Diagnostic Performance of Contrast-Enhanced Ultrasound (CEUS) and Contrast-Enhanced Endoscopic Ultrasound (ECEUS) for the Differentiation of Pancreatic Lesions: A Systematic Review and Meta-Analysis

Abstract

Purpose: To evaluate CEUS for the diagnosis of pancreatic diseases and its application in the clinical routine with a focus on the value of CEUS in ductal pancreatic carcinoma and its use for the differentiation of neoplastic and non-neoplastic lesions.

Materials and Methods: All prospective and retrospective studies published in any language by March 6, 2014 were included based on the following criteria: use of contrast-enhanced ultrasound (CEUS) and contrast-enhanced endoscopic ultrasound (ECEUS) as the imaging methods, use of histology as the reference method and availability of a complete translation. Two authors analyzed the titles and abstracts of the search results to identify all relevant publications. Two independent readers then analyzed the full articles to identify those meeting the inclusion criteria. Details regarding study design, patient characteristics, interventions, and results were then independently extracted by two radiologists and one reviewer with methodological expertise. Sensitivity, specificity and diagnostic odds ratio (DOR) were used to obtain overall estimates.

Results: 1293 articles were initially identified. 27 studies met the inclusion criteria. CEUS was the index test in 23 studies while ECEUS was the index test in 4 studies. The primary study objective was met by 20 studies with respect to ductal adenocarcinoma. CEUS sensitivity was evaluated in all studies. The pooled estimate of CEUS sensitivity for the diagnosis of ductal adenocarcinoma was 0.89 (95 % CI, 0.85 – 0.92). 15 out of 20 studies examined CEUS specificity. The average specificity was 0.84 (95 % CI, 0.77 – 0.89). The pooled estimate for DOR was 61.12 (95 % CI, 34.81 – 107.32). With regard to the secondary study objective, the pooled sensitivity and specificity were 0.95 (95 % CI, 0.93 – 0.96) from 14 studies and 0.72 (95 % CI, 0.58 – 0.83) from 13 studies, respectively. The pooled DOR was 57.63 (95 % CI, 33.62 – 98.78).

Conclusion: The sensitivity, specificity, and DOR results show the high value of CEUS for the characterization and differentiation of ductal adenocarinomas from other pancreatic diseases and for cystic pancreatic lesions. For this reason and due to their noninvasive nature, CEUS and ECEUS should be used as the first methods for characterizing neoplastic pancreatic lesions, especially since these are often incidental findings. The methods improve the quality of ultrasound diagnostics and result in faster diagnosis and better disease management.

Zusammenfassung

Ziel: Bewertung von CEUS für die Diagnostik bei Pankreaserkrankungen und deren Anwendung in der klinischen Routine. Zwei Schwerpunkte waren der Wert der CEUS beim duktalen Pankreaskarzinom und zur Differenzierung von neoplastischen und nicht- neoplastischen Läsionen.

Material und Methoden: Eingeschlossen wurden alle bis zum 6. März 2014 in jeglicher Sprache publizierten prospektiven und retrospektiven Studien mit kontrastverstärktem Ultraschall (CEUS) und kontrastverstärktem endoskopischer Ultraschall (ECEUS), die ausschließlich die Histologie als Referenzmethode aufwiesen und für die eine vollständige Übersetzung verfügbar war.Zwei Autoren analysierten initial Titel und Abstracts der Suchergebnisse, um alle relevanten Publikationen zu erfassen. 2 unabhängige Leser die analysierten die Volltexte der Artikel, ob diese die Einschlusskriterien korrekt erfüllten. Danach wurden Details der Studiendesigns, Patientencharakteristika, Interventionen und Ergebnisse unabhängig von zwei Radiologen und einem Reviewer mit methodischer Expertise extrahiert. Anhand der errechneten oder extrahierten Sensitivität, Spezifität und diagnostischer Odds Ratio (DOR) wurden allgemeine Schätzwerte analysiert.

Ergebnisse: Initial wurden 1293 Artikel identifiziert. 27 Studien erfüllten die Einschlusskriterien. CEUS war die Index-Diagnostik in 23 Studien, ECEUS in vier Studien. Das primäre Studienziel wurde von 20 Studien hinsichtlich des duktalen Adenokarzinoms erfüllt, die CEUS-Sensitivität wurde in allen Studien evaluiert. Der gepoolte Schätzwert der Sensitivität von CEUS für die Diagnose eines duktalen Adenokarzinoms lag bei 0,89 (95 % CI 0,85 – 0,92). Fünfzehn von 20 Studien untersuchten die Spezifität von CEUS. Die mittlere Spezifität lag bei 0,84 (95 % CI 0,77 – 0,89). Der gepoolte Schätzwert der DOR war 61,12 (95 % CI 34,81 – 107,32). Bezüglich des sekundären Studienendpunkts lag die gepoolte Sensitivität und Spezifität bei 0,95 (95 % CI 0,93 – 0,96) von 14 Studien bzw. 0,72 (95 % CI 0,58 – 0,83) von 13 Studien. Die gepoolte DOR war 57,63 (95 % CI 33,62 – 98,78).

Schlussfolgerung: Die Ergebnisse für Sensitivität, Spezifität und DOR sprechen für den hohen Wert der CEUS zur Charakterisierung und Differenzierung des duktalen Adenokarzinoms von anderen Pankreaserkrankungen, ebenso wie für zystische Pankreasläsionen. CEUS und ECEUS sollten daher und wegen ihrer non-invasiven Eigenschaften als initiale Verfahren zur Charakterisierung neoplastischer Pankreasläsionen genutzt werden, zumal diese häufig Zufallsbefunde sind. Sie verbessern sowohl die Qualität der US-Diagnostik Ultraschalls und führen zu einer rascheren Diagnose und besseren Management der Erkrankung.

Key words

pancreas - tumor - ultrasound

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