Digestive Endoscopy (2011) 23 (Suppl. 1), 26–28 doi:10.1111/j.1443-1661.2011.01137.

THE ROLE OF EUS FOR DIAGNOSIS OF PANCREATIC MALIGNANCIES den_1137 26..28

A CONVEX EUS IS USEFUL TO DIAGNOSE VASCULAR INVASION

OF CANCER, ESPECIALLY HEPATIC HILUS CANCER

Kazuo Hara,1 Vikram Bhatia,2 Susumu Hijioka,1 Nobumasa Mizuno1 and Kenji Yamao1
1
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan; and 2Department of Medical Hepatology,
Institute of Liver and Biliary Sciences, Delhi, India

Endoscopic ultrasonography (EUS) has become an indispensable diagnostic procedure pairing endoscopy with translumi-
nal high frequency ultrasonography. EUS provides images with a high resolution such that the depth of tumor invasion can
be accurately determined. It also sees lesions outside of gastrointestinal tract, particularly those in pancreas, biliary system
and periluminal lymph nodes. The most important limitation of EUS was lack of specificity, that is, the differentiation
between benign and malignant lesions. In 1992, EUS-guided fine needle aspiration (EUS-FNA) was introduced with the
sampling of a lesion in the pancreatic head using a convex EUS. Since then the indications of EUS-FNA have been
expanded to include a variety of therapeutic uses. In addition, a convex EUS probe can also be used for detailed evaluation
of the pancreatobiliary system, in lieu of a radial EUS. The vascular structures surrounding liver, biliary system and pancreas
can be showed by a convex EUS system very clearly and easily compared with the more familiar radial EUS images. So we
think a convex EUS is very useful for not only EUS-FNA but also screening and close examination for cancer with vascular
invasion.

Key word: abdominal vessel, convex EUS, EUS, EUS-FNA, EUS procedure.

INTRODUCTION ULTRASOUND IMAGES OF UPPER

ABDOMINAL VASCULAR STRUCTURES BY
Current endoscopic ultrasonography (EUS) systems use two
A CONVEX EUS
types of scanning methods: radial scanning and convex scan-
ning.1 Radial EUS imaging is extensively used for imaging Scanning from the stomach
of small lesions, and diagnoses and staging of cancer.2 In
When the EUS scope has passed the esophagogastric
contrast, convex EUS imaging is used for EUS-guided fine
junction, and the control knobs are free, the left lobe of
needle aspiration (EUS-FNA) to obtain pathological diag-
the liver can usually be seen. Starting with the left liver
noses. Some doctors say ‘A convex EUS is useful only for
lobe in view, we can rotate the scope clockwise to see
EUS-FNA and interventional EUS.’3 Other doctors would
the abdominal aorta in a longitudinal orientation. When the
say ‘It is difficult to understand the ultrasound anatomy of the
scope is advanced gently from this position after the
pancreatobiliary systems thorough a convex EUS, which is
abdominal aorta, the celiac artery take off will be seen. We
not suitable for screening for the pancreatobiliary diseases.’
can trace the celiac artery to its division into common
Are these true? We do not think so. We think a convex EUS
hepatic artery (CHA) and splenic artery (SA) (Fig. 1). We
system is very useful for screening, and has similar or even
can then follow the CHA by rotating the scope counter-
better diagnostic accuracy for pancreatobiliary diseases even
clockwise and slowly pulling back a little bit, and show the
without EUS-FNA, than radial EUS imaging. It has a supe-
rior accuracy for visualization of abdominal vessels.4 So, a
convex EUS is very useful for the assessment of vascular
invasion with cancer.5 In this review we will describe the
procedure for visualization of upper abdominal vascular
structures, and the assessment of vascular invasion with
cancer using a convex EUS.6–8 SPA

CHA

Correspondence: Kazuo Hara, Department of Gastroenterology,

Aichi Cancer Center Hospital, Nagoya 464-8681, Japan. Email: khara@
aichi-cc.jp
Fig. 1. The bifurcation of splenic artery (SPA) and common
Received 24 December 2010; accepted 28 January 2011. hepatic artery (CHA) is seen from the stomach.
© 2011 The Authors
Digestive Endoscopy © 2011 Japan Gastroenterological Endoscopy Society
A CONVEX EUS IS USEFUL TO DIAGNOSE 27

Fig. 2. Common hepatic artery (CHA), gastroduodenal artery Fig. 4. Splenic artery (SPA), splenic vein (SPV), portal vein
(GDA), proper hepatic artery (PHA), right hepatic artery (Rt (PV) and superior mesenteric vein (SMV) are seen from the
HA) and light hepatic artery (Lt HA) are seen clearly from the stomach.
stomach using the color Doppler.

