Published online Nov 16, 2025. doi: 10.4253/wjge.v17.i11.112487
Revised: August 20, 2025
Accepted: October 17, 2025
Published online: November 16, 2025
Processing time: 108 Days and 22.4 Hours
Endoscopic ultrasound (EUS) is crucial for diagnosing solid pancreatic lesions, especially pancreatic ductal adenocarcinoma (PDAC), a highly aggressive cancer which represents the majority with a prevalence of approximately 85%.
To identify EUS features that differentiate PDAC from other lesions such as neuroendocrine tumors (NETs) and helping in the differential diagnosis, by analyzing a large sample of solid pancreatic lesions.
This observational, retrospective, multicenter study analyzed the endosonographic characteristics of 761 patients with a radiological diagnosis of solid pancreatic lesion, who underwent pancreatic EUS for typing and staging with needle biopsies between 2015 and 2023. General patient characteristics (age and sex) and solid lesion features were collected and described, such lesion size (B-mode), vessel involvement (compression or invasion), ductal dilation, lympha
Our study enrolled 761 patients, predominantly male with a mean age of 68.6. PDACs were generally larger (mean 33 mm × 27 mm), often had irregular margins, and displayed significant upstream ductal dilation. Hypoechogenicity was common across malignant lesions. In contrast, NETs were smaller (mean 20 mm × 17 mm) and typically had regular margins with multiple lesions. Vascular involvement, although predominant in PDAC, is a common feature of all malignant neoplasms. Multifocality, however, although a rare finding, is more typical of NETs and metastases, and practically absent in the remaining lesions. Predictive analyses showed that ductal dilation and irregular margins were the most significant predictors for PDAC [odds ratio (OR) = 5.75 and 3.83], with hypoechogenicity, heterogeneous echopattern and lymphadenopathies also highly significant (OR = 3.51, 2.56 and 1.99). These features were inversely associated with NETs, with regular margins and absence of ductal involvement or lymphadenopathies (OR = 0.24, 0.86 and 0.45 respectively), as already shown by the descriptive analysis. Finally, age, despite achieving statistical significance, lacks clinical value given an OR trending towards 1.
This study provides a comprehensive overview of EUS features for solid pancreatic lesions, identifying distinct features like upstream ductal dilation and irregular margins for PDAC vs regular margins for NETs as strong diagnostic predictors. These findings enhance the understanding of pancreatic pathologies, offering valuable insights for improved differential diagnosis and clinical management, especially in complex cases. Further prospective studies could build on these results.
Core Tip: This multicenter observational study provides a broad overview of the endo-sonographic characteristics of solid pancreatic lesions, with detailed descriptions for each pathology and a predictive analysis of the most significant variables for key differential diagnoses. While existing literature touches on this topic, no prior study has analyzed endo-sonographic features with such a large sample size and comprehensive analysis. Our findings can aid clinical practice by optimizing the diagnostic process for solid pancreatic lesions, preventing both false negatives (delayed diagnosis) and false positives (unnecessary surgical intervention), and simultaneously supporting biopsy diagnosis when it is doubtful or inconclusive.