Pancreatic cystic lesions: The value of contrast-enhanced endoscopic ultrasound to influence the clinical pathway

Abstract

Background and Objectives:Cystic pancreatic lesions are a growing diagnostic challenge. The aim of this study was to proof a new diagnostic concept based on contrast-enhanced endoscopic ultrasound (CE-EUS) for differential diagnosis.Patients and Methods:A total of 125 patients with unclear cystic pancreatic lesions were included. The initial diagnostic was made by CE-EUS dividing the lesions in a group without contrast enhancing effect in the cystic wall, septae or nodule indicating pseudocysts or dysontogenetic cysts and a group with contrast enhancing effect in the described structures indicating cystic neoplasias. The investigations were performed using a Pentax echoendoscope and Hitachi Preirus ultrasound machine. The contrast enhancer used was 4.8 mL SonoVue® (Bracco, Italy). The group with suspected cystic neoplasia was referred for endoscopic fine-needle puncture for further diagnostic or treatment decisions.Results:The dividing of the groups by contrast-enhanced ultrasound was feasible because all (n = 56) suspected cystic neoplasias showed a contrast enhancing effect, whereas in only 4 from 69 pseudocystic or dysontogenetic cystic lesions a contrast enhancing effect in the wall could be observed. Endoscopic fine-needle puncture could diagnose all malignant neoplasias and relevant premalignant conditions. The long-term follow-up did not show any development of malignant cystic lesions.Conclusion:Using CE-EUS and endoscopic fine-needle puncture as diagnostic criteria seemed to be a feasible method to deal with different cystic lesions in daily practice.

Intraductal papillary mucinous neoplasms and mucinous cystadenomas: current status and recommendations

“…To address this matter, a recent study (72) reported that mural nodules tend to appear with ill-defined borders and a hyperechoic center, as opposed to mucus that usually presents with a hyperechoic rim and hypoechoic center. Recently, contrast-enhanced EUS has seemed to provide valuable information regarding the vascularity perfusion characteristically seen in mural nodules (73), contributing to the current problematic regarding the differential diagnosis with intracystic mucus. Lastly, several studies have demonstrated an increased efficacy of EUS if combined with through-the-needle confocal laser-induced endomicroscopy.…”

Contrast–enhanced endoscopic ultrasound diagnosis of the intraductal papillary mucinous neoplasm

“…EUS, despite the high number of studies published showing its good diagnostic accuracy in PCNs [12][13][14][15][16][17][18][19][20][21], is recommended as an adjunct imaging modality in the European guidelines [3]. Several studies [5,[15][16][17] have shown that the diameter of the main pancreatic duct or a nodule at the time of diagnosis is a predictor of malignant IPMN. Fine needle aspiration (FNA) is an adjunctive procedure performed during EUS that is helpful in reaching a conclusive diagnosis as it allows the aspiration of cystic fluid or tissue collection of a nodule.…”

Endoscopic diagnosis of cystic lesions of the pancreas

“…Several studies evaluated the utility of CH-EUS for diagnosing pancreatic cystic lesions ( Table 2). [47][48][49][50][51][52][53][54][55] Detection by B-mode EUS of MN-like structures in dilated pancreatic ducts of patients with IPMN may result in difficulties determining whether these structures are mucous clots or MN. However, CH-EUS can distinguish these structures by evaluating the presence or the absence of blood flow in the lesion 47,48 (Figs 1 and 2).…”

“…A comparison of CH-EUS evaluation of MN with pathological findings after surgery in 17 patients who had IPMN with MN found that CH-EUS had a sensitivity of 100% and a specificity of 80% for the detection of MN. 51 Hocke et al 52 found that contrast enhancement at the cyst wall, septa or MN indicated cystic neoplasia. Similarly, Fusaroli et al 53 reported that cystic neoplasia was hyperenhanced on CH-EUS.…”