Advertisement

Endoscopic ultrasonography for the evaluation of pancreatic cystic neoplasms

  • Eizaburo OhnoEmail author
  • Yoshiki Hirooka
  • Hiroki Kawashima
  • Takuya Ishikawa
  • Mitsuhiro Fujishiro
Special Feature: Review Article Ultrasonographic diagnosis of pancreatic diseases-This is all you need
  • 8 Downloads

Abstract

Endoscopic ultrasonography (EUS) is a modality with high spatial resolution that enables comprehensive observation of the entire pancreas and plays an important role in the diagnosis of pancreatic lesions. Recent advances in diagnostic imaging methods such as ultrasound, computed tomography, and magnetic resonance imaging have increased the incidental detection of pancreatic cystic lesions (PCLs). EUS has been recognized as an essential diagnostic method for the detection and evaluation of PCLs. EUS has two important roles: as a detailed (high-resolution) imaging diagnostic method and as an approach for collecting cyst fluid content by EUS-guided fine needle aspiration for pathological diagnosis or biomarker evaluation. Furthermore, in recent years, the usefulness of contrast-enhanced EUS for the differential diagnosis of PCLs or evaluation of grade of malignancy, and a novel imaging technique called needle-based confocal laser endomicroscopy to observe intraductal structures through a needle, has been reported. An understanding of the morphological characteristics of PCLs depicted by ultrasound imaging and of the benefits and limitations of EUS diagnosis in daily practice is needed.

Keywords

Endoscopic ultrasound Pancreatic cystic neoplasms Contrast-enhanced endoscopic ultrasound Endoscopic ultrasound-fine needle aspiration Intraductal papillary mucinous neoplasm 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest for this article.

Ethical statement

As this is a review article based on published literature, no ethics approval was required.

Supplementary material

10396_2019_980_MOESM1_ESM.docx (17 kb)
Supplementary material 1 (DOCX 16 kb)

