Usefulness of Contrast-Enhanced Endoscopic Ultrasound (CH-EUS) to Guide the Treatment Choice in Superficial Rectal Lesions: A Case Series

Abstract

Introduction: Large rectal lesions can conceal submucosal invasion and cancer nodules. Despite the increasing diffusion of high-definition endoscopes and the importance of an accurate morphological evaluation, a complete assessment in this setting can be challenging. Endoscopic ultrasound (EUS) plays an established role in the locoregional staging of rectal cancer, although this technique has a tendency toward the over-estimation of the loco-regional (T) staging. However, there are still few data on contrast-enhanced endoscopic ultrasound (CH-EUS), especially if this ancillary technique may increase the accuracy for predicting invasive nodules among large rectal lesions. Material and Methods: Consecutive large (≥20 mm) superficial rectal lesions with high-definition endoscopy, characterized by focal areas suggestive for invasive cancer/2B type according to JNET classification, were considered for additional standardized evaluation via CH-EUS with Sonovue ©. Results: From 2020 to 2023, we evaluated 12 consecutive superficial rectal lesions with sizes ranging from 20 to 180 mm. This evaluation provided additional elements to support the therapeutic decision made. Lesions were treated with surgical (3/12) or endoscopic treatment (9/12) according to their morphology and CH-EUS evaluation. Conclusion: Contrast-enhanced endoscopic ultrasound can provide an additional evaluation for large and difficult-to-classify rectal lesions. In our experience, CH-EUS staging corresponded to the final pathological stages in 9/12 (75%) lesions, improving the distinction between T1 and T2 lesions. Larger prospective studies and randomized trials should be conducted to support and standardize this approach.

Early Rectal Cancer and Local Excision: A Narrative Review

“…For the evaluation of nodal involvement, different meta-analyses suggest a similar or slightly more accurate nodal staging with ERUS with respect to MRI [36,37]. Contrast-enhanced endoscopic ultrasound (CE-EUS) is not routinely performed in evaluation and local staging of rectal cancer; however, in a small case series by Gibiino et al including 12 rectal lesions, CE-EUS staging provided useful information regarding either the integrity of the muscular layer and the presence of vascularization, which are both factors known to be predictive of non-curative endoscopic resection; CE-EUS staging corresponded to the final pathological stages in 9/12 (75%) lesions, improving the distinction between T1 and T2 lesions [38]. ERUS and MRI are complementary imaging techniques with different limits and advantages; furthermore, their combination in the context of early rectal cancer leads to a lower percentage of overstaging, although this percentage remained as high as 31% [28].…”

Diagnostic Endoscopic Ultrasound (EUS) of the Luminal Gastrointestinal Tract

“…CE-EUS and elastography are useful tools also in this setting. A recent case series suggests that the use of CE-EUS might further increase the accuracy of ERUS in differentiating T1 from T2 tumors [140]. Elastography is also a promising add-on tool to enhance the differentiation of rectal adenomas from tumors, with a reported 84% accuracy [141].…”

Diagnosis by Endoscopic Ultrasonography-Guided Sampling through the Lower Gastrointestinal Tract

“…Most ultrasound endoscopes used for puncture are electronic linear-array scanning ultrasound endoscopes. The latest endoscopic ultrasound host machine has a series of new functions, including the tissue harmonic (THE), elastography (ELST), pulsed-wave Doppler (PW), high-definition blood flow (H-flow), and contrast harmonic EUS (CH-EUS) modes [ 33 , 34 , 35 ]. CH-EUS can be used to indicate pathological staging and improve the differentiation of T1 and T2 lesions in cancer nodules [ 17 ].…”