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. 2021 Apr 22;10(9):1818.
doi: 10.3390/jcm10091818.

Should Contrast-Enhanced Harmonic Endoscopic Ultrasound Be Incorporated into the International Consensus Guidelines to Determine the Appropriate Treatment of Intraductal Papillary Mucinous Neoplasm?

Tomohiro Yamazaki  1 , Mamoru Takenaka  1 , Shunsuke Omoto  1 , Tomoe Yoshikawa  1 , Rei Ishikawa  1 , Ayana Okamoto  1 , Atsushi Nakai  1 , Kosuke Minaga  1 , Ken Kamata  1 , Kentaro Yamao  1 , Yoriaki Komeda  1 , Tomohiro Watanabe  1 , Naoshi Nishida  1 , Keiko Kamei  2 , Ippei Matsumoto  2 , Yoshifumi Takeyama  2 , Takaaki Chikugo  3 , Yasutaka Chiba  4 , Masatoshi Kudo  1
Affiliations

Should Contrast-Enhanced Harmonic Endoscopic Ultrasound Be Incorporated into the International Consensus Guidelines to Determine the Appropriate Treatment of Intraductal Papillary Mucinous Neoplasm?

Tomohiro Yamazaki et al. J Clin Med. .

Abstract

This study aimed to investigate whether the incorporation of contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) into the international consensus guidelines (ICG) for the management of intraductal papillary mucinous neoplasm (IPMN) could improve its malignancy diagnostic value. In this single-center retrospective study, 109 patients diagnosed with IPMN who underwent preoperative CH-EUS between March 2010 and December 2018 were enrolled. We analyzed each malignancy diagnostic value (sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV)) by replacing fundamental B-mode EUS with CH-EUS as the recommended test for patients with worrisome features (WF) (the CH-EUS incorporation ICG) and comparing the results to those obtained using the 2017 ICG. The malignancy diagnostic values as per the 2017 ICG were 78.9%, 42.3%, 60.0%, and 64.7% for Se, Sp, PPV, and NPV, respectively. The CH-EUS incorporation ICG plan improved the malignancy diagnostic values (Se 78.9%/Sp, 53.8%/PPV, 65.2%/NPV 70.0%). CH-EUS may be useful in determining the appropriate treatment strategies for IPMN.

Keywords: contrast-enhanced harmonic endoscopic ultrasound; diagnostic value; international consensus guidelines; intraductal papillary mucinous neoplasm; pancreas.

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Conflict of interest statement

The authors declare no conflict of interests.

Figures

Figure 1
Figure 1
(a) Fundamental B-mode EUS showing a suspected mural nodule (arrowhead); (b) Contrast-enhanced harmonic EUS showing lesion enhancement and a definitive diagnosis of mural nodule (arrowhead); (c,d) Histopathological examination: structural atypia, nuclear enlargement, and irregular papillary structure are evident. EUS, endoscopic ultrasound.
Figure 2
Figure 2
(a) MRCP shows a defect in the cystic lesion suspected as a mural nodule (arrow); (b) Fundamental B-mode EUS shows a suspected mural nodule (arrowhead); (c) Contrast-enhanced harmonic EUS shows the absence of enhancement (arrowhead). MRCP, magnetic resonance cholangiopancreatography; EUS, endoscopic ultrasound.
Figure 3
Figure 3
The flow chart outlining the enrollment of this study. Of the 138 cases who underwent surgical resection for IPMN, 109 patients were finally enrolled after excluding three patients who had concomitant pancreatic ductal adenocarcinoma, nine patients who had not undergone contrast-enhanced CT (CE-CT) or EUS, and 17 patients who were diagnosed with MD-type IPMN. EUS, endoscopic ultrasound; CT, computed tomography, IPMN, intraductal papillary mucinous neoplasm; MD, main pancreatic duct.
Figure 4
Figure 4
A schema rendering the time schedule of CH-EUS. The presence or absence of blood flow in the nodule was evaluated for 20 s immediately after administration (vessel image), and the degree of contrast was evaluated during the period between 40 and 60 s after administration (perfusion image). CH-EUS, contrast-enhanced harmonic endoscopic ultrasound.
Figure 5
Figure 5
Algorithm for the management of BD-type IPMN as per the 2017 ICG. The recommended test for patients with WF on the diagnosis of malignancy is fundamental B-mode EUS. *, the number in parentheses is the number of malignant IPMNs; EUS, endoscopic ultrasound; WF, worrisome features; ICG, international consensus guidelines.
Figure 6
Figure 6
Algorithm for the management of BD-type IPMN as per the “CH-EUS incorporation” ICG. The recommended test for patients with WF on the diagnosis of malignancy was replaced FB-EUS with CH-EUS. *, The number in parentheses is the number of malignant IPMNs; EUS, endoscopic ultrasound; WF, worrisome features; ICG, international consensus guidelines; CH-EUS, contrast-enhanced harmonic endoscopic ultrasound.
Figure 7
Figure 7
Comparison of the ROC curves of nodule height evaluated using CH-EUS and FB-EUS. The highest diagnostic value of the evaluation of the nodule height using CH-EUS was calculated as 5 mm with an AUC of 0.764 (Se 55.8%, Sp 84.2%) using the ROC curve analysis. The highest diagnostic value of the evaluation of the nodule height using FB-EUS was calculated as 8 mm with an AUC of 0.714 (Se 67.3%, Sp 64.9%) using the ROC curve analysis. CH-EUS, contrast-enhanced harmonic endoscopic ultrasound; FB-EUS, fundamental B-mode endoscopic ultrasound; ROC, receiver-operating characteristic; AUC, area under the curve.
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