Contrast enhanced endoscopic ultrasound: More than just a fancy Doppler

Enhanced endoscopic ultrasound imaging for pancreatic lesions: The road to artificial intelligence

Early detection of pancreatic cancer has long eluded clinicians because of its insidious nature and onset. Often metastatic or locally invasive when symptomatic, most patients are deemed inoperable. In those who are symptomatic, multi-modal imaging modalities evaluate and confirm pancreatic ductal adenocarcinoma. In asymptomatic patients, detected pancreatic lesions can be either solid or cystic. The clinical implications of identifying small asymptomatic solid pancreatic lesions (SPLs) of < 2 cm are tantamount to a better outcome. The accurate detection of SPLs undoubtedly promotes higher life expectancy when resected early, driving the development of existing imaging tools while promoting more comprehensive screening programs. An imaging tool that has matured in its reiterations and received many image-enhancing adjuncts is endoscopic ultrasound (EUS). It carries significant importance when risk stratifying cystic lesions and has substantial diagnostic value when combined with fine needle aspiration/biopsy (FNA/FNB). Adjuncts to EUS imaging include contrast-enhanced harmonic EUS and EUS-elastography, both having improved the specificity of FNA and FNB. This review intends to compile all existing enhancement modalities and explore ongoing research around the most promising of all adjuncts in the field of EUS imaging, artificial intelligence.

Endoscopic ultrasound (EUS) and the management of pancreatic cancer

Pancreatic cancer is one of the leading causes of cancer-related mortality in western countries. Early diagnosis of pancreatic cancers plays a key role in the management by identification of patients who are surgical candidates. The advancement in the radiological imaging and interventional endoscopy (including endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography and endoscopic enteral stenting techniques) has a significant impact in the diagnostic evaluation, staging and treatment of pancreatic cancer. The multidisciplinary involvement of radiology, gastroenterology, medical oncology and surgical oncology is central to the management of patients with pancreatic cancers. This review aims to highlight the diagnostic and therapeutic role of EUS in the management of patients with pancreatic malignancy, especially pancreatic ductal adenocarcinoma.

Contrast-enhanced endoscopic ultrasound features of tubercular lymphadenopathy

There is lack of data on the contrast-enhanced endoscopic ultrasound features of tubercular lymph node; our retrospective analysis of 37 patients with enlarged mediastinal and abdominal lymph nodes showed heterogeneous enhancement in the great majority (70%).

Perfluoropentane-filled chitosan poly-acrylic acid nanobubbles with high stability for long-term ultrasound imaging in vivo

Reducing the size of ultrasound contrast agents (UCAs) will decrease the intensity of the ultrasound echogenic signals and reduce the stability of the bubbles. Therefore, it is a challenge to design nanobubbles that are less than 200 nm in size and that have both good imaging abilities and high stability for long-term imaging in vivo. In this work, we successfully prepared perfluoropentane-filled chitosan poly-acrylic acid (PFP-CS-PAA) nanobubbles with a size of about 100 nm via a direct simple core-template-free strategy. In vitro tests demonstrated that the nanobubbles showed satisfactory imaging capabilities in non-linear harmonic imaging mode and had significantly better stability than commercial Sonovue® lipid microbubbles. It was valuable to discover that the prepared PFP-CS-PAA nanobubbles could exhibit good imaging quality in rat livers for 10 min after intravenous injection. Also, the PFP-CS-PAA nanobubbles could maintain imaging capabilities in nude mouse tumors for 7 days after intratumoral injection, which indicated that these nanobubbles could keep their stability for a long time in vivo. To the best of our knowledge, the ultrasound imaging persistence time in vivo was the longest of currently reported polymer nanobubbles that are smaller than 200 nm. This new nanosized UCA with high stability has great potential for long-term ultrasound imaging in vivo. Tumor cellular uptake and histological analysis revealed that PFP-CS-PAA nanobubbles could be taken up into tumor cells, but no intracellular uptake was observed in the case of Sonovue®. Animal fluorescence imaging in vivo demonstrated that PFP-CS-PAA nanobubbles could be effectively cleared after intravenous injection within 168 h. MTT assays indicated that PFP-CS-PAA nanobubbles had appropriate biocompatibility. Abnormal levels of blood urea nitrogen were detected after the intravenous administration of PFP-CS-PAA nanobubbles to rats, and body-weight gain was inhibited for up to 6 d, but, after that, body weights recovered their tendency to increase.

Contrast-Enhanced EUS for Differential Diagnosis of Pancreatic Masses: A Meta-Analysis

BACKGROUND

Though methods for the diagnosis of pancreatic masses are various, such as ultrasonography (US), computed tomography (CT), endoscopic ultrasonography (EUS), and contrast-enhanced computed tomography (CE-CT), their sensitivity, specificity, and accuracy are not quite satisfying. Contrast-enhanced endoscopic ultrasonography (CE-EUS), as a new technique, has its own unique advantages in diagnosing pancreatic disease. However, its sensitivity, specificity, and accuracy are still controversial.

OBJECTIVE

To evaluate the accuracy of CE-EUS for differential diagnosis between benign and malignant pancreatic mass lesions.

DESIGN

Eighteen relevant articles systemically searched from PubMed, Web of Science, Ovid, Scopus, and MEDLINE were selected. The pooled results were calculated in a fixed effects model.

MAIN OUTCOME MEASUREMENT

The pooled sensitivity, specificity, positive likelihood ratio (LR), negative likelihood ratio, diagnostic odds ratio (OR), and summary receiver operating characteristic (SROC) curve.

RESULTS

The pooled sensitivity, specificity, and diagnostic odds ratio of CE-EUS for the differential diagnosis of pancreatic adenocarcinomas were 0.91 (95% confidence interval (CI), 0.89-0.93), 0.86 (95% CI, 0.83-0.89), and 69.50 (95% CI, 48.89-98.80), respectively. The SROC area under the curve was 0.9545. The subgroup analysis based on excluding the outliers showed that the heterogeneity was eliminated and the pooled sensitivity and specificity were 0.92 (95% CI, 0.90-0.93) and 0.87 (95% CI, 0.84-0.89), respectively. The SROC area under the curve was 0.9569.

CONCLUSION

CE-EUS is a useful method to distinguish pancreatic adenocarcinoma from other pancreatic diseases. Compared with EUS elastography, it has higher specificity. However, it is still not superior to pathological diagnosis for the identification of pancreatic carcinomas.

Clinical controversies in endoscopic ultrasound

The field of diagnostic and therapeutic endoscopic ultrasound (EUS) is growing rapidly. Although EUS has enhanced our ability to diagnose and treat a wide variety of GI conditions, there are many controversial issues regarding the appropriate application of EUS techniques. In this review we discuss five controversial topics in EUS: the utility of EUS in staging of esophageal and gastric cancer; selection of appropriate needle gauge for fine needle aspiration (FNA); use of the stylet in FNA; and the emerging role of contrast agents in endoscopic ultrasound.