Clin Endosc.  2018 Jan;51(1):80-88. 10.5946/ce.2017.044.

Clinical Value of Contrast-Enhanced Harmonic Endoscopic Ultrasonography in the Differential Diagnosis of Pancreatic and Gallbladder Masses

• Leem G
• Chung MJ
• Park JY
• Bang S
• Song SY
• Chung JB
• Park SW

• KMID: 2403637
• DOI: http://doi.org/10.5946/ce.2017.044

Abstract

BACKGROUND/AIMS
Recent studies have revealed that contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) is beneficial in the differential diagnosis of malignant neoplasms of the pancreas and gallbladder from benign masses, in terms of the evaluation of microvasculature and real-time perfusion. In this study, we aimed to prove the clinical value of CEH-EUS in the differential diagnosis of pancreatic and gallbladder masses by direct comparison with that of conventional EUS.
METHODS
We reviewed the sonographic images and medical information of 471 patients who underwent conventional EUS and CEH-EUS for the diagnosis of pancreatic and gallbladder masses at a single medical center (Severance Hospital, Seoul, Korea) between March 2010 and March 2016.
RESULTS
The enhancement pattern of CEH-EUS of the pancreatic solid masses showed higher sensitivity and specificity in differentiating pancreatic adenocarcinoma and neuroendocrine tumors (82.0% and 87.9% for pancreatic adenocarcinoma and 81.1% and 90.9% for neuroendocrine tumors, respectively), and the area under the receiver operating characteristic curves was higher than that of conventional EUS. The enhancement texture of CEH-EUS of the gallbladder masses showed a higher sensitivity in differentiating malignant masses than that of conventional EUS; however, the difference between the areas under the receiver operating characteristic curves was not statistically significant.
CONCLUSIONS
CEH-EUS can complement conventional EUS in the diagnosis of pancreatic and gallbladder masses, in terms of the limitations of the latter.

Keyword

Contrast-enhanced harmonic endoscopic ultrasonography; EUS; Pancreatic mass; Gallbladder mass

MeSH Terms

Adenocarcinoma
Complement System Proteins
Diagnosis
Diagnosis, Differential*
Endosonography*
Gallbladder*
Humans
Microvessels
Neuroendocrine Tumors
Pancreas
Perfusion
ROC Curve
Sensitivity and Specificity
Seoul
Ultrasonography
Complement System Proteins

Figure

• 

  Fig. 1. Comparison of the receiver operating characteristic (ROC) curve with predicted probabilities from contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) and conventional EUS. (A) For ductal adenocarcinoma. The area under the ROC curve for CEH-EUS is 0.949 (SE 0.0140) and that for conventional EUS is 0.889 (SE 0.0220). (B) For neuroendocrine tumors. The area under the ROC curve for CEH-EUS is 0.945 (SE 0.0145) and that for conventional EUS is 0.870 (SE 0.0274).

• 

  Fig. 2. Comparison of the receiver operating characteristic (ROC) curve with predicted probabilities from contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) and conventional EUS for gallbladder malignant masses. The area under the ROC curve for CEH-EUS is 0.939 (SE 0.0218) and that for conventional EUS is 0.912 (SE 0.0331).

Reference

1. DeWitt J, Devereaux B, Chriswell M, et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med. 2004; 141:753–763.

2. Ngamruengphong S, Li F, Zhou Y, Chak A, Cooper GS, Das A. EUS and survival in patients with pancreatic cancer: a population-based study. Gastrointest Endosc. 2010; 72:78–83, 83.e1-e2.

3. Khashab MA, Yong E, Lennon AM, et al. EUS is still superior to multidetector computerized tomography for detection of pancreatic neuroendocrine tumors. Gastrointest Endosc. 2011; 73:691–696.

4. Ishikawa T, Itoh A, Kawashima H, et al. Usefulness of EUS combined with contrast-enhancement in the differential diagnosis of malignant versus benign and preoperative localization of pancreatic endocrine tumors. Gastrointest Endosc. 2010; 71:951–959.

5. Sakamoto H, Kitano M, Suetomi Y, Maekawa K, Takeyama Y, Kudo M. Utility of contrast-enhanced endoscopic ultrasonography for diagnosis of small pancreatic carcinomas. Ultrasound Med Biol. 2008; 34:525–532.

6. Becker D, Strobel D, Bernatik T, Hahn EG. Echo-enhanced color- and power-Doppler EUS for the discrimination between focal pancreatitis and pancreatic carcinoma. Gastrointest Endosc. 2001; 53:784–789.

7. Săftoiu A, Popescu C, Cazacu S, et al. Power Doppler endoscopic ultrasonography for the differential diagnosis between pancreatic cancer and pseudotumoral chronic pancreatitis. J Ultrasound Med. 2006; 25:363–372.

8. Hocke M, Schulze E, Gottschalk P, Topalidis T, Dietrich CF. Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer. World J Gastroenterol. 2006; 12:246–250.

9. Dietrich CF, Ignee A, Braden B, Barreiros AP, Ott M, Hocke M. Improved differentiation of pancreatic tumors using contrast-enhanced endoscopic ultrasound. Clin Gastroenterol Hepatol. 2008; 6:590–597.e1.

10. Săftoiu A, Iordache SA, Gheonea DI, et al. Combined contrast-enhanced power Doppler and real-time sonoelastography performed during EUS, used in the differential diagnosis of focal pancreatic masses (with videos). Gastrointest Endosc. 2010; 72:739–747.

11. Kudo M. Various contrast-enhanced imaging modes after administration of levovist. In : Kudo M, editor. Contrast harmonic imaging in the diagnosis and treatment of hepatic tumors. Tokyo: Springer Japan;2003. p. 22–25.

12. Whittingham TA. Contrast-specific imaging techniques: technical perspective. In : Quaia E, editor. Contrast media in ultrasonography: basic principles and clinical applications. Berlin: Springer Berlin Heidelberg;2005. p. 43–70.

13. Hirooka Y, Itoh A, Kawashima H, et al. Contrast-enhanced endoscopic ultrasonography in digestive diseases. J Gastroenterol. 2012; 47:1063–1072.

14. Kitano M, Kudo M, Yamao K, et al. Characterization of small solid tumors in the pancreas: the value of contrast-enhanced harmonic endoscopic ultrasonography. Am J Gastroenterol. 2012; 107:303–310.

15. Sakamoto H, Kitano M, Matsui S, et al. Estimation of malignant potential of GI stromal tumors by contrast-enhanced harmonic EUS (with videos). Gastrointest Endosc. 2011; 73:227–237.

16. Kitano M, Kudo M, Sakamoto H, Komaki T. Endoscopic ultrasonography and contrast-enhanced endoscopic ultrasonography. Pancreatology. 2011; 11 Suppl 2:28–33.

17. Kitano M, Sakamoto H, Matsui U, et al. A novel perfusion imaging technique of the pancreas: contrast-enhanced harmonic EUS (with video). Gastrointest Endosc. 2008; 67:141–150.

18. Schneider M, Arditi M, Barrau MB, et al. BR1: a new ultrasonographic contrast agent based on sulfur hexafluoride-filled microbubbles. Invest Radiol. 1995; 30:451–457.

19. Gong TT, Hu DM, Zhu Q. Contrast-enhanced EUS for differential diagnosis of pancreatic mass lesions: a meta-analysis. Gastrointest Endosc. 2012; 76:301–309.

20. Park CH, Chung MJ, Oh TG, et al. Differential diagnosis between gallbladder adenomas and cholesterol polyps on contrast-enhanced harmonic endoscopic ultrasonography. Surg Endosc. 2013; 27:1414–1421.