Aim of our study was to evaluate the accuracy of Endoscopic Ultrasound Advance Imaging (strain elastography (SE), contrast enhancement (CE) and detective flow imaging (DFI)) for the differential diagnosis of solid pancreatic tumors (SPT), either alone or in combination. 

Patients that underwent EUS-guided advance imaging for SPT between 2023 and 2025 were identified from a prospective EUS registry. EUS was performed with linear FujiFilm echoendoscopes and Hitachi-Arietta system. For EUS-SE, qualitative patterns were described and strain ratio (SR) and strain histogram (SH) were evaluated. For EUS-CE (with Sonovue) and DFI, tumors were classified as iso, hypo or hypervascular. Diagnostic accuracy was analyzed using as gold standard the cyto-histological analysis of the surgical specimen and/or EUS-guided sampling, or the clinical/radiological evaluation with a minimum of 6 months of follow-up. Data are presented as mean ± standard deviation or median and range for quantitative variables and as percentages for categorical variables, correlation was analyzed using linear regression and Spearman test. STARD criteria for studies was followed

217 patients were included (median age 68.2 years+/-11.0 years, 115 males). Median size of SPT was 25.2+/-15.9mm. 131 presented a malignant tumor (60.4%) (116 adenocarcinomas; 7 NETs-G2-3; 8 other etiology), whereas 86 presented a benign lesion (39.6%) (66 NETs-G1; 13 inflammatory masses, 2 lipomas and 5 accessory spleen). Sensitivity, specificity, and overall accuracy of SE (SR and SR) for diagnosing malignancy was 97.7%, 91.9%, and 94.5%, respectively (ROC-curve=0.936). With CE and DFI, the values were 92.4%, 96.5%, 94.0% (ROC-curve=0.944), and 93.9%, 95.4%, 94.5% (ROC-curve=0.946), respectively. Correlation between EUS-CE and DFI was 0.946. Combining SE with DFI±CE yielded a ROC-curve=0.956.

EUS-guided advanced imaging represents a very useful tool for the differential diagnosis and detection of malignancy in SPT.