ISSN: 2320-5407 Int. J. Adv. Res.

10(02), 915-920

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/14293

DOI URL: http://dx.doi.org/10.21474/IJAR01/14293

RESEARCH ARTICLE
CONTRIBUTION OF ENDOSCOPIC ULTRASOUND IN PANCREATIC MASSES

Mouna Figuigui1, Hakima Abid1, Asmae Lamine2, Maria Lahlali2, Nada Lahmidani1, Mounia El Yousfi1, Sidi
Adil Ibrahimi1, Mohammed El Abkari2 and Dafr-Allah Benajah2
1. Hepato-Gastroenterology Department, Hassan II University Hospital, Fez, Morocco.
2. Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco.
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Manuscript Info Abstract
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Manuscript History Endoscopic ultrasound (EUS) is a method of exploration of the
Received: 18 December 2021 digestive system that combines two techniques: endoscopy and
Final Accepted: 20 January 2022 ultrasound. EUS has several applications in digestive pathology. Echo-
Published: February 2022 endoscopic biopsy (EEB) of pancreatic masses is a technique that
allows fine needle aspiration to obtain material for cytohistological
Key words:-
Echo-Endoscopy, Cytopunction, analysis. It is indicated each time a histological examination can have a
Pancreatic Mass, CT, Histopathology diagnostic and/or therapeutic interest.For that we realized a
retrospective study between January 2017 and December 2020. All
patients referred to the department for a bilio-pancreatic echo-
endoscopy in the framework of a pancreatic tumor were included in the
study. We collected 90 patients who met our inclusion criteria. We
recorded the patients' demographics, pathologic history, symptoms, and
ultrasound, CT, and EUS. During the echo-endoscopic examination, we
always tried to specify some essential data according to the
international recommendations, depending on the pathology (benign or
malignant).
Copy Right, IJAR, 2022,. All rights reserved.
……………………………………………………………………………………………………....
Introduction:-
Echo-endoscopy (EE) is an imaging technique with a higher resolution power for the examination of the biliary and
pancreatic region. This high resolution applies both to the analysis of the ductal network and to the study of the
parenchyma [1].The main interest of the method is that, contrary to all the other imaging techniques currently
available for the examination of the pancreas, its performance is inversely proportional to the size of the lesion to be
studied: in other words, the smaller the lesion, the better the results and therefore the indication, the larger the lesion,
the poorer the results and therefore the indication. In case of suspicion, without clear evidence, of a disease of the
pancreas , the EUS is the reference imaging examination to be proposed in priority because it allows to rule out with
an unequalled degree of certainty the diagnosis of disease of the pancreas if the parenchyma and the ductal network
are normal, or on the contrary to detect an incipient disease which has a great chance of going unnoticed or being of
doubtful interpretation, on spiral CT, magnetic resonance imaging (MRI) including pancreato-MRI and
wirsunography. Despite advances in imaging, cytology and tumor markers studies, the diagnosis and management of
pancreatic masses is a major challenge to practitioners [1].The objective of our work is to analyze the
epidemiological, clinical, radiological and echo-endoscopic characteristics of pancreatic masses for which the
decision of echo-endoscopy and cytopuncture has been made in a multidisciplinary consultation meeting and to
Specify the diagnostic cost-effectiveness of this technique

Corresponding Author:- Mouna Figuigui

Address:- Hepato-Gastroenterology Department, Hassan II University Hospital, Fez, Morocco. 915
ISSN: 2320-5407 Int. J. Adv. Res. 10(02), 915-920

Materials and Methods:-

We performed a retrospective study between January 2017 and December 2020. All patients referred to the
department for biliopancreatic echo-endoscopy for clinical and radiological suspicion of a pancreatic tumor were
included in the study. We collected 90 patients who met our inclusion criteria. We recorded the patients'
demographics, pathologic history, symptoms, and ultrasound, CT, and EUS. During the echo-endoscopic
examination, we always tried to specify some essential data which are the size and the localization, the arterial and
loco-regional invasion according to the international recommendations, and this according to the pathology (benign
or malignant)

Results:-
1-Profile of patients
The average age of our patients was 63 years (55-81 years). The male sex was slightly predominant with a sex ratio
of 1.17.

2-Clinical and biological data

Abdominal pain was the most frequent clinical sign with a percentage of 92%, icterus was present in 47% of
patients. It was intense cholestatic with disabling pruritus in 37% of patients, alteration of the general state was the
third symptom with a percentage of 45% and fever was only present in 3%.
Overall number 90

Average age 63 years old

Sex Ratio (M/F) 1.17

Symptomatology:
- Abdominal pain: 92%
- AEG : 45%
- Icterus: 47%
- Fever : 3%

Biological cholestasis 45%

Tumor markers 47%

Table 1:- Illustrating the epidemiological characteristics.

