Endoskopie heute 2010; 23(3): 213-220
DOI: 10.1055/s-0030-1262587
Originalarbeit

© Georg Thieme Verlag Stuttgart ˙ New York

Kontrastverstärkter harmonischer Ultraschall bei soliden Pankreasläsionen: Ergebnisse einer Pilotstudie

Contrast-Enhanced Harmonic Endoscopic Ultrasound in Solid Lesions of the Pancreas: Results of a Pilot StudyB. Napoleon1 , 2 , M. V. Alvarez-Sanchetz1 , 2 , R. Gincoul2 , B. Pujol1 , C. Lefort1 , 2 , V. Lepilliez2 , M. Labadie3 , J. C. Souquet2 , P. E. Queneau2 , J. Y. Scoazec4 , J. A. Chayvialle2 , T. Ponchon2
  • 1Departments of Gastroenterology, Hôpital Privé Jean Mermoz, Lyon, France,
  • 2Departments of Gastroenterology, Hôpital Edouard Herriot, Lyon, France
  • 3Cabinet d’anatomopathologie, 41, Allée des Cyprès, Limonest, France
  • 4Department of Pathology, Hôpital Edouard Herriot, Lyon, France
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
28. September 2010 (online)

Zusammenfassung

Hintergrund und Studienziele: Die Unterscheidung zwischen einem Adenokarzinom des Pankreas und anderen Pankreasraumforderungen bleibt mit zur Zeit verfügbaren Bildgebungstechniken eine Herausforderung. Diese prospektive Studie hat das Ziel, die Genauigkeit einer neuen Methode der Abbildung des Mikrozirkulationsmusters des Pankreas mithilfe des kontrastverstärkten harmonischen endoskopischen Ultraschalls (CEH-EUS), durchgeführt mit einem neuen Ultraschall-Endoskop Prototyp der Firma Olympus, zu untersuchen. Patienten und Methoden: 35 Patienten mit soliden Pankreasläsionen wurden prospektiv in die Studie einbezogen. Bei allen Patienten war ein konventioneller B-Mode- und ein Power-Doppler-EUS durchgeführt worden. Nach der intravenösen Bolusgabe von 2,4 ml eines Ultraschallkontrastmittels der zweiten Generation (SonoVue) wurde die CEH–EUS mit einem neuen Echoendoskop Prototyp der Firma Olympus (xGF-UCT 180) durchgeführt. Das Mikrozirkulationsmuster wurde mit der Enddiagnose verglichen, die auf der pathologischen Untersuchung von während einer Operation gewonnenen Proben oder der EUS-gestützten Feinnadelaspiration (EUS-FNA) oder durch ein Follow-up von mindestens 12 Monaten beruhte. Ergebnisse: Enddiagnosen waren: 18 Adenokarzinome, 9 neuroendokrine Tumoren, 7 chronische Pankreatitis und 1 Stromatumor. Der Power-Doppler konnte keine Mikrozirkulation darstellen, dies war mit dem „harmonic imaging“ in allen Fällen möglich. Von 18 Läsionen mit einem hypointensen Signal bei der CEH-EUS, waren 16 Adenokarzinome. Die Sensitivität, Spezifität, der negative prädiktive Wert (NPV), der positive prädiktive Wert (PPV) und die Genauigkeit (accuracy) der Hypointensität bei der Diagnostik des Pankreaskarzinoms betrug 89, 88, 89 und 88,5 %, verglichen mit den korrespondierenden Ergebnissen der EUS-FNA von 72, 100, 77, 100 und 86 %. Von 5 Adenomkarzinomen mit falsch negativem Resultat bei der EUS-FNA hatten vier ein hypodenses Echosignal bei der CEH-EUS. Schlussfolgerung: Die CEH-EUS mit dem neuen Prototyp der Firma Olympus stellt zuverlässig das Mikrozirkulationsmuster in soliden Pankreasläsionen dar. Es kann hilfreich bei der Unterscheidung eines Adenokarzinoms von anderen Pankreasraumforderungen sein.

