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Fig. 1 Original unenhanced view of the lesion in the pancreatic tail using endoscopic Doppler ultrasound. The rich vascularisation of the tumour is not as impressive as in the 3D reconstruction due to longer scanning time in 3 D mode.
Fig. 2 Clearly hyperenhanced tumour after injection of contrast enhancer in low MI mode. The machine is already set up in 3D data acquiring mode.
Fig. 3 3D Color Doppler reconstruction of the rich vascularisation of a renal cancer metastasis in the pancreatic tail. The normal surrounding tissue is shown in gray colors.
Fig. 4 3D reconstruction of the metastatic lesion after demarcation with help of contrast enhanced low mechanical index endosonography. The normal surrounding pancreatic tissue does not take up the contrast enhancer and therefore remained not visible in the picture.
working diagnosis of a late onset of renal cancer metastasis in the pancreatic tail was made. No further lesions could be shown in further CT and MRI scans and the woman
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could be successfully operated on a second time with confirmation of the diagnosis.
Conclusions ▼▼
The combination of 3D reconstruction with enhanced and unenhancend endoscopic ultrasound seems to be a feasible method to give the investigator and the referring doctor new insights into the anatomy and outer borders of a neoplastic lesion. The advantage of the new method is the small learning curve and the possible combination with any endoscopic ultrasound technique. The disadvantage seems to be the interrupted investigation due to the data aquiring period (in total between 15 and 20 sec.). This means that the advantage of real time contrast enhanced ultrasound has to be compromised. So far using this tool we have to inject two contrast vials, the first time for the dynamic analysis of the lesion and the second time for requiring data for the 3D reconstruction. Developing the low mechanical index endosonography into better scanning quality might outcast the disadvantages and lower the costs. Real time 3D scanner, as already in use in gynecological ultrasound, could improve the method even further. References 1 Dietrich CF. [3D real time contrast enhanced ultrasonography,a new technique]. Rofo 2002; 174(2):160-163. 2 Dietrich CF, Ignee A, Frey H. Contrast-enhanced endoscopic ultrasound with low mechanical index: a new technique. Z Gastroenterol 2005; 43(11):1219-1223. 3 Dietrich CF. Contrast-enhanced low mechanical index endoscopic ultrasound (CELMIEUS). Endoscopy 2009; 41 Suppl 2:E43-E44. 4 Hocke M, Schulze E, Gottschalk P, Topalidis T, Dietrich CF. Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer. World J Gastroenterol 2006; 12(2):246-250. 5 Hocke M, Ignee A, Topalidis T, Stallmach A, Dietrich CF. Contrast-enhanced endosonographic Doppler spectrum analysis is helpful in discrimination between focal chronic pancreatitis and pancreatic cancer. Pancreas 2007; 35(3):286-288. 6 Hocke M, Schmidt C, Zimmer B, Topalidis T, Dietrich CF, Stallmach A. [Contrast enhanced endosonography for improving differential diagnosis between chronic pancreatitis and pancreatic cancer]. Dtsch Med Wochenschr 2008; 133(38):1888-1892.
Michael Hocke, Christoph F Dietrich christoph.dietrich@ckbm.de