References

  1. 1.
    Binmoeller KF, Soehendra N. Endoscopic ultrasonography in the diagnosis and treatment of pancreatic pseudocysts. Gastrointest Endosc Clin N Am. 1995;5:805–16.PubMedCrossRefGoogle Scholar
  2. 2.
    Pausawasdi N, Ratanachu-Ek T. Endoscopic ultrasonography evaluation for pancreatic cysts: necessity or overkill? Dig Endosc. 2017;29:444–54.PubMedCrossRefGoogle Scholar
  3. 3.
    Kamata K, Kitano M. Endoscopic diagnosis of cystic lesions of the pancreas. Dig Endosc. 2019;31:5–15.PubMedCrossRefGoogle Scholar
  4. 4.
    Hijioka S, Hara K, Yamao K, et al. Morphological differentiation and follow-up of pancreatic cystic neoplasms using endoscopic ultrasound. Endosc Ultrasound. 2015;4:312–8.  https://doi.org/10.4103/2303-9027.170423.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Hruban R, Pitman M, Klimstra D. AFIP atlas of tumor pathology, Series 4 fascicle 6: Tumors of the Pancreas. Washington DC: American Registry of Pathology, Armed Forces Institute of Pathology; 2007. p. 6.Google Scholar
  6. 6.
    Kubo H, Nakamura K, Itaba S, et al. Differential diagnosis of cystic tumors of the pancreas by endoscopic ultrasonography. Endoscopy. 2009;41:684–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Ohno E, Hirooka Y, Goto H, NSPINAL study group, et al. Natural history of pancreatic cystic lesions: a multicenter prospective observational study for evaluating the risk of pancreatic cancer. J Gastroenterol Hepatol. 2018;33:320–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Yamao K, Yanagisawa A, Takahashi K, et al. Clinicopathological features and prognosis of mucinous cystic neoplasm with ovarian-type stroma: a multi-institutional study of the Japan Pancreas Society. Pancreas. 2011;40:67–71.PubMedCrossRefGoogle Scholar
  9. 9.
    Nilsson LN, Keane MG, Laukkarinen J, et al. Nature and management of pancreatic mucinous cystic neoplasm (MCN): a systematic review of the literature. Pancreatology. 2016;16:1028–36.PubMedCrossRefGoogle Scholar
  10. 10.
    Acar M, Tatli S. Cystic tumors of the pancreas: a radiological perspective. Diagn Interv Radiol. 2011;17:143–9.PubMedGoogle Scholar
  11. 11.
    Sano M, Driscoll DR, De Jesus-Monge WE, et al. Activated wnt signaling in stroma contributes to development of pancreatic mucinous cystic neoplasms. Gastroenterology. 2014;146:257–67.PubMedCrossRefGoogle Scholar
  12. 12.
    Ishikawa T, Haruta J, Yamaguchi T, et al. A case of mucinous cystic neoplasm of the pancreas misdiagnosed as a pancreatic pseudocyst at the initial exam and resected after a 2-year follow-up. J Med Ultrason. 2015;42:257–65.  https://doi.org/10.1007/s10396-014-0581-5.CrossRefGoogle Scholar
  13. 13.
    Tseng JF, Warshaw AL, Sahani DV, et al. Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg. 2005;242:413–21.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Jais B, Rebours V, Levy P, et al. Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut. 2016;65:305–12.PubMedCrossRefGoogle Scholar
  15. 15.
    Kimura W, Moriya T, Hirai I, et al. Multicenter study of serous cystic neoplasm of the Japan Pancreas Society. Pancreas. 2012;41:380–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Tanaka M, Fernández-del Castillo C, Adsay V, International Association of Pancreatology, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12:183–97.PubMedCrossRefGoogle Scholar
  17. 17.
    Tanaka M, Fernandez-del Castillo C, Kamisawa T, et al. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 2017;17:738–53.PubMedCrossRefGoogle Scholar
  18. 18.
    Adsay V, Mino-Kenudson M, Furukawa T, Members of the Verona Consensus Meeting, 2013, et al. Pathologic evaluation and reporting of intraductal papillary mucinous neoplasms of the pancreas and other tumoral intraepithelial neoplasms of pancreatobiliary tract: Recommendations of Verona Consensus Meeting. Ann Surg. 2016;263:162–77.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Fukushima N, Mukai K, Kanai Y, et al. Intraductal papillary tumors and mucinous cystic tumors of the pancreas: clinicopathologic study of 38 cases. Hum Pathol. 1997;28:1010–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Adsay NV, Merati K, Basturk O, et al. Pathologically and biologically distinct types of epithelium in intraductal papillary mucinous neoplasms: delineation of an ‘intestinal’ pathway of carcinogenesis in the pancreas. Am J Surg Pathol. 2004;28:839–48.PubMedCrossRefGoogle Scholar
  21. 21.
    Maguchi H, Tanno S, Mizuno N, et al. Natural history of branch duct intraductal papillary mucinous neoplasms of the pancreas: a multicenter study in Japan. Pancreas. 2011;40:364–70.PubMedCrossRefGoogle Scholar
  22. 22.