Abstract

Background and study aims: Distinguishing pancreatic adenocarcinoma from other pancreatic masses remains challenging with current imaging techniques. This prospective study aimed to evaluate the accuracy of a new procedure, imaging the microcirculation pattern of the pancreas by contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) with a new Olympus prototype echo endoscope. Patients and methods: 35 patients presenting with solid pancreatic lesions were prospectively enrolled. All patients had conventional B mode and power Doppler EUS. After an intravenous bolus injection of 2.4 ml of a second-generation ultrasound contrast agent (SonoVue) CEH-EUS was then performed with a new Olympus prototype echo endoscope (xGF-UCT 180). The microvascular pattern was compared with the final diagnosis based on the pathological examination of specimens from surgery or EUS-guided fine-needle aspiration (EUS-FNA) or on follow-up for at least 12 months. Results: The final diagnoses were: 18 adenocarcinomas, 9 neuroendocrine tumors, 7 chronic pancreatitis, and 1 stromal tumor. Power Doppler failed to display microcirculation, whereas harmonic imaging demonstrated it in all cases. Out of 18 lesions with a hypointense signal on CEH-EUS, 16 were adenocarcinomas. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of hypointensity for diagnosing pancreatic adenocarcinoma were 89, 88, 88, 89, and 88.5 %, compared with corresponding values of 72, 100, 77, 100, and 86 % for EUS-FNA. Of five adenocarcinomas with false-negative results at EUS-FNA, four had a hypointense echo signal at CEH-EUS. Conclusions: CEH-EUS with the new Olympus prototype device successfully visualizes the microvascular pattern in pancreatic solid lesions, and may be useful for distinguishing adenocarcinomas from other pancreatic masses.

