Innovations in Therapeutic Endoscopy for Pancreatic Disease: Confocal Laser Endomicroscopy

Frank Gress, MD, holding the CLE probe.

CLE allows early detection of cancer at the cellular level.

Pancreatic cysts are abnormal fluid-filled growths on or in the pancreas. Although many are benign, some become cancerous. Therefore it is very important that all pancreatic cysts are detected, evaluated, monitored, and if necessary, removed. Until recently, the only way to be vigilant about potentially cancerous cysts was to check on a regular basis (usually every six months to one year) using a form of imaging such as MRI or endoscopic ultrasound.

What if there were a way to know — early on, definitively and easily — whether the cyst should be removed or if it were harmless?

Thanks to confocal laser endomicroscopy, that capability is well on its way to reality.

CLE is a laser-powered device that allows doctors to view cells in high definition, much like one would view them under a microscope, but from inside the body. According to Frank Gress, MD, Clinical Division Chief and Chief of Interventional Endoscopy in the Division of Digestive Disease and Liver Disease, "This technology is very exciting because it allows us to detect early cancer and changes suggestive of early cancer such as dysplasia at the cellular level." Physicians at NewYork-Presbyterian/Columbia University Medical Center already use CLE in patients with Barrett's Esophagus, and it is used elsewhere for gastric lesions (to check for stomach cancer) and in the colon to evaluate polyps.

At the Pancreas Center, Dr. Gress and colleagues may insert CLE through an endoscope in order to view abnormal tissue in the bile duct or pancreatic duct lining. They may also use CLE during endoscopic ultrasound (EUS) to determine whether pancreatic cysts warrant further treatment or not.

According to Dr. Gress, the ability to characterize cells with CLE is "a game changer" in the management of challenging conditions such as chronic pancreatitis, pancreatic cysts, pancreatic and bile duct strictures, and intraductal papillary mucinous neoplasm (IPMN, an early form of pancreatic cancer). "Until now, we have not had an endoscopic tool that could provide such fine detailed information about a pancreatic or bile duct stricture, or to know whether a pancreatic cyst is benign or malignant," he explains.

Optical biopsies

CLE may be placed on a probe (probe-based CLE, or pCLE) and used to perform what is called an optical biopsy to determine whether cells are malignant or not by looking at them rather than extracting samples of tissue. It is also very helpful for targeting specific areas to biopsy. Some studies suggest that it may eventually replace the need for biopsies, although physicians at the Pancreas Center are still taking tissue biopsies and using CLE to validate their findings.

Researching CLE and its applications

To gain experience with CLE and to independently verify the positive outcomes that others have experienced with pCLE, Dr. Gress and his colleagues are collecting patient data and comparing that data to the images collected during probe-based CLE procedures. The team is also investigating the use of EUS-guided fine needle aspiration (FNA) CLE, also known as nCLE, in patients with pancreatic cysts. This work is part of a multicenter study in which the doctors insert an EUS needle into the pancreatic cyst, put the CLE probe through the needle, and examine the cells lining the walls of cysts. According to Dr. Gress, "We are hoping that nCLE will be able to provide high detailed and accurate characterization of pancreatic cysts such that pancreatic cysts can be more accurately differentiated into benign and malignant cysts."

For more information about advances in treating pancreatic disease, please visit pancreasmd.org.

Frank Gress, MD Clinical Division Chief and Chief of Interventional Endoscopy in the Division of Digestive Disease and Liver Disease
An expert in therapeutic endoscopy, he specializes in performing minimally invasive procedures to diagnose and treat disorders of the gastrointestinal tract, bile ducts, and pancreas.

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