Role of Endoscopic Ultrasound in Predicting Solid Pancreatic Lesions Using Strain Ratio and Elastography
Kiran Bajaj, Taha Yaseen, Abbas Ali Tasneem, Syed Mudassir Laeeq, Ali Khalid, Nasir Hasan Luck, Nasir Mehmood, Sandeep Kumar, Muhammad Qaiser Panezai, Danish Kumar, Nadir Sattar, Nida Rasool, Reeaa Kumari
Elastography, Endoscopic ultrasound, Solid pancreatic lesions, Strain ratio
Citation Information :
Bajaj K, Yaseen T, Tasneem AA, Laeeq SM, Khalid A, Luck NH, Mehmood N, Kumar S, Panezai MQ, Kumar D, Sattar N, Rasool N, Kumari R. Role of Endoscopic Ultrasound in Predicting Solid Pancreatic Lesions Using Strain Ratio and Elastography. Euroasian J Hepatogastroenterol 2023; 13 (1):1-4.
Background: Despite advancement in imaging techniques, the diagnosis of solid pancreatic lesions (SPLs) remains challenging. The latest advancement in elastography permits the quantitative measurements of the average elasticity of a lesion. Therefore, our main aim of this study was to determine the utility of endoscopic ultrasound-guided elastography (EUS-EG) and strain ratio (EUS-SR) in predicting SPLs.
Materials and methods: This cross-sectional study was performed at the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation. All patients with radiological diagnosis of SPLs underwent EUS-EG, followed by strain ratio (SR) measurement and targeted pancreatic fine needle lesion biopsy (FNB). Area under the receiver operating curve (AUROC) was obtained for SR and combined elastography and SR and at an optimal cutoff, diagnostic accuracy was obtained in predicting the nature of SPLs.
Results: A total of 52 patients were included in this study. Out of them, 32 (61.5%) patients were males while 20 (38.5%) were females. The mean age was 50.8 ± 12.5 years. Twenty-four (46.2%) patients had malignant pancreatic lesions. Among malignant lesions, the most common etiology was pancreatic adenocarcinoma seen in 18 (34.6%) patients. Out of 28 (53.8%) patients with benign lesions, 14 (26.9%) patients had inflammatory disease. Area under the receiver operating curve was obtained for both SR alone and SR combined with elastography score in differentiating benign from malignant SPLs which was 0.832 (p-value < 0.001) for SR alone and a slightly higher for combined SR with elastography (AUROC-0.839) (p-value < 0.001). At an optimal cutoff of SR of >17, the sensitivity was 94.8% and the diagnostic accuracy was 74% in predicting SPLs. While, when SR and elastography were combined together, the sensitivity increased to 96% with a diagnostic accuracy of 75%.
Conclusion: Combined EUS-EG and SR were accurate in diagnosing malignant pancreatic lesions with a diagnostic accuracy of 75% providing additional diagnostics information before biopsy. However, multicentric studies with larger sample sizes are required for the validation of our results to determine the utility and diagnostic accuracy of EUS-SR in defining the characteristic of pancreatic lesions.
Gavin Low, Anukul Panu, Noam Millo, et al. Multimodality imaging of neoplastic and nonneoplastic solid lesions of the pancreas. 2011;31(4):993–1015. DOI: 10.1148/rg.314105731.
Gong Z, Holly EA, Bracci PM. Survival in population-based pancreatic cancer patients: San Francisco Bay area, 1995–1999. Am J Epidemiol 2011;174(12):1373–1381. DOI: 10.1093/aje/kwr267.
Okasha HH, Mahdy RE, Elkholy S, et al. Endoscopic ultrasound (EUS) elastography and strain ratio, could it help in differentiating malignant from benign pancreatic lesions? Medicine (Baltimore). 2018; 97(36):e11689. DOI: 10.1097/MD.0000000000011689.
Hewitt MJ, McPhail MJ, Possamai L, et al. EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis. Gastrointest Endosc 2012;75(12):319–331. DOI: 10.1016/j.gie.2011.08.049.
Giovannini M, Seitz JF, Monges G, et al. Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients. Endoscopy 1995;27(2):171–177. DOI: 10.1055/s-2007-1005657.
DeWitt J, McGreevy K, Sherman S, et al. Utility of a repeated EUS at a tertiary-referral center. Gastrointest Endosc 2008;67:610–619. DOI: 10.1016/j.gie.2007.09.037.
Okasha H, Elkoly S, El-Sayed R, et al. Real time endoscopic ultrasound elastography and strain ratio in the diagnosis of solid pancreatic lesions. World J Gastroenterol 2017;23:5962–5968. DOI: 10.3748/wjg.v23.i32.5962.
Frey H. [Realtime elastography. A new ultrasound procedure for the reconstruction of tissue elasticity]. Radiologe. 2003;43:850–855. DOI: 10.1007/s00117-003-0943-2.
Eloubeidi MA, Tamhane A, Varadarajulu S, et al. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006;63:622–629. DOI: 10.1016/j.gie.2005.05.024.
Hartwig W, Schneider L, Diener MK, et al. Preoperative tissue diagnosis for tumours of the pancreas. Br J Surg 2009;96:5–20. DOI: 10.1002/bjs.6407.
Puli SR, Bechtold ML, Buxbaum JL, et al. How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass? A meta-analysis and systematic review. Pancreas 2013;42:20–26. DOI: 10.1097/MPA.0b013e3182546e79.
Dumonceau JM, Polkowski M, Larghi A, et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2011;43(10):897–912. DOI: 10.1055/s-0030-1256754.
Iglesias-Garcia J, Dominguez-Munoz JE, Abdulkader I, et al. Influence of on-site cytopathology evaluation on the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solid pancreatic masses. Am J Gastroenterol 2011;106:1705–1710. DOI: 10.1038/ajg.2011.119.
Iglesias-Garcia J, Lindkvist B, Larino-Noia J, et al. Differential diagnosis of solid pancreatic masses: contrast-enhanced harmonic (CEH-EUS), quantitative-elastography (QE-EUS), or both? United European Gastroenterol J 2017;5(2):236–246. DOI: 10.1177/2050640616640635.
Pei Q, Zou X, Zhang X, et al. Diagnostic value of EUS elastography in differentiation of benign and malignant solid pancreatic masses: a meta-analysis. Pancreatology 2012;12(5):402–408. DOI: 10.1016/j.pan.2012.07.013.
Mei M, Ni J, Liu D, et al. EUS elastography for diagnosis of solid pancreatic masses: a meta-analysis. Gastrointest Endosc 2013; 77(4):578–589. DOI: 10.1016/j.gie.2012.09.035.
Xu W, Shi J, Li X, et al. Endoscopic ultrasound elastography for differentiation of benign and malignant pancreatic masses: a systemic review and meta-analysis. Eur J Gastroenterol Hepatol 2013; 25(2):218–224. DOI: 10.1097/MEG.0b013e32835a7f7c.
Li X, Xu W, Shi J, et al. Endoscopic ultrasound elastography for differentiating between pancreatic adenocarcinoma and inflammatory masses: a meta-analysis. World J Gastroenterol 2013;19(37):6284–6291. DOI: 10.3748/wjg.v19.i37.6284.