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Yee J, Dachman A, Kim DH, Kobi M, Laghi A, McFarland E, Moreno C, Park SH, Pickhardt PJ, Plumb A, Pooler BD, Zalis M, Chang KJ. CT Colonography Reporting and Data System (C-RADS): Version 2023 Update. Radiology 2024; 310:e232007. [PMID: 38289209 DOI: 10.1148/radiol.232007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
The CT Colonography Reporting and Data System (C-RADS) has withstood the test of time and proven to be a robust classification scheme for CT colonography (CTC) findings. C-RADS version 2023 represents an update on the scheme used for colorectal and extracolonic findings at CTC. The update provides useful insights gained since the implementation of the original system in 2005. Increased experience has demonstrated confusion on how to classify the mass-like appearance of the colon consisting of soft tissue attenuation that occurs in segments with acute or chronic diverticulitis. Therefore, the update introduces a new subcategory, C2b, specifically for mass-like diverticular strictures, which are likely benign. Additionally, the update simplifies extracolonic classification by combining E1 and E2 categories into an updated extracolonic category of E1/E2 since, irrespective of whether a finding is considered a normal variant (category E1) or an otherwise clinically unimportant finding (category E2), no additional follow-up is required. This simplifies and streamlines the classification into one category, which results in the same management recommendation.
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Affiliation(s)
- Judy Yee
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Abraham Dachman
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - David H. Kim
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Mariya Kobi
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Andrea Laghi
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Elizabeth McFarland
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Courtney Moreno
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Seong Ho Park
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Perry J. Pickhardt
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Andrew Plumb
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - B Dustin Pooler
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Michael Zalis
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
| | - Kevin J Chang
- From the Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467 (J.Y.); Department of Radiology, University of Chicago, Chicago, Ill (A.D.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.K., P.P., B.D.P.); Department of Radiology, Columbia University Irving Medical Center, New York, NY (M.K.); Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy (A.L.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (E.M.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.M.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Imaging, University College London, London, United Kingdom (A.P.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.Z.); and Department of Radiology, Boston University Medical Center, Boston, Mass (K.J.C.)
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Colon Capsule Endoscopy in the Diagnosis of Colon Polyps: Who Needs a Colonoscopy? Diagnostics (Basel) 2022; 12:diagnostics12092093. [PMID: 36140494 PMCID: PMC9498104 DOI: 10.3390/diagnostics12092093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/16/2022] [Accepted: 08/23/2022] [Indexed: 12/09/2022] Open
Abstract
Colon screening programs have reduced colon cancer mortality. Population screening should be minimally invasive, safe, acceptably sensitive, cost-effective, and scalable. The range of screening modalities include guaiac or immunochemical fecal occult blood testing and CT colonography and colonoscopy. A number of carefully controlled studies concur that second-generation capsule endoscopy has excellent sensitivity for polyp detection and a high negative predictive value. Colon capsules fulfill the screening expectation of safety, high sensitivity for polyp detection, and patient acceptance, and appear to straddle the divide between occult blood testing and colonoscopy. While meeting these criteria, there remains the challenges of scaling, capsule practitioner training, resource allocation, and implementing change of practice. Like CT colonography, capsule screening presents the clinician with a decision on the threshold for colonoscopy referral. Overall, colon capsules are an invaluable tool in polyp detection and colon screening and offer a filter that determines “who needs a colonoscopy?”.
