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Endosc Int Open
Endosc Int Open
10.1055/s-00025476
Endosc Int Open
Endoscopy International Open
2364-3722
2196-9736
Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

10.1055/a-2405-1170
EIO-2024-05-3380-VidEIO
VidEIO
Detective flow imaging endoscopic ultrasound for locating optimal puncture site for a poorly vascularized pancreatic mass
Otsuka Yasuo Dr.
http://orcid.org/0000-0001-5407-7925
Minaga Kosuke Dr.
Hara Akane Dr.
Masuta Yasuhiro Dr.
http://orcid.org/0000-0001-7308-4311
Takenaka Mamoru Dr.
Chikugo Takaaki
Kudo Masatoshi Dr.
1 Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
2 Department of Pathology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
Correspondence Dr. Kosuke Minaga Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan589-8511 Osaka-SayamaJapankousukeminaga@yahoo.co.jp
12 9 2024
9 2024
1 9 2024
12 9 E1063E1064
20 5 2024
13 6 2024
The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
2024
The Author(s).
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.
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pmc Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is an established procedure with high diagnostic accuracy for tissue acquisition and pathological diagnosis of pancreatic ductal adenocarcinoma (PDAC) 1 . However, EUS-FNB sometimes demonstrates inconclusive results in PDAC rich in necrotic or fibrotic components 2 3 . In such cases, identifying hot spot areas with viable cancerous cells is important to obtain adequate samples. Detective flow imaging (DFI) is a novel Doppler imaging technology that visualizes low-velocity blood flow in the absence of motion artifacts 4 5 , which was challenging to visualize on conventional color Doppler imaging. Herein, we present a case in which DFI imaging helped determine the hot spot area during EUS-FNB for a poorly vascularized pancreatic mass.

An 85-year-old male patient was referred to our hospital for pancreatic mass evaluation. Contrast-enhanced computed tomography revealed a large hypodense mass in the pancreatic body and tail with poor contrast enhancement ( Fig. 1 ). EUS detected a well-defined heterogeneous mass in the pancreatic body. EUS-FNB was performed using a 22-gauge Franseen needle (Acquire; Boston Scientific, Natick, Massachusetts, United States) with three needle passes. However, the acquired materials contained only fibrotic and necrotic components without epithelial cells. Repeated EUS-FNB was required to confirm the diagnosis. Previous EUS-FNB findings indicated that the tumor contained abundant fibrotic tissues; thus, intratumoral vessel evaluation using the DFI was planned. Conventional color Doppler imaging revealed no intratumoral vessels ( Fig. 2 a ), whereas DFI imaging demonstrated fine, irregular intratumoral vessels, indicating a hot spot area ( Fig. 2 b ). EUS-FNB with DFI guidance was performed using the same needle type against the area where vessels were displayed on DFI ( Fig. 3 a, Video 1 ). The acquired specimen contained cancerous tissue, resulting in a final diagnosis of PDAC ( Fig. 3 b ). This case indicates that DFI helps determine the optimal puncture site for diagnosis of poorly vascularized PDAC.

Fig. 1 Contrast-enhanced computed tomography showing a large hypodense mass in the pancreatic body and tail with very poor contrast enhancement. a Early phase. b Delayed phase.

Fig. 2 a Conventional color Doppler endoscopic ultrasound (EUS) showing no intratumoral vessels. b Detective flow imaging EUS illustrating fine irregular vessels inside the pancreatic mass.

Fig. 3 a EUS-guided tissue acquisition was performed using a Franseen needle on DFI guidance against the area where intratumoral vessels were displayed. b Histopathological evaluation of the acquired specimen demonstrating atypical cell clusters with irregularly sized nuclei, resulting in pancreatic ductal adenocarcinoma diagnosis.

Detective flow imaging helps determine the optimal puncture site for poorly vascularized pancreatic mass.

Video 1

Conflict of Interest The authors declare that they have no conflict of interest.
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