    Kobayashi G, Fujita N, Takasawa O, et al. Ultrasonographic findings and natural history of intraductal papillary-mucinous neoplasms of the pancreas. J Med Ultrason. 2008;35:85–96.  https://doi.org/10.1007/s10396-008-0188-9 (Review).CrossRefGoogle Scholar
  23. 23.
    Shimizu Y, Kanemitsu Y, Yamao K, et al. A nomogram for predicting the probability of carcinoma in patients with intraductal papillary-mucinous neoplasm. World J Surg. 2010;34:2932–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Shimizu Y, Yamaue H, Maguchi H, et al. Validation of a nomogram for predicting the probability of carcinoma in patients with intraductal papillary mucinous neoplasm in 180 pancreatic resection patients at 3 high-volume centers. Pancreas. 2015;44:459–64.PubMedGoogle Scholar
  25. 25.
    Kobayashi N, Sugimori K, Nakajima A, et al. Endoscopic ultrasonography findings predict the risk of carcinoma in branch duct intraductal papillary mucinous neoplasms of the pancreas. Pancreatology. 2012;12:141–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Ohno E, Hirooka Y, Itoh A, et al. Intraductal papillary mucinous neoplasms of the pancreas: differentiation of malignant and benign tumors by endoscopic ultrasound findings of mural nodules. Ann Surg. 2009;249:628–34.PubMedCrossRefGoogle Scholar
  27. 27.
    Du C, Chai NL, Yang J, et al. Incidents and adverse events of endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions. World J Gastroenterol. 2017;23:5610–8.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Zhong N, Zhang L, Topazian M, et al. Histologic and imaging features of mural nodules in mucinous pancreatic cysts. Clin Gastroenterol Hepatol. 2012;10:192–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Khashab MA, Kim K, Canto MI, et al. Should we do EUS/FNA on patients with pancreatic cysts? The incremental diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms. Pancreas. 2013;42:717–21.PubMedCrossRefGoogle Scholar
  30. 30.
    Kamata K, Kitano M, Kudo M, et al. Value of EUS in early detection of pancreatic ductal adenocarcinomas in patients with intraductal papillary mucinous neoplasms. Endoscopy. 2014;46:22–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Takenaka M, Masuda A, Azuma T, et al. Chronic pancreatitis finding by endoscopic ultrasonography in the pancreatic parenchyma of intraductal papillary mucinous neoplasms is associated with invasive intraductal papillary mucinous carcinoma. Oncology. 2017;93:61–8.  https://doi.org/10.1159/000481232 Epub 2017 Dec 20.CrossRefPubMedGoogle Scholar
  32. 32.
    Mandai K, Uno K, Yasuda K, et al. Association between hyperechogenic pancreas and pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasms. J Med Ultrason. 2019.  https://doi.org/10.1007/s10396-019-00949-z.CrossRefGoogle Scholar
  33. 33.
    Koito K, Namieno T, Morita K, et al. Solitary cystic tumor of the pancreas: EUS-pathologic correlation. Gastrointest Endosc. 1997;45:268–76.PubMedCrossRefGoogle Scholar
  34. 34.
    Kubo H, Nakamura K, Itaba S, et al. Differential diagnosis of cystic tumors of the pancreas by endoscopic ultrasonography. Endoscopy. 2009;41:684–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Zhang W, Linghu E, Li H, et al. New criteria to differentiate between mucinous cystic neoplasm and serous cystic neoplasm in pancreas by endoscopic ultrasound: a preliminarily confirmed outcome of 41 patients. Endosc Ultrasound. 2017;6:116–22.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Aithal GP, Chen RYM, Cunningham JT, et al. Accuracy of EUS for detection of intraductal papillary mucinous tumor of the pancreas. Gastrointest Endosc. 2002;56:701–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Baba T, Yamagichi T, Ishihara T, et al. Distinguishing benign from malignant intraductal papillary mucinous tumors of the pancreas by imaging techniques. Pancreas. 2004;29:212–27.PubMedCrossRefGoogle Scholar
  38. 38.
    Gress F, Gottieb K, Lehman G, et al. Endoscopic ultrasound characteristics of mucinous cystic neoplasms of the pancreas. Am J Gastroenterol. 2000;95:961–5.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Sedlack R, Affi A, Clain JE, Wiersema MJ, et al. Utility of EUS in the evaluation of cystic pancreatic lesions. Gastrointest Endosc. 2002;56:53–7.CrossRefGoogle Scholar
  40. 40.
    Ahmad NA, Kochman ML, Brensinger C, et al. Interobserver agreement among endosonographers for the diagnosis of neoplastic versus non-neoplastic pancreatic cystic lesions. Gastrointest Endosc. 2003;58:59–64.PubMedCrossRefGoogle Scholar
  41. 41.
    Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology. 2004;126:1330–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Gerke H, Jaffe TA, Mitchell RM, et al. Endoscopic ultrasound and computer tomography are inaccurate methods of classifying cystic pancreatic lesions. Dig Liver Dis. 2006;38:39–44.PubMedCrossRefGoogle Scholar
