Contrast-enhanced ultrasound can guide the therapeutic strategy by improving the detection of colorectal liver metastases.

BACKGROUND & AIMS: CT may miss up to 30% of cases of colorectal liver metastases (CRLMs). We assessed the impact of contrast-enhanced ultrasound (CEUS) on the detection of CRLMs and on changes to the therapeutic strategy; additionally, we assessed the accuracy of CEUS in differentiating unclear focal liver lesions (FLLs) compared to staging-CT. METHODS: We prospectively analyzed all patients with newly diagnosed and histologically confirmed colorectal cancer (CRC) at our tertiary gastroenterological center between December 2015 and May 2019. CEUS was performed in a total of 296 patients without CRLMs after staging-CT using the contrast agent (SonoVue®). Standard of reference was obtained by MRI or histology to diagnose CRLMs missed by CT. Benign FLLs were confirmed by MRI or follow-up CT (mean follow-up interval: 18 months). RESULTS: Eight additional CRLMs were detected by CEUS (overall 2.7%; sensitivity 88.9%, specificity 99.0%, positive predictive value 100%, negative predictive value 99.6%). All patients with CRLMs detected only by CEUS were in tumor stage T3/T4 (4.0% additionally detected CRLMs). The number needed to screen to detect 1 additional CRLM by CEUS was 37 in all patients and 24.5 in T3/T4-patients. When results were reviewed by a board-certified radiologist and oncologist, the therapeutic strategy changed in 6 of these 8 patients. Among the 62 patients (20.9%) with unclear FLLs after staging-CT, CEUS determined the dignity (malignant vs. benign) of 98.4% of the FLLs. CONCLUSION: Overall, CEUS detected 2.7% additional CRLMs (including 4.0% in tumor stage T3/T4) with a significant impact on the oncological therapeutic strategy for 75% of these patients. Patients with tumor stage T3/T4 would particularly benefit from CEUS. We propose CEUS as the first imaging modality for CT-detected lesions of unknown dignity. LAY SUMMARY: In patients with newly diagnosed colorectal cancer, contrast-enhanced ultrasound (CEUS) detected additional liver metastases after computed tomography (CT). In the majority of these patients, the oncological therapy was changed after obtaining the CEUS results. After staging-CT, 21% of hepatic lesions remained unclear. In these cases, CEUS was accurate to either reveal or exclude liver metastasis in nearly all patients and could reduce costs (e.g., number of MRI scans).

Contrast-enhanced ultrasound (CEUS) has excellent diagnostic accuracy in differentiating focal liver lesions: results from a Swiss tertiary gastroenterological centre.

INTRODUCTION: Focal liver lesions (FLLs) are common on conventional ultrasound. Contrast-enhanced ultrasound (CEUS) is highly accurate for differentiating between benign and malignant FLLs, with an accuracy comparable to that of contrast-enhanced CT and contrast-enhanced MRI. Notably, there is no evidence supporting the routine use of CEUS for evaluating benign and malignant FLLs in Switzerland. In this study, we assessed the use of CEUS in a clinical routine setting in a tertiary Swiss gastroenterology centre. METHODS: We analysed all CEUS investigations performed on new or unclear FLLs in our department between November 2011 and March 2013. In all patients, the CEUS results (benign versus malignant FLLs) were compared with CT or MRI findings. To avoid interobserver variation, CEUS was performed by a single experienced gastroenterologist using one ultrasound device (Acuson Sequoia 512®, Siemens, Erlangen, Germany). All patients were examined using the intravenous application of 1.5–2 ml Sonovue®. An FLL with arterial enhancement with wash-out in any vascular phase was defined as a malignant FLL. Malignant FLLs were confirmed by histology. RESULTS: The study included 112 patients. None of them experienced side effects after injection of Sonovue®. The final diagnoses included malignant FLLs (n = 37) and benign FLLs (n = 75) that ranged in size from 7 to 120 mm. The biopsy-proven malignant FLLs (n = 37) included hepatocellular carcinoma, metastatic cancers, peripheral cholangiocarcinoma and primary B-cell lymphoma. CEUS correctly identified 36 out of 37 malignant FLLs, showing a sensitivity of 96–97.2% and a negative predictive value (NPV) of 94.1–98.5%. In contrast, CT/MRI did not identify three metastatic cancers, one HCC, one peripheral cholangiocarcinoma and one primary lymphoma in the liver as malignant FLLs, resulting in a sensitivity of 80.6–80.9% and an NPV of 78.9–89.8%. All these malignant FLLs were correctly classified by CEUS. CONCLUSIONS: In daily clinical practice, CEUS is a fast imaging tool which uses a renal-independent contrast agent and shows excellent accuracy for differentiating between malignant and benign FLLs in about five minutes. The use of CEUS helps to avoid false negative results from CT/MRI and improves sensitivity. CEUS should be the first diagnostic step for investigating new or unclear FLLs.

The role of single-balloon colonoscopy for patients with previous incomplete standard colonoscopy: Is it worth doing it?

