Contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) is known for its superior
diagnostic accuracy for solid pancreatic lesions (SPLs), primarily due to its enhanced
visualization of perfusion patterns [1]. However, it may not be suitable for all patients and relies on the use of expensive
contrast agents. In contrast, directional enhanced blood flow imaging (eFLOW) and
the more recent detective flow imaging endoscopic ultrasound (DFI-EUS) are innovative
imaging techniques that improve the visualization of fine vascular structures in various
tissues, all without the need for contrast agents [2]
[3].
We present a brief series of cases of both malignant and benign SPLs evaluated through
eFLOW and DFI-EUS, with a comparative analysis using CH-EUS ([Fig. 1], [Fig. 2], [Video 1]). Notably, this series includes a rare case highlighting the application of DFI
in a patient diagnosed with autoimmune pancreatitis.
Fig. 1 A case of pancreatic cancer: a B-mode imaging reveals a
hypoechoic lesion. On (b) CH, (c)
directional eFLOW, and (d) DFI endoscopic ultrasound, the tumor
consistently shows a hypovascular pattern with central areas of increased blood flow.
Abbreviations: CH, contrast-enhanced harmonic; DFI, detective flow imaging; eFLOW,
enhanced
blood flow imaging.
Fig. 2 A case of degenerated IPMN: a B-mode imaging shows a hypoechoic area with irregular
margins. On (b) DFI, (c) directional eFLOW, and (d) CH endoscopic ultrasound, the
characteristic hypo-enhancement of pancreatic cancer is observed, along with a linear
central vessel. A diagnostic EUS-guided fine needle biopsy was performed on the hypoechoic
area, carefully avoiding the vessel. Abbreviations: CH, contrast-enhanced harmonic;
DFI,
detective flow imaging; eFLOW, enhanced blood flow imaging; EUS, endoscopic ultrasound;
IPMN, intraductal papillary mucinous neoplasm.
Solid pancreatic lesions evaluated through directional enhanced blood flow imaging
(eFLOW) and detective flow imaging (DFI), with a comparative analysis using contrast-enhanced
harmonic endoscopic ultrasound (CH-EUS).Video 1
CH-EUS, DFI-EUS, and eFLOW can provide complementary insights into the vascular characteristics
of the lesions. All three techniques tend to reveal similar findings in terms of vascular
patterns: in pancreatic adenocarcinoma, these imaging modalities typically show a
hypovascular pattern, reflecting the poor blood supply and disorganized blood vessels
that are characteristic of malignancy, often associated with areas of increased blood
flow or neoangiogenesis within the tumor.
While CH-EUS typically offers the most comprehensive analysis of blood perfusion in
SPLs, established criteria for classifying vessels with DFI-EUS and eFLOW are still
lacking. However, using these modalities in a complementary manner can significantly
enhance the differential diagnosis of pancreatic lesions. Both eFLOW and DFI-EUS provide
valuable alternatives, especially for patients who are unable to receive contrast
agents.
Endoscopy_UCTN_Code_TTT_1AS_2AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
