d Original Contribution LIVER CONTRAST-ENHANCED ULTRASOUND IMPROVES DETECTION OF LIVER METASTASES IN PATIENTS WITH PANCREATIC OR PERIAMPULLARY CANCER P AVEL T AIMR,* VIVIAN L. JONGERIUS, y CHULJA J. PEK, y NANDA C. KRAK, z BETTINA E. HANSEN,* HARRY L. A. J ANSSEN,* x HEROLD J. METSELAAR,* and CASPER H. J. VAN EIJCK y *Department of Hepatology and Gastroenterology, Erasmus Medical Center, Rotterdam, The Netherlands; y Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; z Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands; and x Liver Clinic, University Health Network, Toronto Western Hospital, Toronto, Canada (Received 11 February 2015; revised 14 May 2015; in final form 22 June 2015) Abstract—The aim of this study is to provide a diagnostic performance evaluation of contrast-enhanced ultraso- nography (CEUS) in detecting liver metastases in patients with suspected of pancreatic or periampullary cancer. Computed tomography (CT) is often insufficient for detection of liver metastases, but their presence plays a crucial role in the choice of therapy. Eighty-nine patients with suspected pancreatic or periampullary cancer were included in this prospective study with retrospective analysis. Patients underwent an abdominal CT and CEUS. Fifteen patients had liver metastases. The CT sensitivity was 73.3% (11/15), the specificity 93.2% (69/74), the pos- itive predictive value (PPV) 68.8% (11/16) and the negative predictive value (NPV) 94.6% (69/73). Based on CEUS, the sensitivity was 80% (12/15), specificity 98.6% (73/74), PPV 92.3% (12/13) and NPV 96.1% (73/76). CEUS improved characterization of liver lesions in patients with suspected pancreatic or periampullary cancer compared with CT. CEUS can better detect benign liver lesions and distinguish false-positive or indeterminate CT results. (E-mail: p.taimr@erasmusmc.nl) Ó 2015 World Federation for Ultrasound in Medicine & Biology. Key Words: CEUS, CT, Liver metastases, Pancreatic cancer, Detection, SonoVue. INTRODUCTION Pancreatic adenocarcinoma is one of the deadliest types of cancer. The overall U.S. mortality rate for cancer has declined by 20% since 1991, according to the American Cancer Society (2013). In contrast to many other malig- nancies, pancreatic cancer is a grim exception, and its death rate is slowly increasing. For all stages combined, the 5-y relative survival rate is only 6%, and most patients will die within the first year of diagnosis. In particular, pancreatic cancer metastasizes frequently, particularly to the liver. Complete surgical resection combined with adjuvant chemotherapy is currently the only potentially curative treatment. The 5-y overall survival in patients undergoing pancreatectomy is 15%–25% compared to 5% without surgical treatment (Riediger et al. 2009). However, after a tumor is diagnosed, surgery is an option in only 15%–20% of all patients. Most tumors are diag- nosed at an already non-resectable stage due to late detec- tion and early metastases, particularly in the liver (Braat et al. 2012; Sener et al. 1999). Surgery will not improve survival if metastases are present in the liver. The presence or absence of liver metastases plays a pivotal role in the choice of therapy. It is therefore crucial to have accurate pre-operative methods for the detection of liver metastases (Sahani et al. 2008). Computed tomography (CT) is currently the refer- ence method for the detection of metastases and is used in combination with clinical and histologic data. Patients suspected of having pancreatic cancer generally receive only an abdominal CT as a first-line investigation. The CT scan has two objectives: evaluation of the tumor’s local resectability and exclusion of distant metastases. Although the quality of the CT scan has improved in recent years, the sensitivity for the detection of liver metastases is suboptimal and ranges from 38% to 73% (Balci and Semelka 2001; Holzapfel et al. 2011; Motosugi et al. 2011). A CT scan alone is often not enough for the detection of metastases, and surgeons Ultrasound in Med. & Biol., Vol. -, No. -, pp. 1–7, 2015 Copyright Ó 2015 World Federation for Ultrasound in Medicine & Biology Printed in the USA. All rights reserved 0301-5629/$ - see front matter http://dx.doi.org/10.1016/j.ultrasmedbio.2015.06.019 Address correspondence to: Pavel Taimr, Department of Hepatology and Gastroenterology, Postbus 2040, Gravendijkwal 230, 3000 CA, Rotterdam, The Netherlands. E-mail: p.taimr@erasmusmc.nl 1