The Contrast-Enhanced Harmonic Endoscopic Ultrasonography Fine-Needle Aspiration Technique: Comparison
Please note this is a comparison between Version 2 by Conner Chen and Version 1 by Ken Kamata.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is useful for the diagnosis of pancreatic masses. According to three meta-analyses, the sensitivity, specificity, and accuracy of EUS-FNA are 84–92%, 96–98%, and 86–91%, respectively. However, the occurrence of false-negative and false-positive results indicates that the diagnostic performance of EUS-FNA needs to be improved. Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is used for the characterization of pancreatic masses and can be applied to improve the performance of EUS-FNA. 

  • avascular
  • contrast
  • endoscopic ultrasonography
  • endoscopic ultrasound-guided fine-needle aspiration

1. Introduction

Endoscopic ultrasonography (EUS) allows detailed visualization of the pancreas and the localization of pancreatic solid masses. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was first applied clinically by Vilmann et al. in 1992 [1], and is currently widely used for the pathological diagnosis of pancreatic solid masses. According to three meta-analyses evaluating the diagnostic performance of EUS-FNA for pancreatic masses, its sensitivity, specificity, and accuracy range between 84–92%, 96–98%, and 86–91%, respectively [2]. Thus, EUS-FNA is associated with a few false-negative and false-positive results. Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) allows the visualization of intratumor blood flow using an ultrasound contrast agent, such as Perflubutane microspheres, and is applied for the identification and characterization of pancreatobiliary masses [3,4][3][4]. Although EUS-FNA is usually performed under EUS guidance, CH-EUS can be used to guide the needle to a specific site in the tumor to improve specimen collection.

2. The CH-EUS-FNA Technique

In selecting the literature, the following search terms were used in PubMed: contrast (title or abstract) OR contrast-enhanced (title or abstract) OR contrast-enhanced harmonic (title or abstract) OR CE-EUS (title or abstract) OR CH-EUS (title or abstract) OR CEH-EUS (title or abstract) AND endoscopic ultrasound (title or abstract) OR EUS (title or abstract) OR endosonography (title or abstract or MeSH terms) OR endoscopic ultrasonography (title or abstract) AND FNA (title or abstract) OR FNB (title or abstract) OR fine needle aspiration (title or abstract) OR fine needle biopsy (title or abstract) OR sampling (title or abstract). Then, after sequential screening of abstracts and texts, eight studies were determined as shown in Table 1 [5,6,7,8,9,10,11,12][5][6][7][8][9][10][11][12]. In most studies, CH-EUS-FNA was performed in the late phase of CH-EUS (Table 1), suggesting that CH-EUS-FNA was performed after evaluation of blood flow in the pancreatic mass in late-phase CH-EUS. However, in one study, CH-EUS-FNA was performed in the early arterial phase [12].
Table 1.
Studies on CH-EUS-FNA for pancreatic masses.

