Needle-based confocal laser endomicroscopy for the diagnosis of pancreatic cystic lesions: an international external interobserver and intraobserver study (with videos)

Published:March 09, 2017DOI:

      Background and Aims

      EUS-guided needle-based confocal laser endomicroscopy (nCLE) characteristics of common types of pancreatic cystic lesions (PCLs) have been identified; however, surgical histopathology was available in a minority of cases. We sought to assess the performance characteristics of EUS nCLE for differentiating mucinous from non-mucinous PCLs in a larger series of patients with a definitive diagnosis.


      Six endosonographers (nCLE experience >30 cases each) blinded to all clinical data, reviewed nCLE images of PCLs from 29 patients with surgical (n = 23) or clinical (n = 6) correlation. After 2 weeks, the assessors reviewed the same images in a different sequence. A tutorial on available and novel nCLE image patterns was provided before each review. The performance characteristics of nCLE and the κ statistic for interobserver agreement (IOA, 95% confidence interval [CI]), and intraobserver reliability (IOR, mean ± standard deviation [SD]) for identification of nCLE image patterns were calculated. Landis and Koch interpretation of κ values was used.


      A total of 29 (16 mucinous PCLs, 13 non-mucinous PCLs) nCLE patient videos were reviewed. The overall sensitivity, specificity, and accuracy for the diagnosis of mucinous PCLs were 95%, 94%, and 95%, respectively. The IOA and IOR (mean ± SD) were κ = 0.81 (almost perfect); 95% CI, 0.71-0.90; and κ = 0.86 ± 0.11 (almost perfect), respectively. The overall specificity, sensitivity, and accuracy for the diagnosis of serous cystadenomas (SCAs) were 99%, 98%, and 98%, respectively. The IOA and IOR (mean ± SD) for recognizing the characteristic image pattern of SCA were κ = 0.83 (almost perfect); 95% CI, 0.73-0.92; and κ = 0.85 ± 0.11 (almost perfect), respectively.


      EUS-guided nCLE can provide virtual histology of PCLs with a high degree of accuracy and inter- and intraobserver agreement in differentiating mucinous versus non-mucinous PCLs. These preliminary results support larger multicenter studies to evaluate EUS nCLE. (Clinical trial registration number: NCT02516488.)


      CEA (carcinoembryonic antigen), CI (confidence interval), CLE (confocal laser endomicroscopy), HGD (high-grade dysplasia), IOA (interobserver agreement), IOR (intraobserver reliability), IPMN (intraductal papillary mucinous neoplasm), IV (intravenous), MCN (mucinous cystic neoplasm), MRI (magnetic resonance imaging), nCLE (needle-based confocal laser endomicroscopy), NET (neuroendocrine tumor), PCL (pancreatic cystic lesion), SCA (serous cystadenoma), SD (standard deviation)
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      Linked Article

      • Erratum
        Gastrointestinal EndoscopyVol. 87Issue 6
        • Preview
          In the October 2017 issue of Gastrointestinal Endoscopy, the article “Needle-based confocal laser endomicroscopy for the diagnosis of pancreatic cystic lesions: an international external interobserver and intraobserver study (with videos)” by Somashekar G. Krishna, et al (Gastrointest Endosc 2017;86:644-54.), contains typographical errors in Table 2. The corrected table appears below.
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      • Pancreas cyst fluid viscocity assesment in the diagnosis of mucinous cyts
        Gastrointestinal EndoscopyVol. 87Issue 6
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          We read with interest the article by Krishna et al1 about the use of EUS-guided needle-based confocal laser endomicroscopy (nCLE) in differentiating between mucinous and nonmucinous pancreatic cysts. They reported a cohort of patients with 16 mucinous and 13 nonmucinous pancreas cysts to assess the performance characteristics of EUS-guided nCLE, which was found to have a high accuracy. However, in our experience, nCLE is a very expensive evaluation method for daily practice. In differentiating between mucinous and nonmucinous pancreas cysts, determination of the viscosity of the cyst fluid may be useful.
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