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Endoscopic ultrasound tissue acquisition, in the form of fine needle biopsy (EUS-FNB) was designed to provide a proper quantitative sample for determining the histologic architecture and further immunohistochemical staining. This study aimed to investigate the contribution of associating contrast-enhanced ultrasound imaging (CEUS) with EUS-FNB for differentiating solid pancreatic lesions without on-site cytopathology. Patients from our institutional database who underwent CE-FNB-EUS for the evaluation of a solid pancreatic lesion were retrieved. Micro vascularization of the tumor was evaluated over 2 min during CEUS after intravenous injection of 4.8 mL SonoVue and was classified as hypervascular, isovascular or hypovascular during both arterial and venous phase. Final diagnosis was based on histopathology of surgical specimens or EUS-guided tissue acquisition and clinical follow-up. Our retrospective study (2018-2021) enrolled 46 patients with a mean age of 58, female to male ratio 1:2, mass location: 2/3 head, 1/3 body and tail of the pancreas, average mass size 3.5 cm, mean number of needle passes (fanning technique): 2. Final pathology revealed pancreatic ductal adenocarcinoma-PDAC (26), mass-forming pancreatitis-MFP (10), pancreatic neuroendocrine tumors-pNETs (4), undifferentiated carcinoma (3), mucinous carcinoma (1), pancreatic metastasis (1). Hypo-enhancement was noted in 67% of the patient, and the final diagnosis was malignancy in all those cases. Regarding the enhancement patterns: hypovascularity in both arterial and venous phase was associated to PDAC, hypervascularity or isovascularity in both phases were associated to either MFP or NETs, while the carcinomas were hypervascular. A heterogeneous appearance with non-enhancing areas was noted in a small percentage of the hypo-enhancing lesions and it might suggest necrosis. The overall diagnostic accuracy was 91%. CE-EUS allows detailed visualization of the dynamic enhancement patterns hence it helps to identify the target of EUS-FNB among different pathological areas of the lesions. CE-FNB-EUS can be used for the differential diagnosis and adequate sampling of solid pancreatic lesions without on-site cytopathology. [ABSTRACT FROM AUTHOR]

Pancreatic pseudoaneurysm is a rare condition usually associated with pancreatic disorders: pancreatitis, neoplasm, or cystic lesions of the pancreas. Almost 10% of patients with chronic pancreatitis develop during disease progression a pseudoaneurysm. Usually appears secondary to a communication between a pseudocyst and a nearby artery. We present the case of a patient with chronic pancreatitis, with recurrent exacerbations and pseudocyst of 4 cm diameter located posterior of the pancreatic body. The conventional abdominal ultrasound revealed the hypoechoic mass, suspected at that moment for complicated pseudocyst. Contrast enhanced ultrasound revealed a hypervascular area 1.5 cm diameter inside de cystic lesion, suspected of pseudoaneurysm. The digital arteriography confirms the diagnosis of pseudoaneurysm originated form first branch of superior mesenteric artery (SMA), but without treatment options at that time. EUS confirmed the diagnosis of chronic pancreatitis and pancreatic pseudoaneurysm, no other suspected masses were detected. Two weeks later, the patient presented again in the emergency room for severe abdominal pain, laboratory tests showing an increased serum amylase and lipase level. Ultrasound revealed the same lesion of 5 cm diameter posterior of the body, with color Doppler suggestive of pseudoaneurysm, this time 3 cm in diameter. During hospitalization patient presented upper GI bleeding without any lesion found at upper GI endoscopy. Further emergency arteriography was performed, with coils angioembolization of the lesion, without complications. CT scan and ultrasound performed at one week confirm the successful treatment of pseudoaneurysm. The review of the literature in the field of pancreatic pseudoaneurysm revealed isolated cases reports, few data series. Although the role of CEUS in pancreatic disorders is largely discussed in the literature, in pancreatic pseudoaneurysm, due to the rarity of the cases, is not well standardized. [ABSTRACT FROM AUTHOR]