Literatur

  • 1 Vanbeckevoort D. Solid pancreatic masss: benign or malignant.  JBR-BTR. 2007;  90 487-489
  • 2 Carter D C. Cancer of the head of pancreas or chronic pancreatitis? A diagnostic dilemma.  Surgery. 1992;  111 602-603
  • 3 Taylor B. Carcinoma of the head of the pancreas versus chronic pancreatitis: diagnostic dilemma with significant consequences.  World J Surg. 2003;  27 1249-1257
  • 4 Wharton S M, Rahman Z, Johnson C D. Missed curable carcinoma of the pancreas presenting as chronic pancreatitis.  Postgrad Med J. 1997;  73 577-579
  • 5 Hartmann D, Schilling D, Bassler B et al. ERCP and MRCP in the differentiation of pancreatic tumors.  Dig Dis. 2004;  22 18-25
  • 6 Boll D T, Merkle E M. Differentiating a chronic hyperplastic mass from pancreatic cancer: a challenge remaining in multidetector CT of the pancreas.  Eur Radiol. 2003;  13 Suppl 5 M42-M49
  • 7 DeBacker A I, Mortele K J, Ros R R et al. Chronic pancreatitis: diagnostic role of computed tomography and magnetic resonance imaging.  JBR-BTR. 2002;  85 304-310
  • 8 Schima W. MRI of the pancreas: tumours and tumour-simulating processes.  Cancer Imag. 2006;  6 199-203
  • 9 Brand B, Pfaff T, Binmoeller K F et al. Endoscopic ultrasound for differential diagnosis of focal pancreatic lesions, confirmed by surgery.  Scand J Gastroenterol. 2000;  35 1221-1228
  • 10 Bhutani M S, Hawes R H, Baron P L et al. Endoscopic ultrasound-guided fine-needle aspiration of malignant pancreatic lesions.  Endoscopy. 1997;  29 854-858
  • 11 Chang K, Nguyen P, Erickson R et al. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma.  Gastrointest Endosc. 1997;  45 387-394
  • 12 Giovannini M. Guided puncture-biopsy under endosonography.  Gastroenterol Clin Biol. 1997;  21 355-357
  • 13 Gress F G, Hawes R H, Savides T J et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography.  Gastrointest Endosc. 1997;  45 243-250
  • 14 Wiersema M J, Vilmann P, Giovannini M et al. Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment.  Gastroenterology. 1997;  112 1087-1095
  • 15 Williams D B, Sahai A V, Aabakken L et al. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience.  Gut. 1999;  44 720-726
  • 16 Fritscher-Ravens A, Schirrow L, Atay Z et al. Endosonographically controlled fine needle aspiration cytology – indications and results in routine diagnosis.  Z Gastroenterol. 1999;  37 343-351
  • 17 Voss M, Hammel P, Molas G et al. Value of endoscopic ultrasound guided fine needle aspiration biopsy in the diagnosis of solid pancreatic masses.  Gut. 2000;  46 244-249
  • 18 Gress F, Gottlieb K, Sherman S et al. Endoscopic ultrasonography-guided fine-needle aspiration biopsy of suspected pancreatic cancer.  Ann Intern Med. 2001;  134 459-464
  • 19 Harewood G C, Wiersema M J. Endosonography-guided fine needle aspiration biopsy in the evaluation of pancreatic masses.  Am J Gastroenterol. 2002;  97 1386-1391
  • 20 Eloubeidi M A, Chen V K, Eltoum I A et al. Endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer: diagnostic accuracy and acute and 30-day complications.  Am J Gastroenterol. 2003;  98 2663-2668
  • 21 Raut C P, Grau A M, Staerkel G A et al. Diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration in patients with presumed pancreatic cancer.  J Gastrointest Surg. 2003;  1 118-126
  • 22 Wilson J L, Kalade A, Prasad S et al. Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration.  Intern Med J. 2009;  39 32-37
  • 23 Dietrich C F. Characterisation of focal liver lesions with contrast enhanced ultrasonography.  Eur J Radiol. 2004;  51 9-17
  • 24 Bachmann M, Bang N. Contrast enhanced ultrasound in liver imaging.  Eur J Radiol. 2004;  51 3-S8
  • 25 Dietrich C F, Ignee A, Trojan J et al. Improved characterisation of histologically proven liver tumours by contrast enhanced ultrasonography during the portal venous and specific late phase of SHU 508A.  Gut. 2004;  53 401-405
  • 26 Rettenbacher T. Focal liver lesions: role of contrast-enhanced ultrasound.  Eur J Radiol. 2007;  64 173-182
  • 27 Morin S, Lim A, Cobbold J et al. Use of second generation contrast-enhanced ultrasound in the assessment of focal liver lesions.  World J Gastroenterol. 2007;  13 5963-5970
  • 28 De Jong N, Frinking P, Bouakaz A et al. Detection procedures of ultrasound contrast agents.  Ultrasonics. 2000;  38 87-92
  • 29 Hirooka Y, Goto H, Ito A et al. Contrast-enhanced endoscopic ultrasonography in pancreatic diseases: A preliminary study.  Am J Gastroenterol. 1998;  93 632-635
  • 30 Dietrich C F, Ignee A, Braden B et al. Improved differentiation of pancreatic tumors using contrast enhanced endoscopic ultrasound.  Clin Gastroenterol Hepatol. 2008;  6 590-597
  • 31 Becker D, Strobel D, Bernatik T et al. Echo-enhanced and color- and power-Doppler EUS for the discrimination between focal pancreatitis and pancreatic carcinoma.  Gastrointest Endosc. 2001;  53 784-789