BACKGROUND: The rate of cecal intubation is a well-recognized quality measure of successful colonoscopy. Infrequently, the standard colonoscopy techniques fail to achieve complete examination. The role of single-balloon overtube-assisted colonoscopy (SBC) in these situations has only been sparsely studied. This prospective single-center study aimed to investigate the technical success (rate of cecal intubation) and the diagnostic gain of SBC. METHODS: The study recruited consecutive patients with previous incomplete standard colonoscopy who were admitted for SBC at our tertiary center in Eastern Switzerland between February 2008 and October 2014. The primary outcome was defined as successful cecal intubation. Data on patient characteristics, indication, technical details of procedure, and outcome were collected prospectively. The Olympus enteroscope SIF-Q180 was used. RESULTS: The study included 100 consecutive patients (median age 70 years; range 38-87 years; 54 % female) who were examined using a single-balloon overtube-assisted technique. The cecal intubation rate was 98 % (98/100). The median time of total procedure was 54 min (range 15-119 min); the median time to reach the cecal pole was 27.5 min (range 4-92 min). Passage of the sigmoid colon was not possible in two cases with a fixed, angulated sigmoid colon. The diagnostic gain was 21 % regarding adenomatous polyps in the right colon. The complication rate was 2 % (2/100, minor) without need for surgery. CONCLUSIONS: This prospective patient cohort study shows that single-balloon colonoscopy is a safe and effective procedure to achieve a complete endoscopic examination in patients with a previous failed standard colonoscopy. A significant diagnostic and therapeutic gain in the right colon justifies additional procedure time.

Prospective Swiss pilot study of Endocuff-assisted colonoscopy in a screening population.

BACKGROUND AND STUDY AIMS: The adenoma detection rate (ADR) is one of the quality measures in screening colonoscopy and is crucial for reducing colorectal cancer morbidity and mortality. Up to 25 % of adenomas are missed during colonoscopy. Endocuff is an easy-to-use device that is attached like a cap to the distal tip of the colonoscope in order to optimize visualization behind the folds of the colon and increase the ADR. This is the first prospective study of Endocuff-assisted colonoscopy (EC) in a screening population with follow-up to determine the ADR and adverse events of EC. PATIENTS AND METHODS: We prospectively enrolled asymptomatic patients referred for screening colonoscopy during the 4-month study period. We documented the Boston Bowel Preparation Scale (BBPS) score, cecal intubation rate, polyp detection rate, ADR, number of advanced adenomas, and number of adverse events. Colonoscopies were performed by five board-certified gastroenterologists. During follow-up, the patients were called 4 to 12 weeks after EC. RESULTS: A total of 104 EC procedures were performed. Cecal intubation was achieved in 99 % of the patients, with a median intubation time of 6 minutes. The polyp detection rate and ADR in our study were 72 % and 47 %, respectively, and 13.5 % of the lesions were advanced adenomas. A significant number of adenomas were detected in the right side of the colon. Considering all the adenomas and hyperplastic polyps above the sigmoid, we recommended that nearly 60 % of our patients repeat an endoscopic follow-up according to the existing Swiss guidelines. We noted no perforations or other serious adverse events, even in the patients with extensive diverticulosis. CONCLUSIONS: EC is feasible with the most commonly available colonoscopes without severe adverse events. EC seems to be a safe and effective device for increasing the ADR, including small adenomas in the right side of the colon. Therefore, this technique may be recommended in the future to increase the ADR in a screening population.

[Malignant hypoglycaemia]. / Maligne Hypoglykämie.

We describe the case of a 19-years old patient with seizure due to severe hypoglycaemia during general practitioner consultation. Because of hyperinsulinaemic hypoglycaemia and suspected liver metastasis a neuroendocrine hormone active tumor was suspected. After liver biopsy and CT scan a neuroendocrine pancreatic tumor could be diagnosed. Afterwards oncological therapy was induced.

How is the increased risk of colorectal cancer in first-degree relatives of patients communicated?

OBJECTIVES: Compared with the general population, first-degree relatives (FDRs) of colorectal cancer (CRC) patients have a two-fold to four-fold higher risk of developing CRC. Little data is available regarding communication between doctors and CRC patients about risk to FDRs. We aimed to evaluate CRC patients' knowledge of FDRs' increased CRC risk, and FDRs' knowledge of this risk and adherence to CRC screening. MATERIALS AND METHODS: In this retrospective, single-center, population-based observational study, patients aged 18-80 years who underwent surgery for CRC between January 2005 and May 2010 were asked to complete a questionnaire. A questionnaire sent to the patients' FDRs (siblings and children) asked whether they had been advised to undergo any CRC screening examination, whether they had done so, and if so, when initiated and by whom. Main outcome measurements were: CRC patients' and their FDRs' information status regarding the FDRs' increased CRC risk and screening status. RESULTS: Of 343 index patients (390 contacted, 47 deceased/moved), 134 replied to the survey (39.1% response rate). Among index patients, 82.1% (110/134) were informed about FDRs' increased CRC risk. This information was provided mainly by gastroenterologists and general practitioners (65.7 and 28.4%, respectively). Among FDRs, 85.1% (143/168) were informed about their increased CRC risk, but 69% did not undergo a screening colonoscopy. Among the FDRs more than 50 years of age, 40.8% did not undergo a screening colonoscopy. CONCLUSION: In Switzerland, CRC patients and their FDRs are well informed about FDRs' increased CRC risk. However, the majority of FDRs do not undergo the recommended CRC screening.