3-Radiological data
3.1 - Comparison between EUS and ultrasound
The results of the explorations carried out on the same patients, suffering from a bilio-pancreatic pathology, by
transcutaneous ultrasound and endoscopic ultrasound, allowed us to note the following observations

43 ultrasound scans showed dilatation of the intra and/or extra hepatic bile ducts without visible obstruction. The
ultrasound was able to detect 22 cases of pancreatic tumors and the rest were normal. These results were confirmed
by endoscopic ultrasound in 92% of cases. On the other hand, EES was able to detect 31 cases of pancreatic or
biliary tract tumor, ultrasound identified only 18.

3.2- Comparison between EUS and CT

A similar treatment was applied to the population of beneficiaries of both CT and EUS, which numbered 90, 46
cases had pancreatic tumors according to CT. Cephalic locations were predominant with a frequency of 78%,
corporal locations in second place with a frequency of 22%, The EUS confirmed only 32 with cephalic locations in
68%, and corporal locations in 29%. The rest were divided between ampullomas (11 cases), 19 cases of benign

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lesions distributed on serous cystadenoma (4 cases), false cyst of the pancreas (6 cases), chronic calcifying
pancreatitis (6 cases), cysts of the pancreas (3 cases) and normal echo-endoscopy (25 cases).

Among the 11 cases, identified by EUS as ampulla of vater 8 of them were diagnosed on CT, The individual cases
of calcifying chronic pancreatitis, identified by EUS were considered normal on CT. Taking the result of the EES as
the reference diagnosis, the error rate of the CT scan for solid pancreatic tumors can be considered to be about 20%,
taking into account these results.

4-Echoendoscopy results
The following characteristics were determined by the EUS:
-Tumor location:
Cephalic locations were predominant with a frequency of 68%, corporal locations in second place with a frequency
of 29%.

-Echogenicity of the tumor:

Heterogeneous tumors presented 94.25% of cases. Hypoechogenic 84%, anechogenic 33%, hyperechogenic tumors
represented 96.5% of cases.

-Tumor contour:
Tumors with irregular contours accounted for 86.20% of cases.

-Tumor size in cm:

Tumor size between 3 - 6 cm was the most frequent with 82.8%. 17.2% of the patients had a tumor size less than or
equal to 2 cm diagnosed only by EUS and not seen on the other imaging studies that preceded the indication of EUS.

-Vascular invasion on EUS:

Venous invasion on EUS concerned 39 patients, i.e. 45% of all our patients studied.

-Arterial invasion:
Arterial invasion on EUS was found in 33 patients, i.e. 38% of all the patients studied.

-Cytopuncture:
Cytopuncture under echo-endoscopy of pancreatic masses was performed in 33 patients after eliminating
contraindications (blood flow disorders by a blood count to evaluate the platelet count and by the prothrombin
level). It concerned adenopathies in 2 patients, using a 19 or 22 gauge needle and aspiration with a 20 ml syringe.
Two passes were performed in 91% of cases. No complications related to the procedure were noted.

We noted a predominance of malignant tumor pathology with 42% divided into four categories: 32 cases of
pancreatic tumors, 11 cases of ampullomas, 19 cases of benign lesions (cystic, cystadenomas, chronic pancreatitis).
The sensitivity of EUS in the diagnosis of pancreatic cancer is 85%, the specificity 100%. The positive and negative
predictive values are respectively 100% and 85%.

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Malignant lesions were found in 80% of the cases of all the patients studied, the most represented histological type
was pancreatic adenocarcinoma with a percentage of 64%.a well differentiated endocrine carcinoma grade 3 in 4
patients were noted in 3.52% of cases. An immunohistochemical complement was requested in 5.88% of patients,
for poorly differentiated carcinomatous processes. In addition, 1 case of lymph node tuberculosis was described on
cytopunctions of peripancreatic adenopathies. The histological study was inconclusive in 30% of all fragments
reported.

5- Impact of echo-endoscopy management

EUS plays a very important role in pancreatic cancer. Its interest is indisputable for the diagnosis and for the
extension assessment of cancers considered operable. It should be noted that surgical resection is currently possible
in only 10 to 15% of cases [1]. Pancreatic cancer presents on EUS as a hypoechoic mass with irregular contours,
heterogeneous content and usually dilatation of the proximal pancreatic duct. In our series, we diagnosed 32 cases of
pancreatic cancer by echo-endoscopy. The sensitivity of EUS in the diagnosis of pancreatic tumors is 85%; the
specificity reaches 100%. The positive and negative predictive values were respectively 100% and 85%.

