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.