Characterization of Small Solid Tumors in the Pancreas: The Value of Contrast-Enhanced Harmonic Endoscopic Ultrasonography

OBJECTIVES: Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS), a novel technology, visualizes parenchymal perfusion in the pancreas. This study prospectively evaluated how accurately CH-EUS characterizes pancreatic lesions and compared its diagnostic ability with that of contrast-enhanced multidetector-row computed tomography (MDCT) and endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). METHODS: A total of 277 consecutive patients with pancreatic solid lesions that were detected by conventional EUS underwent CH-EUS for evaluation of vascularity. After infusing an ultrasound contrast, CH-EUS was performed by using an echoendoscope and a specific mode for contrast harmonic imaging. On the basis of the intensity of enhancement, the lesions were categorized into four patterns: nonenhancement, hypoenhancement, isoenhancement, and hyperenhancement. For comparison, all patients underwent MDCT. The ability of CH-EUS to differentiate ductal carcinomas from the other solid tumors, particularly small lesions (<= 2 cm in diameter) was assessed, and compared with the differentiating abilities of MDCT and EUS-FNA. RESULTS: In terms of reading the CH-EUS images, the kappa-coefficient of the interobserver agreement test was 0.94 (P<0.001). CH-EUS-depicted hypoenhancement diagnosed ductal carcinomas with a sensitivity and specificity of 95.1% (95% confidence interval (CI) 92.7-96.7%) and 89.0% (95% CI 83.0-93.1%), respectively. For diagnosing small carcinomas by CH-EUS, the sensitivity and specificity were 91.2% (95% CI 82.5-95.1%) and 94.4% (95% CI 86.2-98.1%), respectively. CH-EUS-depicted hypervascular enhancement diagnosed neuroendocrine tumors with a sensitivity and specificity of 78.9% (95% CI 61.4-89.7%) and 98.7% (95% CI 96.7-98.8%), respectively. Although CH-EUS and MDCT did not differ significantly in diagnostic ability with regard to all lesions, CH-EUS was superior to MDCT in diagnosing small (<= 2 cm) carcinomas (P<0.05). In 12 neoplasms that MDCT failed to detect, 7 ductal carcinomas and 2 neuroendocrine tumors had hypoenhancement and hyperenhancement on CH-EUS, respectively. When CH-EUS was combined with EUS-FNA, the sensitivity of EUS-FNA increased from 92.2 to 100%. CONCLUSIONS: CH-EUS is useful for characterizing conventional EUS-detected solid pancreatic lesions. EUS equipped with contrast harmonic imaging may play an important role in the characterization of small tumors that other imaging methods fail to depict and may improve the diagnostic yield of EUS-FNA.