In the literature, some studies have found that the diagnostic reliability of T-stage (tumor infiltration) by EES is 80%
[1]. The sensitivity of EUS in the detection of pancreatic cancer exceeds 95%. However, this sensitivity depends on
the experience of the operator. The specificity is limited, especially if inflammatory lesions exist at the same time,
and is about 80%. The main cause of error is represented by localized pancreatitis nuclei[1]. The EUS allows the
assessment of operable pancreatic cancers, which are lesions smaller than 4 cm, diagnosed by conventional
examinations, without known metastases, in patients without contraindications to surgery. Also, EUS is the most
sensitive examination for the detection of small pancreatic cancers, including lesions smaller than 10 mm [1].
However, this ability to detect centimetric tumors has raised the problem of the specificity of these nodular lesions,
especially on pancreas already remodeled from chronic pancreatitis

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Discussion:-
During the course of the study, we had 90 patients who underwent EUS for suspicion of a pancreatic mass

Pancreatic cancer is predominantly a cancer of the elderly: more than half of the cases are diagnosed after 75 years
of age in a SEER study published in 2003 [2]. In our study, the age group 55 to 81 years was the most represented
with a percentage of 60% and an average age of 65 years. This average age is comparable to that of the European
authors [3] but significantly different from that of the African authors who reported an average age of 58 years. In
any case, it is established that the risk of pancreatic cancer increases with age [2].. There is a clear male
predomiance with a sex ratio was 1.5 to 2.4 [2]. In our study, the male/female sex ratio was 1.17, which is in line
with the data in the literature from several studies

A. Clinical aspects :
1. According to the general signs: Weight loss was the most represented general sign with a percentage of 45%,
which is consistent with the results of European authors with 58.13% of cases and African authors with 81.82% of
cases [4]. The predominance of weight loss in most studies confirms the delay in diagnosis of this tumor. 2.
According to functional signs: In our study, abdominal pain was the most represented functional sign with 92% of
cases, which was noted in European works with 75, 11% [3] and in African works [4] with 77.3%. These data allow
us to say that the first symptoms during pancreatic cancer are non-specific. 3. According to physical signs: Icterus
was the most common physical sign in our patients with a percentage of 47%. The predominance of hepatomegaly
was noted in European works [3], while abdominal mass was the physical sign frequently found in African authors
[4].

B. Morphological aspects of pancreatic cancers:

The main goal of imaging will therefore be to make an assessment of the extension of the disease as precise as
possible in order to differentiate patients who can benefit from curative treatment (surgical resection) from those
who require palliative treatment (essentially chemotherapy) [5]. If ultrasound does not show the pancreas well (20%
of cases) or does not allow the tumor to be seen, the radiological diagnosis is based on spiral CT with injection and
EES. Spiral CT should be preferred in the first instance to echo-endoscopy because it is not invasive and allows
better exploration of the entire abdomen (especially the liver) in search of metastases. Its sensitivity is 90% for the
diagnosis of pancreatic cancer [6]. However, 20% to 30% of pancreatic cancers with a diameter of 2 cm or less are
not recognized by this examination. In this case, echo-endoscopy should be performed because its sensitivity is
independent of the tumor size [6]. In our study, CT was performed in 92% of our patients before the indication of
echo-endoscopy, which confirms that SEA is nowadays a third-line examination after ultrasound and spiral CT. The
typical echo-endoscopic appearance of a pancreatic adenocarcinoma is that of a hypoechoic formation with irregular
boundaries and coarse echostructure [7]. In our study, EES showed a hypoechoic lesion in 94.25% of the cases,
heterogeneous in 84% of the cases and with irregular contours in 86.6% of the cases studied.

However, echo-endoscopy is currently the best examination for the diagnosis of small tumors (< 2 cm in diameter)
of the pancreas. Its sensitivity is superior to that of CT, percutaneous ultrasound and MRI [7]. Regarding the
diagnosis of pancreatic tumors, two studies have shown that echo-endoscopy is superior to spiral CT for the
diagnosis of small tumors less than 2 cm in diameter: The first one is that of Midwinter et al [8] who compared
spiral CT with echo-endoscopy in 58 patients. This study shows that echo-endoscopy is more accurate for the
diagnosis and localization of pancreatic tumors less than 2.5 cm in diameter. The second study is that of Bender et al
[8] who performed linear echo-endoscopy in 65 patients suspected of having a pancreatic lesion on helical CT. The
echo-endoscopy confirmed the existence of a pancreatic lesion in 33 patients and found a normal pancreas in the
other 32 . These results were compared with the data from surgical exploration. In this study, the specificity of echo-
endoscopy for the diagnosis of pancreatic cancer was found to be significantly higher (p < 0.005) than that of helical
CT (88% vs. 41%). In our study, among 90 patients, EUS objectified the existence of a small pancreatic lesion <
2cm in 15 patients not seen on CT.

