The Impact of Endoscopic Ultrasound and Multidisciplinary Team Evaluation on the Management of Pancreatic Cystic Lesions.

BACKGROUND

Retrospective evaluations of multidisciplinary team (MDT) review of pancreatic cystic lesions (PCL) demonstrate improved PCL management. Endoscopic ultrasound (EUS) evaluates PCL for worrisome features; however, its influence on MDT is unclear and may be attenuated by anchoring/confirmation bias. We aimed to evaluate the impact of EUS and the overall performance of MDT evaluation of PCL.

METHODS

Four mock MDT sessions at two institutions were presented imaging from 40 consecutive PCL cases (20 "high-risk" with advanced neoplasia, 20 "low-risk" with pathologic low-grade dysplasia or ≥ 3 years of non-progression on surveillance), with and without upfront EUS/FNA (cytology, CEA, Amylase), in a randomized, crossover design. Group 1 adjudicated without EUS, Group 2 adjudicated with EUS, and Group 3 adjudicated with EUS after initially adjudicating without it.

RESULTS

The cohort included branch-duct (n = 20), mixed type (n = 6), and main duct (n = 4) IPMN, MCN (n = 5), and non-mucinous PCL (n = 5). Group 2 (EUS) correctly identified mucinous PCL with 97% sensitivity and 70% specificity, significantly higher than Group 1 (No EUS) (Sensitivity 91%, Specificity 20%; p = 0.04). Group 3 (Unblinded to EUS) performed significantly worse in mucinous PCL identification compared with Group 2, indicating cognitive bias (Sensitivity 97%, Specificity 10% (p = 0.0003)). Group 2 correctly identified high-risk PCL that required surgical intervention with 85% sensitivity and 85% specificity, significantly higher than Group 1 (Sensitivity 60%, Specificity 75%; p = 0.0016) and Group 3 (Sensitivity 73%, Specificity 80%, p = 0.0485).

CONCLUSION

While susceptible to cognitive bias, EUS significantly improves MDT assessment of PCL. MDT establishes a high bar for iterative additions of biomarkers to PCL analysis.