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

Published:October 13, 2020DOI:


      • CEUS detected 4% additional colorectal liver metastasis in tumor stage T3/T4.
      • This resulted in a change of the oncological strategy in 75% of these patients.
      • The number needed to screen to detect 1 additional CRLM by CEUS was 24.5.
      • CEUS correctly classified lesions of uncertain dignity (21% in CT) in 98.4%.
      • CEUS has an excellent diagnostic accuracy for these lesions (PPV: 100%; NPV: 99.6%).

      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.


      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).


      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.


      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).

      Graphical abstract


      Linked Article

      • Contrast-enhanced ultrasound of the liver in colorectal cancer: A useful tool in the right patient
        Journal of HepatologyVol. 74Issue 2
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          Contrast-enhanced ultrasound (CEUS) was introduced around 20 years ago and hepatological applications have been the mainstay of its use since then. Several studies have demonstrated its high accuracy in characterizing focal liver lesions, not only to distinguish benign from malignant lesions,1 but also to accurately diagnose either hepatocellular carcinoma in the setting of background cirrhosis2,3 or benign entities, such as hemangioma, focal nodular hyperplasia or adenoma.4 Extensive work has been carried out in this field, with hundreds of publications dealing with CEUS of focal liver lesions.
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