Dr Bertrand Napoléon is a gastroenterologist and interventional endoscopist at Hospital Jean Mermoz, Lyon, France who has been treating patients with pancreatic lesions and cancer for nearly 30 years and is a world leading expert in Confocal Laser Endomicroscopy.
Q. Which type of indications do you currently use Confocal Laser Endomicroscopy (CLE) for in your clinic?Since 2011 I have been using CLE, notably Cellvizio to characterize pancreatic cysts which have the possibility to develop into pancreatic cancer. My clinic is using this unique technology as a complimentary solution to diagnosis in order to improve patient outcomes.
Q. As an early adopter to CLE, how did you first become interested in the technique and the use of Cellvizio?
I was first interested by the originality of Cellvizio’s capabilities process. I considered this technology to be a real breakthrough for my patients, bringing a new generation of possibilities to see tissue in vivo and in real-time.
Q. What are issues with current standards of care in the diagnosis of pancreatic cysts?
With an aging population and better performing imaging technology there is an increasing number of patients found with cysts. It is very important to find the high-risk pancreatic cysts as early as possible and the issue we had was a real lack in our ability to diagnose cysts by traditional methods. This was mainly because of the low sensitivity of the cytology when we were doing traditional puncture biopsies and the impossibility to look inside the cysts in order to decide where to puncture and take the biopsy.
The characterization of cysts is a challenge, and there are many issues around deciding between malignant and benign characterization. This is important as it has a direct impact on the type of follow-up the patient receives. Depending on the characterization results a patient can be sent home, receive treatment or in the worst case be sent for complex surgery. We certainly do not want to send patients for unnecessary surgery due to uncertain diagnosis, this is a real problem.
Q.What is the potential utility of CLE and Cellvizio in the characterization of pancreatic cysts?
Cellvizio offers patients and physicians an alternative to traditional limited diagnostic solutions.
We had a particular problem in differentiation between Serous Cystic Adenoma (SCA), which are benign cysts and Intraductal Papillary Mucinous Neoplasms (IPMN) which are clearly precancerous cysts that need immediate follow-up, sometimes even surgery. One particular patient was passed to us after an initial MRI with the diagnosis of SCA plus continued follow-up. When my team investigated this patient with Cellvizio we saw the specific images of a large IPMN and we immediately considered surgery.
The opposite is also true, I have seen cases which were initially misdiagnosed as IPMN and when you actually examine the patient with Cellvizio you suddenly see it is a benign SCA. This differentiation between benign and malignant tumors prevents unnecessary procedures and allows better informed treatment decisions
In essence, Cellvizio completely changes how we approach each patient.
What are the patient benefits to choosing Cellvizio over other diagnostic techniques?
The great point with patients is that directly after a Cellvizio examination we are able to confirm the exact type of cyst in 80-90% of cases. For example, when we see on the Cellvizio image the typical microvascular network of an SCA we can inform the patient directly and they can be confident that there is no risk of cancer from this cyst. Even if the lab analysis, of the fluid sample taken during the Cellvizio case, is inconclusive we are now confident about the diagnosis based on Cellvizio images.
Is CLE with Cellvizio widely practiced in France?
CLE is gaining increased recognition across France. This is partly due to my team’s work, and another one in Paris who have been communicating on the fact that Cellvizio completely changes pancreatic cyst patient management. We now get patients referred to us from other endosonographers, with a specific request for Cellvizio analysis, as these patients were inconclusive from traditional methods.
What I also want to highlight is that we are no longer in a scientific study phase. My team is using and purchasing Cellvizio probes routinely because it changes our approach and we really believe in it.
What can be done to increase the use of Confocal Laser Endomicroscopy in preventing pancreatic cancers?
An important step is working with patient associations as they have strong networks of healthcare professionals who we can connect with to promote this type of examination through education on image interpretation.
For the long term, in my opinion, the inclusion of CLE in medical guidelines will also be important for the increased use of CLE worldwide. Existing published clinical results and the initial results of the recent CONTACT study demonstrate that the use of needle-based endomicroscopy should be considered for inclusion in the guidelines of pancreatic cyst diagnosis.