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    Contents lists available at ScienceDirect
    Digestive and Liver Disease
    Digestive Endoscopy
    Contrast-enhanced harmonic endoscopic ultrasonography for evaluating the response to chemotherapy in pancreatic cancer
    Hidekazu Tanaka a , Ken Kamata a,∗ , Mamoru Takenaka a , Tomoe Yoshikawa a , Rei Ishikawa a, Ayana Okamoto a, Tomohiro Yamazaki a, Atsushi Nakai a, Shunsuke Omoto a , Kosuke Minaga a , Kentaro Yamao a , Toshiharu Sakurai a , Tomohiro Watanabe a , Naoshi Nishida a , Yasutaka Chiba b , Masayuki Kitano c , Masatoshi Kudo a
    a Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan b Clinical Research Center, Kindai University Hospital, Osaka-sayama, Japan c Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
    Article history:
    Available online xxx
    Contrast-enhanced harmonic endoscopic
    Endoscopic ultrasonography
    Pancreatic cancer 
    Background and aims: Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is used for the diagnosis of pancreatic cancer (PC). Here, we examined the usefulness of CH-EUS for evaluating therapeutic responses in PC.
    Methods: The study included 23 patients with PC who received chemotherapy. Patients underwent contrast-enhanced computed tomography (CE-CT) and CH-EUS before chemotherapy and at the time of evaluation of the therapeutic response. Patients with a 50% MK-2206 in serum carbohydrate antigen 19–9 levels after chemotherapy were defined as “super responders”. The incidence of an avascular area in the tumor on CH-EUS after chemotherapy was compared between “super responders” and non-super responders.
    Results: Nine patients were included in the “super responders” group.Tumor reduction rates did not differ significantly between CE-CT and CH-EUS in the “super responders”. The appearance of an avascular area was detected in 7 of 9 super responders (77.8%) and in 4 of 14 non-super responders (28.6%), and the difference was significant (P = 0.036). The mean survival time of patients with an avascular area after chemotherapy was longer than thermiogenesis of without an avascular area.
    Conclusions: Detection of avascular areas by CH-EUS after chemotherapy may predict long-term survival of patients with PC.
    © 2019 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.
    1. Introduction
    Pancreatic cancer (PC) is one of the deadliest cancers with a 5-year survival rate of 5% [1]. Although complete surgical resection is the only curative treatment for PC, less than 20% of patients undergo surgical resection [1]. The majority of patients with PC require chemotherapy from the time of diagnosis because surgical treat-ment alone does not improve survival [2]. PC is diagnosed by several imaging modalities including ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and endo-scopic ultrasonography (EUS) [3]. In particular, contrast-enhanced
    ∗ Corresponding author at: Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osaka-sayama 589-8511, Japan.
    CT (CE-CT) is essential for the diagnosis and determination of treat-ment policy in PC [3]. CE-CT is used for evaluating the response to chemotherapy in patients with PC according to RECIST guidelines (ver. 1.1) [4] and CHOI criteria [5], which are determined based on changes in tumor diameter and CT values. Previous work from our group recommended the use of contrast-enhanced US (CE-US) for evaluating the response to chemotherapy in PC [6]. However, contrast-enhanced harmonic EUS (CH-EUS) recently emerged as a promising tool for MK-2206 the diagnosis of pancreatic diseases [7–11]. CH-EUS is superior to US for detecting PC [7–11]. In the present study, we compared the abilities of CH-EUS and CT to measure reductions in tumor size. A previous report showed that avascular areas on CE-US in patients with PC are related to severe fibrosis and necrosis within the lesion [12]. In previous work from our group, evaluation of avascular areas using CH-EUS showed that EUS-guided fine nee-dle aspiration has low sensitivity in PC patients with avascular areas