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CEUS Pancreas: Solid Lesions
Christian Jenssen, MD; Mirko D‘Onofrio, MD
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KEY FACTS

  • Terminology

    • Clinical Implications

      • Role of CEUS

        TERMINOLOGY

        • Definitions

          • Pancreatic ductal adenocarcinoma (PDAC): > 80% of solid pancreatic neoplasms
            • Origin
              • Pancreatic ductal or acinar epithelium
            • Outcome
              • Poor in most cases
                • Curative surgical treatment possible in only ~ 15%
            • Clinical presentation
              • Abdominal pain, weight loss, and obstructive jaundice
            • 85% of PDACs are located within pancreatic head and tend to involve both main pancreatic duct (MPD) &/or common bile duct (CBD) (double duct sign)
              • Dilatation of MPD &/or CBD facilitates detection of pancreatic head cancer using US and cross-sectional imaging
          • Pancreatic neuroendocrine tumor (PNET) and pancreatic neuroendocrine carcinoma (PNEC) are 2nd most common solid neoplastic lesions of pancreas, accounting for < 5% of solid pancreatic neoplasms (with incidence increasing)
            • Origin
              • Endocrine pancreatic cells
            • Classification
              • Functioning (hormone producing, less common)
              • Nonfunctioning (up to 90% of cases)
            • Outcome
              • Depends on grade of differentiation
                • Excellent in small G1 PNET
                • Favorable in PNEC
            • Clinical presentation
              • Nonfunctioning PNET: Incidental in majority of patients
              • Functioning PNET: Determined by particular symptoms produced by tumor, i.e., hypoglycemia in insulinoma or by metastatic disease
              • PNET rarely causes ductal dilatation
          • Rare pancreatic solid neoplasms
            • Metastases
              • Renal cell cancer
              • Lung cancer
              • GI tract cancer
              • Lymphoma
            • Solid pseudopapillary tumor
              • Rare, low-grade malignancy of exocrine pancreas
              • Typically presents as large, well-defined, round mass without communication with MPD

        CLINICAL IMPLICATIONS

        • Solid Pancreatic Mass

          CEUS TECHNIQUE

          • Transabdominal CEUS

            • CE-EUS

              IMAGING

              • Pancreatic Mass Imaging

                STAGING AND TREATMENT RESPONSE EVALUATION

                • Disease Staging

                  • Treatment Response

                    Selected References

                    1. Li XZ et al: Diagnostic performance of contrast-enhanced ultrasound for pancreatic neoplasms: a systematic review and meta-analysis. Dig Liver Dis. 50(2):132-138, 2018
                    2. Sidhu PS et al: The EFSUMB guidelines and recommendations for the clinical practice of contrast-enhanced ultrasound (CEUS) in non-hepatic applications: update 2017 (long version). Ultraschall Med. 39(2):e2-e44, 2018
                    3. Del Prete M et al: Role of contrast-enhanced ultrasound to define prognosis and predict response to biotherapy in pancreatic neuroendocrine tumors. J Endocrinol Invest. 40(12):1373-1380, 2017
                    4. Ran L et al: Value of contrast-enhanced ultrasound in differential diagnosis of solid lesions of pancreas (SLP): a systematic review and a meta-analysis. Medicine (Baltimore). 96(28):e7463, 2017
                    5. Dietrich CF et al: Differential diagnosis of small solid pancreatic lesions. Gastrointest Endosc. 84(6):933-940, 2016
                    6. Lin LZ et al: Contrast-enhanced ultrasound for differential diagnosis of pancreatic mass lesions: a meta-analysis. Med Ultrason. 18(2):163-9, 2016
                    7. Taimr P et al: Liver Contrast-enhanced ultrasound improves detection of liver metastases in patients with pancreatic or periampullary cancer. Ultrasound Med Biol. 41(12):3063-9, 2015
                    8. Vitali F et al: Quantitative perfusion analysis in pancreatic contrast enhanced ultrasound (DCE-US): a promising tool for the differentiation between autoimmune pancreatitis and pancreatic cancer. Z Gastroenterol. 53(10):1175-81, 2015
                    9. D'Onofrio M et al: 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 Med. 35(6):515-21, 2014
                    10. D'Onofrio M et al: Comparison between CT and CEUS in the diagnosis of pancreatic adenocarcinoma. Ultraschall Med. 34(4):377-81, 2013
                    11. D'Onofrio M et al: Pancreatic multicenter ultrasound study (PAMUS). Eur J Radiol. 81(4):630-8, 2012
                    12. Dietrich CF et al: Improved characterisation of solitary solid pancreatic tumours using contrast enhanced transabdominal ultrasound. J Cancer Res Clin Oncol. 134(6):635-43, 2008
                    13. Dörffel Y et al: Neuroendocrine tumors: characterization with contrast-enhanced ultrasonography. Ultraschall Med. 29(5):506-14, 2008
                    Related Anatomy
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                    Related Differential Diagnoses
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                    References
                    Tables