References

  1. Vilmann, P.; Jacobsen, G.K.; Henriksen, F.W.; Hancke, S. Endoscopic ultrasonography with guided fine needle aspiration biopsy in pancreatic disease. Gastrointest. Endosc. 1992, 38, 172–173.
  2. Yang, Y.; Li, L.; Qu, C.; Liang, S.; Zeng, B.; Luo, Z. Endoscopic ultrasound-guided fine needle core biopsy for the diagnosis of pancreatic malignant lesions: A systematic review and Meta-Analysis. Sci. Rep. 2016, 6, 22978.
  3. Imazu, H.; Uchiyama, Y.; Matsunaga, K.; Ikeda, K.-I.; Kakutani, H.; Sasaki, Y.; Sumiyama, K.; Ang, T.L.; Omar, S.; Tajiri, H. Contrast-enhanced harmonic EUS with novel ultrasonographic contrast (Sonazoid) in the preoperative T-staging for pancreaticobiliary malignancies. Scand. J. Gastroenterol. 2010, 45, 732–738.
  4. Kitano, M.; Kamata, K.; Imai, H.; Miyata, T.; Yasukawa, S.; Yanagisawa, A.; Kudo, M. Contrast-enhanced harmonic endoscopic ultrasonography for pancreatobiliary diseases. Dig. Endosc. 2015, 27, 60–67.
  5. Napoleon, B.; Alvarez-Sanchez, M.V.; Gincoul, R.; Pujol, B.; Lefort, C.; Lepilliez, V.; Labadie, M.; Souquet, J.C.; Queneau, P.E.; Scoazec, J.Y.; et al. Contrast-enhanced harmonic endoscopic ultrasound in solid lesions of the pancreas: Results of a pilot study. Endoscopy 2010, 42, 564–570.
  6. Gincul, R.; Palazzo, M.; Pujol, B.; Tubach, F.; Palazzo, L.; Lefort, C.; Fumex, F.; Lombard, A.; Ribeiro, D.; Fabre, M.; et al. Contrast-harmonic endoscopic ultrasound for the diagnosis of pancreatic adenocarcinoma: A prospective multicenter trial. Endoscopy 2014, 46, 373–379.
  7. Hou, X.; Jin, Z.; Xu, C.; Zhang, M.; Zhu, J.; Jiang, F.; Li, Z. Contrast-Enhanced Harmonic Endoscopic Ultrasound-Guided Fine-Needle Aspiration in the Diagnosis of Solid Pancreatic Lesions: A Retrospective Study. PLoS ONE 2015, 10, e0121236.
  8. Sugimoto, M.; Takagi, T.; Hikichi, T.; Suzuki, R.; Watanabe, K.; Nakamura, J.; Kikuchi, H.; Konno, N.; Waragai, Y.; Watanabe, H.; et al. Conventional versus contrast-enhanced harmonic endoscopic ultrasonography-guided fine-needle aspiration for diagnosis of solid pancreatic lesions: A prospective randomized trial. Pancreatology 2015, 15, 538–541.
  9. Seicean, A.; Badea, R.; Moldovan-Pop, A.; Vultur, S.; Botan, E.C.; Zaharie, T.; Săftoiu, A.; Mocan, T.; Iancu, C.; Graur, F.; et al. Harmonic Contrast-Enhanced Endoscopic Ultrasonography for the Guidance of Fine-Needle Aspiration in Solid Pancreatic Masses. Ultraschall der Med.-Eur. J. Ultrasound 2015, 38, 174–182.
  10. Facciorusso, A.; Cotsoglou, C.; Chierici, A.; Mare, R.; Crinò, S.F.; Muscatiello, N. Contrast-Enhanced Harmonic Endoscopic Ultrasound-Guided Fine-Needle Aspiration versus Standard Fine-Needle Aspiration in Pancreatic Masses: A Propensity Score Analysis. Diagnostics 2020, 10, 792.
  11. Seicean, A.; Samarghitan, A.; Bolboacă, S.D.; Pojoga, C.; Rusu, I.; Rusu, D.; Sparchez, Z.; Gheorghiu, M.; Al Hajjar, N.; Seicean, R. Contrast-enhanced harmonic versus standard endoscopic ultrasound-guided fine-needle aspiration in solid pancreatic lesions: A single-center prospective randomized trial. Endoscopy 2020, 52, 1084–1090.
  12. Itonaga, M.; Kitano, M.; Kojima, F.; Hatamaru, K.; Yamashita, Y.; Tamura, T.; Nuta, J.; Kawaji, Y.; Shimokawa, T.; Tanioka, K.; et al. The usefulness of EUS-FNA with contrast-enhanced harmonic imaging of solid pancreatic lesions: A prospective study. J. Gastroenterol. Hepatol. 2020, 35, 2273–2280.
  13. Kitano, M.; Kudo, M.; Maekawa, K.; Suetomi, Y.; Sakamoto, H.; Fukuta, N.; Nakaoka, R.; Kawasaki, T. Dynamic imaging of pancreatic diseases by contrast enhanced coded phase inversion harmonic ultrasonography. Gut 2004, 53, 854–859.
  14. Yamashita, Y.; Shimokawa, T.; Napoléon, B.; Fusaroli, P.; Gincul, R.; Kudo, M.; Kitano, M. Value of contrast-enhanced harmonic endoscopic ultrasonography with enhancement pattern for diagnosis of pancreatic cancer: A meta-analysis. Dig. Endosc. 2018, 31, 125–133.
  15. Kitano, M.; Yamashita, Y.; Kamata, K.; Ang, T.L.; Imazu, H.; Ohno, E.; Hirooka, Y.; Fusaroli, P.; Seo, D.-W.; Napoléon, B.; et al. The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) Guidelines for Contrast-Enhanced Endoscopic Ultrasound. Ultrasound Med. Biol. 2021, 47, 1433–1447.
  16. Bang, J.Y.; Magee, S.H.; Ramesh, J.; Trevino, J.M.; Varadarajulu, S. Randomized trial comparing fanning with standard technique for endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic mass lesions. Endoscopy 2013, 45, 445–450.
  17. D’Onofrio, M.; Biagioli, E.; Gerardi, C.; Canestrini, S.; Rulli, E.; Crosara, S.; De Robertis, R.; Floriani, I. Diagnostic Performance of Contrast-Enhanced Ultrasound (CEUS) and Contrast-Enhanced Endoscopic Ultrasound (ECEUS) for the Differentiation of Pancreatic Lesions: A Systematic Review and Meta-Analysis. Ultraschall der Med. Eur. J. Ultrasound 2014, 35, 515–521.
  18. Fusaroli, P.; Napoleon, B.; Gincul, R.; Lefort, C.; Palazzo, L.; Palazzo, M.; Kitano, M.; Minaga, K.; Caletti, G.; Lisotti, A. The clinical impact of ultrasound contrast agents in EUS: A systematic review according to the levels of evidence. Gastrointest. Endosc. 2016, 84, 587–596e10.
  19. Kamata, K.; Takenaka, M.; Omoto, S.; Miyata, T.; Minaga, K.; Yamao, K.; Imai, H.; Sakurai, T.; Nishida, N.; Chikugo, T.; et al. Impact of avascular areas, as measured by contrast-enhanced harmonic EUS, on the accuracy of FNA for pancreatic adenocarcinoma. Gastrointest. Endosc. 2017, 87, 158–163.
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