to the new AGA guidelines, none of these cases would have met criteria for EUS/FNA evaluation. Three of the four patients who underwent surgical resection of the cyst were found to have dysplastic cysts. Only one of these patients would have met criteria, during their surveillance period, according to the new guidelines to undergo an EUS evaluation. This patient had a benign lesion (serous cystadenoma). The other three lesions did not meet criteria for EUS evaluation, but were all found to have worrisome features on EUS/FNA, which helped lead to surgery. These patients’ surgical pathology identified mucinous cysts with dysplastic components. Conclusion: In this retrospective analysis, if the 2015 AGA guidelines were followed, none of the three patients with dysplastic mucinous cysts would have fit criteria for EUS/FNA during the time their surveillance period. Evaluation of pancreatic cysts with EUS/FNA may provide clinically useful information, which may help guide management strategy.
Su1352 Supplementing American Gastroenterological Association Guidelines With Confocal Laser Endomicroscopy in the Evaluation of Asymptomatic Pancreatic Cystic Lesions Rohan Modi*1, Samer El-Dika2, Jon Walker2, Sean T. McCarthy2, Phil A. Hart2, Darwin L. Conwell2, Somashekar G. Krishna2 1 Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH Objective: Due to suboptimal diagnostic accuracy of the current standard of care (cyst fluid CEA and cytology) in differentiating mucinous versus non-mucinous pancreatic cystic lesions (PCLs), the 2015 American Gastroenterological Association (AGA) guidelines for asymptomatic pancreatic cystic lesions (PCLs) recommend endoscopic ultrasound (EUS) when two high-risk features including size 3 cm, dilated main pancreatic duct, or presence of an associated solid component are identified. EUS-guided needle based confocal laser endomicroscopy (nCLE) is a novel technology with specific patterns for mucinous PCLs having been described and validated among independent external observers. The aim of this study was to assess the impact of EUS-nCLE on AGA guidelines in the management of PCLs. Methods: Subjects with PCLs were prospectively enrolled in a study evaluating EUSnCLE. Diagnostic parameters of different investigative modalities were computed for all subjects. Results: Forty-nine subjects with incidental PCLs underwent EUS-nCLE. Only 3 of 49 (6.1%) subjects met the criteria for EUS as per AGA guidelines. 18 subjects underwent surgical resection (mean cyst size 32. 3 11 mm), including 10 subjects with mucinous PCLs (Table 1). EUS-nCLE revealed diagnostic ‘epithelial bands or papillae’ in all 10 mucinous PCLs (sensitivity, specificity, and diagnostic accuracy of 100%), where as a combination of cyst fluid CEA 192 ng/mL or ‘mucin’ on cytology was observed in 7 of 10 mucinous PCLs (sensitivity 70%, specificity 50%, accuracy 61%). Among subjects with mucinous PCLs, 3 were intraductal papillary mucinous neoplasms with high-grade dysplasia (2 of 3 met AGA criteria for EUS) and 3 were mucinous cystic neoplasms (0/3 patients met AGA guidelines). Conclusions: The AGA guidelines dictate similar management of all incidental asymptomatic neoplastic PCLs not meeting criteria for EUS. These preliminary results suggest incorporating EUS-nCLE within AGA guidelines can improve diagnostic accuracy in identifying mucinous PCLs. Further validation in a larger, multi-center studies may result in a lower threshold to perform EUS for asymptomatic cysts.
Table 1: Surgical resection of pancreatic cystic lesions after undergoing endoscopic ultrasound guided needle-based confocal laser endomicroscopy Final Diagnosis IPMN MCN CNET SCA LE Cyst Others Total
AB346 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Frequency
Percentage (%)
7 3 2 1 1 4 18
38.9 16.7 11.1 5.6 5.6 22.2 100.0
www.giejournal.org