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Wesp P, Grosu S, Graser A, Maurus S, Schulz C, Knösel T, Fabritius MP, Schachtner B, Yeh BM, Cyran CC, Ricke J, Kazmierczak PM, Ingrisch M. Deep learning in CT colonography: differentiating premalignant from benign colorectal polyps. Eur Radiol 2022; 32:4749-4759. [PMID: 35083528 PMCID: PMC9213389 DOI: 10.1007/s00330-021-08532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/06/2021] [Accepted: 12/20/2021] [Indexed: 11/24/2022]
Abstract
Objectives To investigate the differentiation of premalignant from benign colorectal polyps detected by CT colonography using deep learning. Methods In this retrospective analysis of an average risk colorectal cancer screening sample, polyps of all size categories and morphologies were manually segmented on supine and prone CT colonography images and classified as premalignant (adenoma) or benign (hyperplastic polyp or regular mucosa) according to histopathology. Two deep learning models SEG and noSEG were trained on 3D CT colonography image subvolumes to predict polyp class, and model SEG was additionally trained with polyp segmentation masks. Diagnostic performance was validated in an independent external multicentre test sample. Predictions were analysed with the visualisation technique Grad-CAM++. Results The training set consisted of 107 colorectal polyps in 63 patients (mean age: 63 ± 8 years, 40 men) comprising 169 polyp segmentations. The external test set included 77 polyps in 59 patients comprising 118 polyp segmentations. Model SEG achieved a ROC-AUC of 0.83 and 80% sensitivity at 69% specificity for differentiating premalignant from benign polyps. Model noSEG yielded a ROC-AUC of 0.75, 80% sensitivity at 44% specificity, and an average Grad-CAM++ heatmap score of ≥ 0.25 in 90% of polyp tissue. Conclusions In this proof-of-concept study, deep learning enabled the differentiation of premalignant from benign colorectal polyps detected with CT colonography and the visualisation of image regions important for predictions. The approach did not require polyp segmentation and thus has the potential to facilitate the identification of high-risk polyps as an automated second reader. Key Points • Non-invasive deep learning image analysis may differentiate premalignant from benign colorectal polyps found in CT colonography scans. • Deep learning autonomously learned to focus on polyp tissue for predictions without the need for prior polyp segmentation by experts. • Deep learning potentially improves the diagnostic accuracy of CT colonography in colorectal cancer screening by allowing for a more precise selection of patients who would benefit from endoscopic polypectomy, especially for patients with polyps of 6–9 mm size. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08532-2.
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Affiliation(s)
- Philipp Wesp
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Sergio Grosu
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Anno Graser
- Radiologie München, Burgstraße 7, 80331, Munich, Germany
| | - Stefan Maurus
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Christian Schulz
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Thomas Knösel
- Department of Pathology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Matthias P Fabritius
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Balthasar Schachtner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Max-Lebsche-Platz 31, 81377, Munich, Germany
| | - Benjamin M Yeh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94117, USA
| | - Clemens C Cyran
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Philipp M Kazmierczak
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Michael Ingrisch
- Department of Radiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Mang T, Bräuer C, Gryspeerdt S, Scharitzer M, Ringl H, Lefere P. Electronic cleansing of tagged residue in CT colonography: what radiologists need to know. Insights Imaging 2020; 11:47. [PMID: 32170498 PMCID: PMC7070139 DOI: 10.1186/s13244-020-00848-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
CT colonography (CTC) is the radiological examination of choice for the diagnosis of colorectal neoplasia. Faecal tagging is considered a mandatory part of bowel preparation. However, the colonic mucosa, obscured by tagged residue, is not accessible to endoluminal 3D views and requires time-consuming 2D evaluation. Electronic cleansing (EC) software algorithms can overcome this limitation by digitally subtracting tagged residue from the colonic lumen. Ideally, this enables a seamless 3D endoluminal evaluation. Despite this benefit, EC is a potential source of a wide range of artefacts. Accurate EC requires proper CTC examination technique and faecal tagging. The digital subtraction process has been shown to affect the relevant morphological features of both colonic anatomy and colonic lesions, if submerged under faecal residue. This article summarises the potential effects of EC on CTC imaging, the consequences for reporting and patient management, and strategies to avoid pitfalls. Furthermore, potentially negative effects on clinical reporting and patient management are shown, and problem-solving techniques, as well as recommendations for the appropriate use of EC techniques, are presented. Radiologists using EC should be familiar with EC-related effects on polyp size and also with correct measurement techniques.
