Clin Endosc.  2024 Jul;57(4):434-445. 10.5946/ce.2023.157.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for pancreatic cystic lesions: current status and future prospects

• Wu CCH
• Lim SJM
• Tan DMY

• KMID: 2558097
• DOI: http://doi.org/10.5946/ce.2023.157

Abstract

Pancreatic cystic lesions (PCLs) have increased in prevalence due to the increased usage and advancements in cross-sectional abdominal imaging. Current diagnostic techniques cannot distinguish between PCLs requiring surgery, close surveillance, or expectant management. This has increased the morbidity and healthcare costs from inappropriately aggressive and conservative management strategies. Endoscopic ultrasound (EUS) needle-based confocal laser endomicroscopy (nCLE) allows for microscopic examination and delineation of the surface epithelium of PCLs. Landmark studies have identified characteristics distinguishing various types of PCLs, confirmed the high diagnostic yield of EUS-nCLE (especially for PCLs with an equivocal diagnosis), and shown that EUS-nCLE helps to change management and reduce healthcare costs. Refining procedure technique and reducing procedure length have improved the safety of EUS-nCLE. The utilization of artificial intelligence and its combination with other EUS-based advanced diagnostic techniques would further improve the results of EUS-based PCL diagnosis. A structured training program and device improvements to allow more complete mapping of the pancreas cyst epithelium will be crucial for the widespread adoption of this promising technology.

Keyword

Confocal laser scanning microscopy; Endoscopic ultrasound-guided fine needle aspiration; Pancreatic cyst

Figure

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  Fig. 1. The AQ-Flex 19-needle confocal laser endomicroscopy miniprobe (Cellvizio AQ-Flex 19 miniprobe; Mauna Kea Technologies).

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  Fig. 2. (a) The ferrule is a metallic tap at the distal end of the probe that protects the device from the beveled needle tip. (b) The sheath of the probe comprises a robust, protective, biocompatible coating. (c) A locking device is attached by a Luer lock on the fine needle aspiration needle’s proximal hub and is secured onto the probe to maintain needle position and prevent migration.

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  Fig. 3. A schema of endoscopic ultrasound-guided needle-based confocal laser endomicroscopy (nCLE) being performed for a pancreatic cystic lesion. Black: duodenoscope; blue: 19G FNA needle; red: nCLE miniprobe; gray circle: pancreatic cyst.

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  Fig. 4. The superficial vascular network is seen on needle-based confocal laser endomicroscopy of a serous cystadenoma. Arrows indicate blood vessels forming a superficial vascular network.

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  Fig. 5. Papillary projections characterized by a vascular core (in white, indicated by arrows) surrounded by an epithelial border (in gray) are seen on needle-based confocal laser endomicroscopy of an intraductal papillary mucinous neoplasm.

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  Fig. 6. A thick epithelial band (indicated by an arrow) is seen on needle-based confocal laser endomicroscopy of a mucinous cystadenoma.

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  Fig. 7. Bright uniform particles are seen against a dark background on needle-based confocal laser endomicroscopy of a pseudocyst.

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