Original article—liver, pancreas, and biliary tract
Improved Differentiation of Pancreatic Tumors Using Contrast-Enhanced Endoscopic Ultrasound

https://doi.org/10.1016/j.cgh.2008.02.030Get rights and content

Background & Aims: Endoscopic ultrasound is a widely accepted imaging method for staging of ductal adenocarcinoma and the localization of neuroendocrine tumors of the pancreas. We prospectively evaluated conventional color Doppler imaging and contrast-enhanced endoscopic Doppler ultrasound (CE-EDUS) as a new imaging technique for further characterization and differentiation of solid pancreatic tumors. Methods: From 300 patients with pancreatic lesions investigated using contrast-enhanced endoscopic ultrasound we could finally include 93 patients with an undetermined, solitary, predominantly solid, lesion 40 mm or less, and a definite histologically proven diagnosis. After bolus injection of the contrast agent SHU 508A 4 g (400 mg/dL) the vascular pattern of the lesion during the arterial phase was compared with the vascularity of the residual pancreatic parenchyma. Results: Color Doppler imaging did not reveal vascularity of the pancreatic parenchyma in any of the patients, and therefore tumor hypovascularity could not be determined in contrast to all CE-EDUS–examined patients revealing at least some degree of parenchymal vascularity. Fifty-seven of 62 patients with ductal adenocarcinoma of the pancreas showed a hypovascularity of the tumor using CE-EDUS. All other pancreatic lesions revealed an isovascular or hypervascular pattern using contrast-enhanced endoscopic ultrasound (20 neuroendocrine tumors, 10 serous microcystic adenomas, and 1 teratoma). Hypovascularity as a sign of malignancy in contrast-enhanced endoscopic ultrasound obtained 92% (82%–97%) sensitivity and 100% specificity (89%–100%). Conclusions: Contrast-enhanced endoscopic ultrasound is effective in differentiating small solid pancreatic tumors of different origin in most cases. Hypovascularity indicates malignancy of pancreatic tumors.

Section snippets

Patients

From 1999 to 2006 we prospectively examined more than 300 patients with pancreatic lesions using CE-EDUS. Institutional Board approval and oral informed consent according to the ethical guidelines from Helsinki were obtained from all patients after informing the patient about the purpose and aim of the study before the endoscopic ultrasound examination was started.

Inclusion Criteria for Study Analysis

Inclusion criteria for study analysis were an undetermined, solitary, predominantly solid, lesion 40 mm or less with a definite

Methods

Endoscopic ultrasound was performed using an electronic linear ultrasound probe (Pentax FG 34 or Pentax FG 38 UX; [Pentax, Hamburg, Germany]; Hitachi EUB 525, Hitachi 6500, or Hitachi 8500 [Hitachi, Wiesbaden, Germany]). The pancreas was evaluated as recently described.32 A contrast-enhancing agent (Levovist) was applied in all patients (4 g, 400 mg/dL, bolus injection) via a catheter of 1.2-mm diameter or larger into a cubital vein.33 Levovist consists of air and a galactose palmitate shell

Ductal Adenocarcinoma

During the study period we observed 212 patients with histologically proven ductal adenocarcinoma of the pancreas. Ninety-eight patients were excluded because of liver and/or lung metastases or metastases of other organs. A total of 114 patients with undetermined lesions were examined by endoscopic ultrasound, all with solitary nodules of the pancreas. In 52 patients, lesions were greater than 40 mm with or without chronic pancreatitis and, therefore, also excluded from study analysis.

Discussion

If a pancreatic tumor is diagnosed, its differentiation is mandatory for adequate therapy and important for prognosis. The role of conventional endoscopic ultrasound and other imaging methods (eg, computerized tomography and magnetic resonance imaging) in the differential diagnosis of pancreatic masses were reported to be disappointing.37, 38, 39, 40 Therefore, a method with high sensitivity and specificity for tumor differentiation is necessary. The vascularity pattern of pancreatic tumors has

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