EUS is essential for the diagnosis and assessment of locoregional extension of small pancreatic cancers (less than or
equal to 2 cm in diameter), when ultrasound, spiral CT or MRI have ruled out large tumors with metastatic or
locoregional extension. It is also the first examination to be proposed in case of suspicion of pancreatic or duodenal
endocrine tumor, because its sensitivity exceeds 90% for the diagnosis of localization of insulinomas, and because in
association with somatostatin receptors, it exceeds 90% for the diagnosis of localization of gastrinomas. The
sensitivity and negative predictive value (NPV) of EUS for the diagnosis of pancreatic cancers exceeds 95%,

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including for small tumors with a diameter of less than 2 cm. These performances remain superior to those of other
imaging techniques, including the most recent ones, such as multi-bar CT (10% of undetectable cancers), MRI or
PET. The latter two are, to date, inferior to multi-bar CT. This superiority of EES is corroborated by its performance
in the detection of small pancreatic tumors, which are not detected by the other explorations [9]. However, EES has
limitations: - It may ignore a carcinomatous graft on chronic pancreatitis, especially if it is calcifying, but it may also
fail to detect a tumor at the origin of a severe acute pancreatitis if it is performed too early compared to the onset of
the complication. It is therefore important to know how to repeat the examination, a second or third time in the
following weeks, if the suspicion of associated cancer persists.

The characterization of a mass remains a problem. If a hypoechoic appearance with poorly limited irregular contours
argues for adenocarcinoma, or if a well-limited nodule with little hypoechoic posterior enhancement suggests an
endocrine nature, no criterion is sufficiently specific to make a diagnosis of nature or to formally exclude a benign
pathology. Elastography and contrast echo-endoscopy, two conceptually attractive new techniques, can help
characterize a mass by its hardness and hypo vascularization respectively. Puncture under EES allows a cyto-
histological diagnosis of cancer with a high sensitivity [10]. To summarize, the specificity of echo-endoscopy for the
diagnosis of pancreatic tumors is better than the other examinations and increases even more if guided biopsy is
added.

Conclusion:-
Bilio-pancreatic echo-endoscopy in pancreatic cancer is of considerable value both in terms of positive diagnosis
and locoregional extension. It is currently the most accurate examination for the diagnosis of small pancreatic
tumors less than 2 cm in diameter. The development of guided biopsy under echo-endoscopy has increased the
specificity of echo-endoscopy. Our study described the contribution of SEA in the management of pancreatic cancer
at the National Institute of Oncology in Rabat. The results of our series are globally comparable to those published
by the different series in the literature. Histological evaluation under echo-endoscopy, non-invasive (contrast echo,
elastography, confocal) It is under development and evaluation but is not routinely used. Therapeutic echo-
endoscopy is also a real future of echo-endoscopy because it allows mini-invasive access to adjacent organs; its
place compared to conventional radiological methods is currently the subject of randomized studies. For this reason
and despite the extraordinary progress in cross-sectional imaging in recent years, diagnostic echo-endoscopy and
echo-endoscopy with echo-endoscopically guided biopsy remain more than ever the body of the technique and its
short and medium term future. Finally, nothing will replace the multidisciplinary evaluation of imaging
examinations to best orient therapeutic decisions, especially in cases of tumors with borderline operability and it is
important to insist on the urgency of an early and adequate diagnosis that will be able to select patients candidates
for R0 curative surgery.

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[2] Laurent PALAZZO. APPORT DE L’ECHO-ENDOSCOPIE A LA PRISE EN CHARGE DES MALADIES DU
PANCREAS. 2014.
[3] SEER Cancer statisticsreview, 1975–2003. http//Seer.gov/csr/ 1975- 2000. 2003
[4] Queneau PE, Pitard A, Labourey JM, Koch S, Sauve G, Carayon P. Évolution de la prise en charge de
l’adénocarcinome pancréatique. Gastroenterol clin biol 2000 ; 24 : 501- 505.
[5] Berrada S, D’Khissy M, Ridal M, Zerou Ali NO. Place de la dérivation biliodigestive dans le traitement du
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