Computed tomographic colonography: automated tool for polyp measurement delivering on patient risk stratification

Variable interpretation of polyp size by using open forceps by experienced colonoscopists

BACKGROUND

Endoscopic measurement of colorectal polyps by using open forceps is commonly used in clinical trials but is subject to several sources of error.

OBJECTIVE

Assess error rates in polyp size determination with open forceps at the step of measurement after the forceps are aligned on the polyp.

DESIGN

This was a prospective assessment of 49 gastroenterologists who received training on 10 photographs of polyps with aligned forceps and then measured 10 additional test polyps from photographs. One of the test photographs was excluded because of incorrect forceps alignment.

SETTING

Data analyzed at an academic medical center.

INTERVENTION

Photographs displayed in a webinar.

MAIN OUTCOME MEASUREMENTS

Description of rates of accurate measurements, including the fraction correct within 50% and 25% margins of error.

RESULTS

A total of 37% of all measurements were correct to the exact millimeter, 34% were larger, and 29% smaller compared with the reference standard. A total of 47 of 49 doctors measured all 9 polyps within 50% of the reference standard, and 21 measured all 9 correctly within a 25% error margin.

LIMITATIONS

Other potential sources of error in open forceps measurement were not evaluated.

CONCLUSION

Open forceps polyp size determination is subject to error at the step of using the fully aligned forceps as a scale for measurement. A margin of error of 50% up or down is needed to prevent this step in size determination from causing errors in polyp matching in clinical trials comparing diagnosis-only imaging to colonoscopy.

Polyp size measurement at CT colonography: what do we know and what do we need to know?

Polyp size is a critical biomarker for clinical management. Larger polyps have a greater likelihood of being or of becoming an adenocarcinoma. To balance the referral rate for polypectomy against the risk of leaving potential cancers in situ, sizes of 6 and 10 mm are increasingly being discussed as critical thresholds for clinical decision making (immediate polypectomy versus polyp surveillance) and have been incorporated into the consensus CT Colonography Reporting and Data System (C-RADS). Polyp size measurement at optical colonoscopy, pathologic examination, and computed tomographic (CT) colonography has been studied extensively but the reported precision, accuracy, and relative sizes have been highly variable. Sizes measured at CT colonography tend to lie between those measured at optical colonoscopy and pathologic evaluation. The size measurements are subject to a variety of sources of error associated with image acquisition, display, and interpretation, such as partial volume averaging, two- versus three-dimensional displays, and observer variability. This review summarizes current best practices for polyp size measurement, describes the role of automated size measurement software, discusses how to manage the measurement uncertainties, and identifies areas requiring further research.

Nonlinear regression-based method for pseudoenhancement correction in CT colonography

In CT colonography (CTC), orally administered positive-contrast tagging agents are often used for differentiating residual bowel contents from native colonic structures. However, tagged materials can sometimes hyperattenuate observed CT numbers of their adjacent untagged materials. Such pseudoenhancement complicates the differentiation of colonic soft-tissue structures from tagged materials, because pseudoenhanced colonic structures may have CT numbers that are similar to those of tagged materials. The authors developed a nonlinear regression-based (NLRB) method for performing a local image-based pseudoenhancement correction of CTC data. To calibrate the correction parameters, the CT data of an anthropomorphic reference phantom were correlated with those of partially tagged phantoms. The CTC data were registered spatially by use of an adaptive multiresolution method, and untagged and tagged partial-volume soft-tissue surfaces were correlated by use of a virtual tagging scheme. The NLRB method was then optimized to minimize the difference in the CT numbers of soft-tissue regions between the untagged and tagged phantom CTC data by use of the Nelder-Mead downhill simplex method. To validate the method, the CT numbers of untagged regions were compared with those of registered pseudoenhanced phantom regions before and after the correction. The CT numbers were significantly different before performing the correction (p<0.01), whereas, after the correction, the difference between the CT numbers was not significant. The effect of the correction was also tested on the size measurement of polyps that were covered by tagging in phantoms and in clinical cases. In phantom cases, before the correction, the diameters of 12 simulated polyps submerged in tagged fluids that were measured in a soft-tissue CT display were significantly different from those measured in an untagged phantom (p<0.01), whereas after the correction the difference was not significant. In clinical cases, before the correction, the diameters of 29 colonoscopy-confirmed 3-14 mm polyps affected by tagging that were measured in a soft-tissue CT display were significantly different from those measured in a lung CT display (p<0.0001) or in colonoscopy (p<0.05), whereas after the correction the difference was not significant. Finally, the effect of the correction was tested on automated detection of 25 polyps > or =6 mm affected by tagging in 56 clinical CTC cases. The application of the correction increased the detection accuracy from 60% with 5.0 FP detections per patient without correction to 96% with 2.9 FP detections with correction. This improvement in detection accuracy was statistically significant (p<0.05). The results indicate that the proposed NLRB method can yield an accurate pseudoenhancement correction with potentially significant benefits in clinical CTC examinations.