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Affiliation(s)
- Thomas Mang
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
| | - Christian Bräuer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Stefaan Gryspeerdt
- Department of Radiology, AZ Delta, Bruggesteenweg 90, B-8800, Roeselare, Belgium
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Helmut Ringl
- Department of Radiology, Danube Hospital Vienna, Langobardenstrasse 122, A-1220, Wien, Austria
| | - Philippe Lefere
- Department of Radiology, AZ Delta, Bruggesteenweg 90, B-8800, Roeselare, Belgium
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Ivancic MM, Anson LW, Pickhardt PJ, Megna B, Pooler BD, Clipson L, Reichelderfer M, Sussman MR, Dove WF. Conserved serum protein biomarkers associated with growing early colorectal adenomas. Proc Natl Acad Sci U S A 2019; 116:8471-8480. [PMID: 30971492 PMCID: PMC6486772 DOI: 10.1073/pnas.1813212116] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A major challenge for the reduction of colon cancer is to detect patients carrying high-risk premalignant adenomas with minimally invasive testing. As one step, we have addressed the feasibility of detecting protein signals in the serum of patients carrying an adenoma as small as 6-9 mm in maximum linear dimension. Serum protein biomarkers, discovered in two animal models of early colonic adenomagenesis, were studied in patients using quantitative mass-spectrometric assays. One cohort included patients bearing adenomas known to be growing on the basis of longitudinal computed tomographic colonography. The other cohort, screened by optical colonoscopy, included both patients free of adenomas and patients bearing adenomas whose risk status was judged by histopathology. The markers F5, ITIH4, LRG1, and VTN were each elevated both in this patient study and in the studies of the Pirc rat model. The quantitative study in the Pirc rat model had demonstrated that the elevated level of each of these markers is correlated with the number of colonic adenomas. However, the levels of these markers in patients were not significantly correlated with the total adenoma volume. Postpolypectomy blood samples demonstrated that the elevated levels of these four conserved markers persisted after polypectomy. Two additional serum markers rapidly renormalized after polypectomy: growth-associated CRP levels were enhanced only with high-risk adenomas, while PI16 levels, not associated with growth, were reduced regardless of risk status. We discuss biological hypotheses to account for these observations, and ways for these signals to contribute to the prevention of colon cancer.
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Affiliation(s)
- Melanie M Ivancic
- Biotechnology Center, University of Wisconsin-Madison, Madison, WI 53706;
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI 53706
| | - Leigh W Anson
- Biotechnology Center, University of Wisconsin-Madison, Madison, WI 53706
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792;
| | - Bryant Megna
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705
| | - Bryan D Pooler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792
| | - Linda Clipson
- McArdle Laboratory for Cancer Research, Department of Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705
| | - Mark Reichelderfer
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705;
| | - Michael R Sussman
- Biotechnology Center, University of Wisconsin-Madison, Madison, WI 53706;
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI 53706
| | - William F Dove
- McArdle Laboratory for Cancer Research, Department of Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705;
- Laboratory of Genetics, University of Wisconsin-Madison, Madison, WI 53706
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Plumb AA, Eason D, Goldstein M, Lowe A, Morrin M, Rudralingam V, Tolan D, Thrower A. Computed tomographic colonography for diagnosis of early cancer and polyps? Colorectal Dis 2019; 21 Suppl 1:23-28. [PMID: 30809907 DOI: 10.1111/codi.14490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/08/2018] [Indexed: 02/08/2023]
Affiliation(s)
- A A Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - D Eason
- Department of Radiology, Raigmore Hospital, Inverness, UK
| | - M Goldstein
- Department of Radiology, Heart of England NHS Trust, Birmingham, UK
| | - A Lowe
- Department of Radiology, Musgrove Park Hospital, Taunton, UK
| | - M Morrin
- Department of Radiology, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - V Rudralingam
- Department of Radiology, Wythenshawe Hospital, Manchester Foundation Trust, Manchester, UK
| | - D Tolan
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A Thrower
- Department of Radiology, Basingstoke Hospital, Basingstoke, UK
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Pickhardt PJ, Pooler BD, Kim DH, Hassan C, Matkowskyj KA, Halberg RB. The Natural History of Colorectal Polyps: Overview of Predictive Static and Dynamic Features. Gastroenterol Clin North Am 2018; 47:515-536. [PMID: 30115435 PMCID: PMC6100796 DOI: 10.1016/j.gtc.2018.04.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
For decades, colorectal screening strategies have been largely driven by static features, particularly polyp size. Although cross-sectional features of polyp size, morphology, and location are important determinants of clinical relevance before histology, they lack any dynamic information on polyp growth rates. Computed tomography colonography allows for in vivo surveillance of colorectal polyps, providing volumetric growth rates that are providing new insights into tumorigenesis. In this article, existing cross-sectional and longitudinal data on colorectal polyps are reviewed, with an emphasis on how these features may affect clinical relevance and patient management.