Lt HA(A2+3)

Lt PV
Middle HA

Fig. 5. The bifurcation of right hepatic arteries (Rt HA), left

Fig. 3. We can see the left portal vein (Lt PV), middle hepatic hepatic arteries (Lt HA) is seen from the duodenal bulb.
artery (HA) and lateral hepatic artery in the left lobe of the liver.

gastroduodenal artery and the proper hepatic artery (PHA)

(Fig. 2). If we further withdraw the scope to follow the
CASE PRESENTATION
PHA toward hepatic hilum, we can see the right and A 60-year-old woman was referred to our hospital in January
left hepatic arteries (Rt and Lt HA) (Fig. 2). At the hepatic 2010 for further examination of a liver tumor, which was
hilum, we can trace portal vein (PV) to its division into detected by abdominal ultrasound during a health examina-
Rt and Lt PV. We can follow the Lt PV by rotating the tion. The tumor was characterized as a cholangiocarcinoma
scope counterclockwise, and recognize the middle hepatic by MD-CT at the referring hospital. We suspected perineural
artery (MHA) and lateral hepatic artery and left PV invasion surroundings the Rt HA and MHA from the CT
(Fig. 3). We can then insert the scope along the PV to show images (Fig. 10). During the EUS study we could show the
the confluence of the superior mesenteric vein and the perineural invasion surroundings of the Rt HA and MHA
splenic vein (Fig. 4). very clearly compared with the CT images (Fig. 10).We could
easily and clearly see Rt HA, Lt HA and MHA. A convex
EUS was very useful to assess vascular invasion of cancer in
this case.
Scanning from the duodenal bulb
We insert the scope into the duodenal bulb and rotate it to
see the pancreatic head and CHA. If we push the scope
CONCLUSION
with down angle following the PHA towards the hepatic
hilum, we can see its bifurcation into Lt HA and Rt HA A convex EUS is useful for not only EUS-FNA but
(Fig. 5). Following the Rt HA by pushing the scope gently, also assessment of vascular invasion by cancer, especially
we can see its anterior and posterior branches (Fig. 6). at the hepatic hilum.6,7 We recommend the increased use
Color Doppler mode is very useful to detect the HA and its of a convex EUS to determine the relation of hilar cancers
branches. If we see the PV, we can see its Lt and Rt PV to the adjacent vascular structures. Because we can get
divisions at the hepatic hilum (Figs 7,8). If we rotate the the contrast tissue harmonic images by a new type convex
scope counterclockwise following the Rt PV, we can see its EUS, we can get the clear images of abdominal vessel, con-
further bifurcation into its anterior and posterior branches trast images and EUS-FNA specimen by only a convex
(Fig. 9). EUS.
© 2011 The Authors
Digestive Endoscopy © 2011 Japan Gastroenterological Endoscopy Society
28 K HARA ET AL.

Anterior artery

Posterior artery

Rt PV
Rt PV

Fig. 6. We can see the anterior and posterior hepatic artery

near right portal vein (Rt PV) clearly. Fig. 8. Right portal vein (Rt PV) is seen at hepatic hilum.

PV
Anterior PV
Lt HA
Posterior PV
Lt PV

Fig. 7. Both left portal vein (Lt PV) and left hepatic arteries Fig. 9. We can see the bifurcation anterior and posterior portal
(Lt HA) are seen at hepatic hilum. vein (PV) in the right lobe of the liver.

a b

Rt HA Middle HA Rt HA Middle HA

Rt HA Middle HA
Middle HA
Liver Fig. 10. Right hepatic artery (Rt HA)
Rt HA and middle HA are seen in the tumor at
hepatic hilum. This tumor surrounding
Liver hepatic artery is perivascular invasion
of cholangiocarcinoma. Rt and middle
hepatic artery are seen clearly by a
convex EUS.

single-center experience. Gastroinest. Endosc. 2011; 73: 71–

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© 2011 The Authors
Digestive Endoscopy © 2011 Japan Gastroenterological Endoscopy Society