  43. 43.
    Pais SA, Attasaranya S, DeWitt J, et al. Role of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms: correlation with surgical histopathology. Clin Gastroenterol Hepatol. 2007;5:489–95.PubMedCrossRefGoogle Scholar
  44. 44.
    Kitano M, Sakamoto H, Matsui U, et al. A novel perfusion imaging technique of the pancreas: contrast-enhanced harmonic EUS (with video). Gastrointest Endosc. 2008;67:141–50.PubMedCrossRefGoogle Scholar
  45. 45.
    Hirooka Y, Goto H, Ito A, et al. Contrast-enhanced endoscopic ultrasonography in pancreatic diseases: a preliminary study. Am J Gastroenterol. 1998;93:632–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Hocke M, Cui XW, Domagk D, et al. Pancreatic cystic lesions: the value of contrast-enhanced endoscopic ultrasound to influence the clinical pathway. Endosc Ultrasound. 2014;3:123–30.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Fusaroli P, Serrani M, De Giorgio R, et al. Contrast harmonic-endoscopic ultrasound is useful to identify neoplastic features of pancreatic cysts (with videos). Pancreas. 2016;45:265–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Kamata K, Kitano M, Omoto S, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of pancreatic cysts. Endoscopy. 2016;48:35–41.PubMedCrossRefGoogle Scholar
  49. 49.
    Yamashita Y, Ueda K, Itonaga M, et al. Usefulness of contrast enhanced endoscopic sonography for discriminating mural nodules from mucous clots in intraductal papillary mucinous neoplasms: a single-center prospective study. J Ultrasound Med. 2013;32:61–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Harima H, Kaino S, Shinoda S, et al. Differential diagnosis of benign and malignant branch duct intraductal papillary mucinous neoplasm using contrast-enhanced endoscopic ultrasonography. World J Gastroenterol. 2015;21:6252–60.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Yamamoto N, Kato H, Tomoda T, et al. Contrast-enhanced harmonic endoscopic ultrasonography with time-intensity curve analysis for intraductal papillary. Endoscopy. 2016;48:26–34.PubMedGoogle Scholar
  52. 52.
    Marchegiani G, Andrianello S, Salvia R, et al. Systematic review, meta-analysis, and a high-volume center experience supporting the new role of mural nodules proposed by the updated 2017 international guidelines on IPMN of the pancreas. Surgery. 2018;163:1272–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Fujita M, Itoi T, Moriyasu F, et al. Effectiveness of contrast-enhanced endoscopic ultrasound for detecting mural nodules in intraductal papillary mucinous neoplasm of the pancreas and for making therapeutic decisions. Endosc Ultrasound. 2016;5:377–83.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Ohno E, Itoh A, Kawashima H, et al. Malignant transformation of branch duct-type intraductal papillary mucinous neoplasms of the pancreas based on contrast-enhanced endoscopic ultrasonography morphological changes: focus on malignant transformation of intraductal papillary mucinous neoplasm itself. Pancreas. 2012;41:855–62.PubMedCrossRefGoogle Scholar
  55. 55.
    Frossard JL, Amouyal P, Amouyal G, et al. Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions. Am J Gastroenterol. 2003;98:1516–24.PubMedCrossRefGoogle Scholar
  56. 56.
    Maire F, Voitot H, Hammel P, et al. Intraductal papillary mucinous neoplasms of the pancreas: performance of pancreatic fluid analysis for positive diagnosis and the prediction of malignancy. Am J Gastroenterol. 2008;103:2871–7.PubMedCrossRefGoogle Scholar
  57. 57.
    Zhu H, Jiang F, Zhu J, Du Y, Jin Z, Li Z. Assessment of morbidity and mortality associated with endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: a systematic review and meta-analysis. Dig Endosc. 2017;29:667–75.PubMedCrossRefGoogle Scholar
  58. 58.
    Rodríguez-D’Jesús A, Fernández-Esparrach G, Ginès A, et al. Adverse events of EUS-guided FNA of pancreatic cystic and solid lesions by using the lexicon proposed in an ASGE workshop: a prospective and comparative study. Gastrointest Endosc. 2016;83:780–4.PubMedCrossRefGoogle Scholar
  59. 59.
    Yoon WJ, Daqlilar ES, Brugge WR, et al. Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: the PIPE Study. Endoscopy. 2014;46:382–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Levy MJ, Gleeson FC, Clayton A, et al. Prospective cytological assessment of gastrointestinal luminal fluid acquired during EUS: a potential source of false-positive FNA and needle tract seeding. Am J Gastroenterol. 2010;105:1311–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Hirooka Y, Goto H, Itoh A, et al. A case of intraductual papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. J Gastroenterol Hepatol. 2003;18:1323–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Yamabe A, Irisawa A, Hojo H, et al. Rare condition of needle tract seeding after EUS-guided FNA for intraductal papillary mucinous carcinoma. Endosc Int Open. 2016;4:E756–8.PubMedPubMedCentralCrossRefGoogle Scholar
