CEUS FNA of cysts and NET of the tail of the pancreas

Contrast enhanced endoscopic ultrasound (CE-EUS) is an endosonographic technique in which an intravenous contrast agent is used to assess the vascular pattern of a lesion. It is particularly useful in the pancreas, where it separates a solid tumour from inflammatory tissue and from the wall of a cyst.

This video shows a case of a young lady with the pancreatic cyst, initially presumed to be pseudocysts. EUS revealed two IPMNs, as well as a mass in the tail of the pancreas which turned out to be a NET G2.

What endoscopic ultrasound provides

Endoscopic ultrasound combines an endoscope and an ultrasound transducer in one instrument. The probe reaches the pancreas through the stomach or duodenum, within millimetres of the organ, with no intervening bowel gas or abdominal wall. This gives resolution no other modality offers for the pancreas, detecting lesions of a few millimetres that escape CT.

Cystic lesions of the pancreas

Not all cysts are alike, and the distinction determines management. Pseudocysts are inflammatory collections, usually following pancreatitis, with no malignant potential. IPMN, intraductal papillary mucinous neoplasms, are true neoplasms communicating with the ductal system and can progress, which is why they are kept under surveillance.

When the diagnosis changes

A finding presumed benign may prove to be something quite different after endoscopic ultrasound, or a second lesion may emerge that had not been identified. Neuroendocrine tumours are a typical example: often small, slow growing and asymptomatic. Their grade, based on the Ki-67 index, determines prognosis and treatment.

After the procedure

The material obtained is sent for histology, and it is that report rather than the endoscopic appearance that determines the next step. Recovery is short compared with surgery: eating and normal daily activities are generally resumed within a few days. Patients are given instructions on avoiding strenuous effort and on medications affecting coagulation, in particular anticoagulants and antiplatelet agents. Decisions about further treatment are usually taken by a multidisciplinary team, taking histology, staging and general condition into account.

Key figures: Neuroendocrine tumours are graded under WHO 2019 by the Ki-67 index: G1 below 3 percent, G2 3 to 20 percent, G3 above 20 percent. Endoscopic ultrasound reaches the pancreas within a few millimetres.

Frequently asked questions

Does every pancreatic cyst need to be removed?

No. Pseudocysts are inflammatory collections with no malignant potential. IPMN, by contrast, are true neoplasms kept under surveillance, with the decision to operate depending on size, main duct involvement and worrisome features. Endoscopic ultrasound is the investigation that makes this distinction.

How long does recovery take?

Considerably shorter than after surgery. Eating and normal daily activities are usually resumed gradually within a few days, depending on the extent and site of the lesion. The instructions that matter concern avoiding strenuous effort and how to handle medications that affect blood clotting.