                    Tables

                    KEY FACTS

                    • Terminology

                      • Clinical Implications

                        • Role of CEUS

                          TERMINOLOGY

                          • Definitions

                            • Pancreatic ductal adenocarcinoma (PDAC): > 80% of solid pancreatic neoplasms
                              • Origin
                                • Pancreatic ductal or acinar epithelium
                              • Outcome
                                • Poor in most cases
                                  • Curative surgical treatment possible in only ~ 15%
                              • Clinical presentation
                                • Abdominal pain, weight loss, and obstructive jaundice
                              • 85% of PDACs are located within pancreatic head and tend to involve both main pancreatic duct (MPD) &/or common bile duct (CBD) (double duct sign)
                                • Dilatation of MPD &/or CBD facilitates detection of pancreatic head cancer using US and cross-sectional imaging
                            • Pancreatic neuroendocrine tumor (PNET) and pancreatic neuroendocrine carcinoma (PNEC) are 2nd most common solid neoplastic lesions of pancreas, accounting for < 5% of solid pancreatic neoplasms (with incidence increasing)
                              • Origin
                                • Endocrine pancreatic cells
                              • Classification
                                • Functioning (hormone producing, less common)
                                • Nonfunctioning (up to 90% of cases)
                              • Outcome
                                • Depends on grade of differentiation
                                  • Excellent in small G1 PNET
                                  • Favorable in PNEC
                              • Clinical presentation
                                • Nonfunctioning PNET: Incidental in majority of patients
                                • Functioning PNET: Determined by particular symptoms produced by tumor, i.e., hypoglycemia in insulinoma or by metastatic disease
                                • PNET rarely causes ductal dilatation
                            • Rare pancreatic solid neoplasms
                              • Metastases
                                • Renal cell cancer
                                • Lung cancer
                                • GI tract cancer
                                • Lymphoma
                              • Solid pseudopapillary tumor
                                • Rare, low-grade malignancy of exocrine pancreas
                                • Typically presents as large, well-defined, round mass without communication with MPD

                          CLINICAL IMPLICATIONS

                          • Solid Pancreatic Mass

                            CEUS TECHNIQUE

                            • Transabdominal CEUS

                              • CE-EUS

                                IMAGING

                                • Pancreatic Mass Imaging

                                  STAGING AND TREATMENT RESPONSE EVALUATION

                                  • Disease Staging

                                    • Treatment Response

                                      Selected References

                                      1. Li XZ et al: Diagnostic performance of contrast-enhanced ultrasound for pancreatic neoplasms: a systematic review and meta-analysis. Dig Liver Dis. 50(2):132-138, 2018
                                      2. Sidhu PS et al: The EFSUMB guidelines and recommendations for the clinical practice of contrast-enhanced ultrasound (CEUS) in non-hepatic applications: update 2017 (long version). Ultraschall Med. 39(2):e2-e44, 2018
                                      3. Del Prete M et al: Role of contrast-enhanced ultrasound to define prognosis and predict response to biotherapy in pancreatic neuroendocrine tumors. J Endocrinol Invest. 40(12):1373-1380, 2017
                                      4. Ran L et al: Value of contrast-enhanced ultrasound in differential diagnosis of solid lesions of pancreas (SLP): a systematic review and a meta-analysis. Medicine (Baltimore). 96(28):e7463, 2017
                                      5. Dietrich CF et al: Differential diagnosis of small solid pancreatic lesions. Gastrointest Endosc. 84(6):933-940, 2016
                                      6. Lin LZ et al: Contrast-enhanced ultrasound for differential diagnosis of pancreatic mass lesions: a meta-analysis. Med Ultrason. 18(2):163-9, 2016
                                      7. Taimr P et al: Liver Contrast-enhanced ultrasound improves detection of liver metastases in patients with pancreatic or periampullary cancer. Ultrasound Med Biol. 41(12):3063-9, 2015
                                      8. Vitali F et al: Quantitative perfusion analysis in pancreatic contrast enhanced ultrasound (DCE-US): a promising tool for the differentiation between autoimmune pancreatitis and pancreatic cancer. Z Gastroenterol. 53(10):1175-81, 2015
                                      9. D'Onofrio M et al: 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 Med. 35(6):515-21, 2014
                                      10. D'Onofrio M et al: Comparison between CT and CEUS in the diagnosis of pancreatic adenocarcinoma. Ultraschall Med. 34(4):377-81, 2013
                                      11. D'Onofrio M et al: Pancreatic multicenter ultrasound study (PAMUS). Eur J Radiol. 81(4):630-8, 2012
                                      12. Dietrich CF et al: Improved characterisation of solitary solid pancreatic tumours using contrast enhanced transabdominal ultrasound. J Cancer Res Clin Oncol. 134(6):635-43, 2008
                                      13. Dörffel Y et al: Neuroendocrine tumors: characterization with contrast-enhanced ultrasonography. Ultraschall Med. 29(5):506-14, 2008