  63. 63.
    Minaga K, Takenaka M, Kudo M, et al. Needle tract seeding: an overlooked rare complication of endoscopic ultrasound-guided fine-needle aspiration. Oncology. 2017;93:107–12.PubMedCrossRefGoogle Scholar
  64. 64.
    van der Waaij LA, van Dulleman HM, Porte RJ. Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest Endosc. 2005;62:383–9.PubMedCrossRefGoogle Scholar
  65. 65.
    Thosani N, Thosani S, Guha S, et al. Role of EUS-FNA-based cytology in the diagnosis of mucinous pancreatic cystic lesions: a systematic review and meta-analysis. Dig Dis Sci. 2010;55:2756–66.PubMedPubMedCentralCrossRefGoogle Scholar
  66. 66.
    De Jong K, Poley JW, Fockens P, et al. Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions provides inadequate material for cytology and laboratory analysis: initial results from a prospective study. Endoscopy. 2011;43:585–90.PubMedCrossRefGoogle Scholar
  67. 67.
    Al-Haddad M, Gill KR, Wallace MB, et al. Safety and efficacy of cytology brushings versus standard fine-needle aspiration in evaluating cystic pancreatic lesions: a controlled study. Endoscopy. 2010;42:127–32.PubMedCrossRefGoogle Scholar
  68. 68.
    Hong SK, Loren DE, Kowalski TE, et al. Targeted cyst wall puncture and aspiration during EUS-FNA increases the diagnostic yield of premalignant and malignant pancreatic cysts. Gastrointest Endosc. 2012;75:775–82.PubMedCrossRefGoogle Scholar
  69. 69.
    Mittal C, Obuch JC, Wagh MS, et al. Technical feasibility, diagnostic yield, and safety of microforceps biopsies during EUS evaluation of pancreatic cystic lesions (with video). Gastrointest Endosc. 2018;87:1263–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Bruno M, Bosco M, Carucci P, et al. Preliminary experience with a new cytology brush in EUS-guided FNA. Gastrointest Endosc. 2009;70:1220–4.PubMedCrossRefGoogle Scholar
  71. 71.
    Khalid A, Zahid M, Finkelstein SD, et al. Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study. Gastrointest Endosc. 2009;69:1095–102.PubMedCrossRefGoogle Scholar
  72. 72.
    Gillis A, Cipollone I, Conlon K, et al. Does EUS-FNA molecular analysis carry additional value when compared to cytology in the diagnosis of pancreatic cystic neoplasm? A systematic review. HPB (Oxford). 2015;17:377–86.CrossRefGoogle Scholar
  73. 73.
    Kadayifci A, Atar M, Wang JL, et al. Value of adding GNAS testing to pancreatic cyst fluid KRAS and carcinoembryonic antigen analysis for the diagnosis of intraductal papillary mucinous neoplasms. Dig Endosc. 2017;29:111–7.PubMedCrossRefGoogle Scholar
  74. 74.
    Wu J, Matthaei H, Vogelstein B, et al. Recurrent GNAS mutations define an unexpected pathway for pancreatic cyst development. Sci Transl Med. 2011;3:92ra66.PubMedPubMedCentralCrossRefGoogle Scholar
  75. 75.
    Singhi AD, McGrath K, Brand RE, et al. Preoperative next-generation sequencing of pancreatic cyst fluid is highly accurate in cyst classification and detection of advanced neoplasia. Gut. 2018;67:2131–41.PubMedCrossRefGoogle Scholar
  76. 76.
    Nakai Y, Iwashita T, Chang KJ, et al. Diagnosis of pancreatic cysts: EUS-guided, through-the needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study. Gastrointest Endosc. 2015;81:1204–14.PubMedCrossRefGoogle Scholar
  77. 77.
    Konda VJ, Aslanian HR, Waxman I, et al. First assessment of needle-based confocal laser endomicroscopy during EUS-FNA procedures of the pancreas (with videos). Gastrointest Endosc. 2011;74:1049–60.PubMedCrossRefGoogle Scholar
  78. 78.
    Konda VJ, Meining A, Jamil LH, et al. A pilot study of in vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy under endosonographic guidance. Endoscopy. 2013;45:1006–13.PubMedCrossRefGoogle Scholar
  79. 79.
    Krishna SG, Lee JH. Appraisal of needle-based confocal laser endomicroscopy in the diagnosis of pancreatic cyst. World J Gastroenterol. 2016;22:1701–10.PubMedPubMedCentralCrossRefGoogle Scholar
  80. 80.
    Napoleon B, Lemaistre AI, Pujol B, et al. A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy. Endoscopy. 2015;47:26–32.PubMedCrossRefGoogle Scholar

Copyright information

© The Japan Society of Ultrasonics in Medicine 2019

Authors and Affiliations

  • Eizaburo Ohno
    • 1
    Email author
  • Yoshiki Hirooka
    • 2
  • Hiroki Kawashima
    • 1
  • Takuya Ishikawa
    • 1
  • Mitsuhiro Fujishiro
    • 1
  1. 1.Department of Gastroenterology and HepatologyNagoya University Graduate School of MedicineNagoyaJapan
  2. 2.Department of Liver, Biliary Tract and Pancreas DiseasesFujita Health UniversityAichiJapan

Personalised recommendations