Midgut carcinoid tumors are rare neuroendocrine tumors that can spread to the intestinal mesentery. Although the mesenteric tumor is usually the first finding due to abdominal discomfort, some patients with hepatic metastases might experience symptoms of carcinoid syndrome. We present the case of a 74 year old male with weight loss, diffuse abdominal pain, facial flushing and diarrhea for about 2 months who was diagnosed with an ill-defined mesenteric mass andhepatic, pulmonary and lymph node metastatic lesions. To better characterize the hepatic lesions, contrast-enhanced ultrasonography (CEUS) was performed. It revealed hypervascular lesions in the arterial phase and complete washout during the portal phase, suggestive for liver metastases. Surprisingly, a reflux of contrast into the inferior vena cava was also noticed in the arterial phase. This can be an uncommon finding on contrast-enhanced ultrasound (CEUS) or computed tomography (CECT) that may indicate right-sided heart disease or high flow contrast injection rates. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) confirmed the diagnosis of peripancreaticlymph node and liver metastases of neuroendocrine tumor. This case report illustrates the role of ultrasound imaging for the diagnosis of rare tumors such as carcinoid tumors and also a peculiar finding on liver CEUS. [ABSTRACT FROM AUTHOR]

CEUS has increased the capability of ultrasonography for the detection of focal liver lesions (FLL). The differential diagnosis between hepatocellular carcinoma (HCC) and other malignant tumors may be limited by similarities in the appearance of CEUS. The aim of this study was to evaluate the role of combination of LR-4 and LR-5 by adding ancillary features (AFs) in the CEUS LI-RADS v2017 algorithm for the diagnosis of definite HCC. This retrospective single- center study included 143 patients with 191 FLL detected by abdominal ultrasound from a total of 823 consecutive patients. The risk factors were liver cirrhosis of any etiology and non-cirrhotic HBV patients. Diagnosis was established either through histopathology or based on CT/MRI scan. CEUS recordings were assessed by an EFSUMB level 3 sonographer, with more than 10 years experience in CEUS and who was blinded to clinical data and to the final diagnosis. All lesions have been categorized according to the CEUS LI-RADS® described by The American College of Radiology scheme. The AFs were taken into account. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were calculated. PPV for primitive malignancy (LR-4 + LR-5) was 95.7% (95CI%: 90.7–98%), with 88.07% sensitivity, 89.3% specificity and 88.4% accuracy for HCC (95CI%: 82.8–92.6%). LR4 + LR5 had 81.8% sensitivity for HCCs over 2 cm (n = 127), and 78.57% sensitivity for HCCs less than 2 cm (n = 14). Both sensitivity and accuracy of LR-4 + LR-5 for the diagnosis of definite HCC considerably raised to 88.07% and 88.4%, unlike the sensitivity and accuracy for LR-5 of only 60.45% and 69%, respectively. NPV also improved (73.4% vs. 46.6%), while similar high PPVs (95.7% vs. 96.2%) and quite similar specificity (89.3% vs. 93.6%) were maintained. Higher sensitivity than estimated for the diagnosis of HCCs smaller than 2 cm was achieved for CEUS LR-4 and LR-5. The use of AFs might improve the overarching goal of CEUS LR-5 + LR-4 diagnosis of high specificity for HCC and exclusion of non-HCC malignancy, despite the size of the lesion. [ABSTRACT FROM AUTHOR]

Clinical utility of ancillary features (AFs) in contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS®) is yet to be established. In this study, we assessed the diagnostic yield of CEUS LI-RADS and AFs in hepatocellular carcinoma (HCC). We retrospectively included patients with risk factors for HCC and newly diagnosed focal liver lesions (FLL). All lesions have been categorized according to the CEUS LI-RADS v2017 by an experienced sonographer blinded to clinical data and to the final diagnosis. From a total of 143 patients with 191 FLL, AFs favoring HCC were observed in 19.8% cases as hypoechoic rim and in 16.7% cases as nodule-in nodule architecture. From the total of 141 HCC cases, 83.6% were correctly classified: 57.4%- LR-5 and 26.2%- LR-4. In 9.21% cases, CEUS indicated LR-M; 2.12% cases- LR-3. The LR-5 category was 96.2% predictive (PPV) of HCC. LR-5 had 60.4% sensitivity and 93.6% specificity. PPV for primitive malignancy (LR-4 + LR-5) was 95.7%, with 88% sensitivity, 89.3% specificity and 88.4% accuracy for HCC. LR-4 category had 94.8% PPV and 26.2% sensitivity. CEUS LR4 + LR5 had 81,8% sensitivity for HCCs over 2 cm and 78.57% sensitivity for smaller HCCs. CEUS LR-5 remains an excellent diagnostic tool for HCC, despite the size of the lesion. The use of AFs might improve the overarching goal of LR-5 + LR-4 diagnosis of high specificity for HCC and exclusion of non-HCC malignancy. [ABSTRACT FROM AUTHOR]