Elastography and Contrast-Enhanced Endoscopic Ultrasound Findings in a Pseudo-Solid Variant of a Pancreatic Serous Cystadenoma

mediate-high signal intensity on T2-weighted images, suggesting a complex solid microcystic lesion ( Fig. 1 ). Endoscopic ultrasound (EUS) showed a well-circumscribed, 45-mm, predominantly hypoechogenic complex mass in the pancreatic isthmus, with scattered cystic areas. EUS-guided fine-needle aspiration with a 25-gauge needle was performed (3 passes) and cytology was suspicious, although not definitive, for malignancy. In a multidisciplinary team meeting, surveillance was decided based on MRCP/EUS morphologic findings, compatible with a pseudo-solid variant of a serous cystadenoma (SCA) and equivocal findings for malignancy on cytology, besides the location of the lesion (pancreatic isthmus) and the patient’s age and comorbidities. EUS was repeated 12 months later, with stable morphologic findings. Additional evaluation with Doppler-EUS showed increased color-Doppler signal ( Fig. 2 a), real-time elastography presented a soft pattern (strain ratio 3.1) ( Fig. 2 b) and, in the dynamic study with contrast (Sonovue ® ), the pseudosolid areas presented intense enhancement with slow washout ( Fig. 2 c). No suspicious lymph nodes were found. The differential diagnosis of complex pancreatic lesions is often challenging, and EUS morphology alone cannot provide a diagnosis in the majority of cases. EUS