Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions: A single-center study

Figure 1 Case No. 13: A 77 years old woman with a pancreatic cyst lesion corresponding to an intraductal papillary mucinous neoplasm. The lesion exhibited malignancy criteria at endoscopic ultrasound (EUS) and related techniques. A: EUS identifying a 4 cm pancreatic cyst lesion with mural nodules (yellow arrow); B: Mural nodule with hyper-enhancing at EUS (green arrow) shown in contrast-enhanced EUS; C: EUS-guided cystoscopy using a digital probe showing vascularity (red arrow) of a pancreatic macrocystic lesion filled with clear fluid.

Figure 2 Population study flowchart. ¹Numbers of techniques were not mutually exclusive. Endoscopic ultrasound could be combined with more than one other technique, as shown on the illustrated Venn diagram in Figure 3. EUS: Endoscopic ultrasound; EUS-FNA: Endoscopic ultrasound-guided fine needle aspiration; Cystoscopy: Fiberoptic probe cystoscopy; nCLE: Endoscopic ultrasound-guided needle-based confocal laser-endomicroscopy; mFB: Endoscopic ultrasound-guided through-the-needle direct intracystic micro forceps biopsy; CE-EUS: Contrast-enhanced endoscopic ultrasound; M: Malignancy.

Figure 3 Venn diagram describing distribution of additional diagnostic techniques performed in the studied population. EUS: Endoscopic ultrasound; EUS-FNA: Endoscopic ultrasound-guided fine needle aspiration; Cystoscopy: Fiberoptic probe cystoscopy; nCLE: Endoscopic ultrasound-guided needle-based confocal laser-endomicroscopy; mFB: Endoscopic ultrasound-guided through-the-needle direct intracystic micro forceps biopsy; CE-EUS: Contrast-enhanced endoscopic ultrasound.

Figure 4 Received operating characteristics describing overall diagnostic accuracy of endoscopic ultrasound alone and in addition with fine needle aspiration or contrast-enhanced endoscopic ultrasound, needle-based confocal laser-endomicroscopy and/or with direct intracystic micro forceps biopsy for detecting malignancy. A: Comparison among endoscopic ultrasound (EUS) alone vs additional diagnostic techniques; B: Comparison among EUS alone vs EUS + EUS-guided needle-based confocal laser-endomicroscopy (nCLE) + EUS-guided through-the-needle direct intracystic micro forceps biopsy (mFB). ¹DeLong’s test for two received operating characteristics (ROC) curves comparing EUS-alone area under the ROC curve (red line) with EUS + fine needle aspiration (FNA)/contrast-enhanced (CE) (orange line), EUS + nCLE (yellow line), EUS + mFB (blue line) and EUS + nCLE + mFB (green line). ²DeLong’s test for two ROC curves comparing EUS + FNA/CE (orange line) with EUS + nCLE + mFB (green line). EUS: Endoscopic ultrasound; FNA: Fine needle aspiration; Cystoscopy: Fiberoptic probe cystoscopy; nCLE: Endoscopic ultrasound-guided needle-based confocal laser-endomicroscopy; mFB: Endoscopic ultrasound-guided through-the-needle direct intracystic micro forceps biopsy; CE: Contrast-enhanced.