  • 32 Hocke M, Schulze E, Gottschalk U et al. Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer.  World J Gastroenterol. 2006;  12 246-250
  • 33 Hocke M, Ignee A, Topalidis T et al. Contrast-enhanced endosonographic Doppler spectrum analysis is helpful in discrimination between focal chronic pancreatitis and pancreatic cancer.  Pancreas. 2007;  35 286-288
  • 34 Hocke M, Schmidt C, Zimmer B et al. Contrast enhanced endosonography for improving differential diagnosis between chronic pancreatitis and pancreatic cancer.  Dtsch Med Wochenschr. 2008;  133 1888-1892
  • 35 Sakamoto H, Kitano M, Suetomi Y et al. Utility of contrast-enhanced endoscopic ultrasonography for diagnosis of small pancreatic carcinomas.  Ultrasound Med Biol. 2008;  34 525-532
  • 36 Kitano M, Sakamoto H, Matsui U et al. A novel perfusion imaging technique of the pancreas: contrast-enhanced harmonic EUS.  Gastrointest Endosc. 2008;  67 141-149
  • 37 Hosoki T. Dynamic CT on pancreatic tumors.  AJR Am J Roentgenol. 1983;  140 959-965
  • 38 Freeny P C, Marks W M, Ryan J A et al. Pancreatic adenocarcinoma: diagnosis and staging with dynamic CT.  Radiology. 1988;  166 125-133
  • 39 Johnson P T, Outwater E K. Pancreatic carcinoma versus chronic pancreatitis: dynamic MR imaging.  Radiology. 1999;  212 213-218
  • 40 Linder S, Blåsjö M, Rosen A et al. Pattern of distribution and prognostic value of angiogenesis in pancreatic duct carcinoma.  Pancreas. 2001;  22 240-247
  • 41 Gritzmann N, Macheiner P, Hollerweger A et al. CT in the differentiation of pancreatic neoplasms – progress report.  Dig Dis. 2004;  22 6-17
  • 42 Claudon M, Cosgrove D, Albrecht T et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) – update 2008.  Ultraschall Med. 2008;  29 28-44
  • 43 Nagase M, Furuse J, Ishii H et al. Evaluation of contrast enhancement patterns in pancreatic tumors by coded harmonic sonographic imaging with a microbubble contrast agent.  J Ultrasound Med. 2003;  22 789-795
  • 44 Hohl C, Schmidt T, Haage P et al. Phase-inversion tissue harmonic imaging compared with conventional B-mode ultrasound in the evaluation of pancreatic lesions.  Eur Radiol. 2004;  14 1109-1117
  • 45 Kitano M, Kudo M, Maekawa K et al. Dynamic imaging of pancreatic diseases by contrast enhanced coded phase inversion harmonic ultrasonography.  Gut. 2004;  53 854-859
  • 46 D'Onofrio M, Martone E, Malagô R et al. Contrast-enhanced ultrasonography of the pancreas.  J Pancreas. 2007;  8 Suppl 71-76
  • 47 Kitano M, Sakamoto H, Maekawa K et al. Preliminary study of contrast-enhanced harmonic endosonography with second-generation contrast agents.  J Med Ultrasonics. 2008;  35 11-18
  • 48 Strobel D, Hahn E G, Becker D. Harmonic imaging for improving diagnosis of liver tumors – preliminary report.  Z Gastroenterol. 2001;  39 287-289
  • 49 Strobel D, Raeker S, Martus P et al. Phase inversion harmonic imaging versus contrast-enhanced power Doppler sonography for the characterization of focal liver lesions.  Int J Colorect Dis. 2003;  18 63-72
  • 50 Giovannini M, Hookey L C, Bories E et al. Endoscopic ultrasound elastography: the first step towards virtual biopsy? Preliminary results in 49 patients.  Endoscopy. 2006;  38 344-348
  • 51 Janssen J, Schlörer E, Greiner L. EUS elastography of the pancreas: feasibility and pattern description of the normal pancreas, chronic pancreatitis, and focal pancreatic lesions.  Gastrointest Endosc. 2007;  65 971-978
  • 52 Hirche T O, Ignee A, Barreiros A P et al. Indications and limitations of endoscopic ultrasound elastography for evaluation of local pancreatic lesions.  Endoscopy. 2008;  49 910-917
  • 53 Saftoiu A, Vilmann P, Gorunescu F et al. Neural network analysis of dynamic sequences of EUS elastography used for the differential diagnosis of chronic pancreatitis and pancreatic cancer.  Gastrointest Endosc. 2008;  68 1086-1094
  • 54 Bournet B, Souque A, Senesse P et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy coupled with KRAS mutation assay to distinguish pancreatic cancer from pseudotumoral chronic pancreatitis.  Endoscopy. 2009;  41 552-557
  • 55 Bhutani M S. Digital analysis of EUS images: “promising” method, but is it ready for “prime time”?.  Gastrointest Endosc. 2008;  67 868-70
  • 56 Esteban J M, Gil J. Therapeutic effect of chemoembolization therapy on hepatocellular carcinoma: evaluation with contrast-enhanced power Doppler sonography and contrast-enhanced harmonic imaging.  Acad Radiol. 2002;  Suppl 2 382-383
  • 57 Korpanty G, Carbon J G, Grayburn P et al. Monitoring response to anticancer therapy by targeting microbubbles to tumor vasculature.  Clin Cancer Res. 2007;  13 323-330
  • 58 Hernot S, Klibanov A L. Microbubbles in ultrasound-triggered drug and gene delivery.  Adv Drug Deliv Rev. 2008;  60 1153-1166

Prof. Dr. med. H.-J. Schulz

Klinik für Innere Medizin · Sana Klinikum Lichtenberg

Fanningerstr. 32

10365 Berlin

Telefon: 0 30 / 55 18 22 10

Fax: 0 30 / 55 18 22 50

eMail: hj.schulz@sana-kl.de

    >