Diagnostic Dilemma of Biliopancreatic Contrast-Enhanced Harmonic Endoscopic Ultrasonography

Abstract

Background: The utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) alone in the biliopancreatic region appears to be limited because it is highly dependent on the experience and skill of the endoscopist. Therefore, the present study aimed to validate the efficacy of CH-EUS in clinical practice. Methods: Between January 2018 and March 2019, 301 consecutive patients who underwent CH-EUS were prospectively enrolled in this study. The diagnostic performance of CH-EUS was compared with that of dynamic computed tomography (CT), magnetic resonance imaging (MRI), and all combinations (i.e., CH-EUS, dynamic CT, and MRI) using a Bonferroni correction. A multiple logistic regression analysis was performed to extract each disease that allowed the CH-EUS diagnosis to be consistent with the final diagnosis. Results: In multiple comparisons of diagnostic performance, no significant differences were observed among dynamic CT, MRI, and CH-EUS (p = 1.00), but the diagnostic performance was significantly higher when all modalities were combined (p < 0.001). Moreover, only intraductal papillary mucinous neoplasm comprising adenoma or carcinoma (IPMN, n = 161) showed significance with respect to the agreement with the final diagnosis (p = 0.006). Conclusions: Our results showed that CH-EUS-based diagnosis of IPMN may be possible in clinical practice. On the contrary, to accurately diagnose biliopancreatic diseases other than IPMN, comprehensive diagnosis using multiple modalities may be necessary, rather than relying on CH-EUS alone.

Keywords: biliary tract diseases; diagnostic performance; endosonography; pancreatic diseases; ultrasound contrast agents.

Figure 1

Comparison of the diagnostic performance among dynamic CT, MRCP, CH-EUS, and all combinations (i.e., CH-EUS, dynamic CT, and MRI) using Bonferroni correction (n = 301) during complete case analysis.

Figure 2

Typical and atypical contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) imaging of the biliopancreatic lesions (Left: fundamental B mode as a monitor image; Right: CH-EUS mode). (A) Typical intraductal papillary mucinous carcinoma imaging with hyperenhancement and a heterogenous pattern of the mural nodule (white arrow, 120 s after contrast infusion). Pathologic diagnosis by surgery: intraductal papillary mucinous carcinoma, invasive. (B) Typical intraductal papillary mucinous adenoma imaging with an avascular enhancement of mucinous clot (white arrow, 40 s after contrast infusion). This patient was followed up every 6 months for 15 months and with no signs of malignancy at the end of the follow-up period. (C) Typical pancreatic cancer imaging with hypoenhancement and a heterogenous pattern (60 s after contrast infusion). Pathologic diagnosis by surgery: pancreatic ductal adenocarcinoma. (D) Atypical pancreatic cancer imaging with a hyperenhancement pattern (90 s after contrast infusion). Pathologic diagnosis by surgery: pancreatic ductal adenocarcinoma. (E) Typical pancreatic neuroendocrine neoplasm imaging with an early hyperenhancement (10 s after contrast infusion). Pathologic diagnosis by endoscopic ultrasound-guided fine needle aspiration: pancreatic neuroendocrine tumor, G1 [20]. (F) Atypical pancreatic neuroendocrine neoplasm with hypoenhancement and heterogenous pattern (50 s after contrast infusion). Pathologic diagnosis by surgery: pancreatic neuroendocrine tumor, G2 [20]. (G) Typical gallbladder carcinoma imaging with an irregular intratumoral vessel (white arrow) and a perfusion defect (white arrowheads) at 120 s after contrast infusion. Pathologic diagnosis by surgery: papillary and tubular adenocarcinoma (pap > tub1). (H) Atypical gallbladder carcinoma imaging with a homogeneous enhancement (120 s after contrast infusion). Pathologic diagnosis by surgery: papillary and tubular adenocarcinoma (pap > tub1).