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Affiliation(s)
| | | | | | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
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Obaro AE, Burling DN, Plumb AA. Colon cancer screening with CT colonography: logistics, cost-effectiveness, efficiency and progress. Br J Radiol 2018; 91:20180307. [PMID: 29927637 DOI: 10.1259/bjr.20180307] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Colorectal cancer (CRC) incidence and mortality can be significantly reduced by population screening. Several different screening methods are currently in use, and this review focuses specifically on the imaging technique computed tomographic colonography (CTC). The challenges and logistics of CTC screening, as well as the importance of test accuracy, uptake, quality assurance and cost-effectiveness will be discussed. With comparable advanced adenoma detection rates to colonoscopy (the most commonly used whole-colon investigation), CTC is a less-invasive alternative, requiring less laxative, and with the potential benefit that it permits assessment of extra colonic structures. Three large-scale European trials have contributed valuable evidence supporting the use of CTC in population screening, and highlight the importance of selecting appropriate clinical management pathways based on initial CTC findings. Future research into CTC-screening will likely focus on radiologist training and CTC quality assurance, with identification of evidence-based key performance indicators that are associated with clinically-relevant outcomes such as the incidence of post-test interval cancers (CRC occurring after a presumed negative CTC). In comparison to other CRC screening techniques, CTC offers a safe and accurate option that is particularly useful when colonoscopy is contraindicated. Forthcoming cost-effectiveness analyses which evaluate referral thresholds, the impact of extra-colonic findings and real-world uptake will provide useful information regarding the feasibility of future CTC population screening.
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Affiliation(s)
- Anu E Obaro
- 1 Centre for Medical Imaging, University College London , London , UK.,2 St Mark's Academic Institute, St Mark's Hospital , Harrow , UK
| | - David N Burling
- 2 St Mark's Academic Institute, St Mark's Hospital , Harrow , UK
| | - Andrew A Plumb
- 1 Centre for Medical Imaging, University College London , London , UK
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Scalise P, Mantarro A, Pancrazi F, Neri E. Computed tomography colonography for the practicing radiologist: A review of current recommendations on methodology and clinical indications. World J Radiol 2016; 8:472-483. [PMID: 27247713 PMCID: PMC4882404 DOI: 10.4329/wjr.v8.i5.472] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/23/2015] [Accepted: 02/24/2016] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) represents one of the most relevant causes of morbidity and mortality in Western societies. CRC screening is actually based on faecal occult blood testing, and optical colonoscopy still remains the gold standard screening test for cancer detection. However, computed tomography colonography (CT colonography) constitutes a reliable, minimally-invasive method to rapidly and effectively evaluate the entire colon for clinically relevant lesions. Furthermore, even if the benefits of its employment in CRC mass screening have not fully established yet, CT colonography may represent a reasonable alternative screening test in patients who cannot undergo or refuse colonoscopy. Therefore, the purpose of our review is to illustrate the most updated recommendations on methodology and the current clinical indications of CT colonography, according to the data of the existing relevant literature.
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Lambert L, Ourednicek P, Briza J, Giepmans W, Jahoda J, Hruska L, Danes J. Sub-milliSievert ultralow-dose CT colonography with iterative model reconstruction technique. PeerJ 2016; 4:e1883. [PMID: 27069813 PMCID: PMC4824919 DOI: 10.7717/peerj.1883] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/12/2016] [Indexed: 12/14/2022] Open
Abstract
Purpose. The purpose of this study was to evaluate the technical and diagnostic performance of sub-milliSievert ultralow-dose (ULD) CT colonograpy (CTC) in the detection of colonic and extracolonic lesions. Materials and Methods. CTC with standard dose (SD) and ULD acquisitions of 64 matched patients, half of them with colonic findings, were reconstructed with filtered back projection (FBP), hybrid (HIR) and iterative model reconstruction techniques (IMR). Image noise in six colonic segments, in the left psoas muscle and aorta were measured. Image quality of the left adrenal gland and of the colon in the endoscopic and 2D view was rated on a five point Likert scale by two observers, who also completed the reading of CTC for colonic and extracolonic findings. Results. The mean radiation dose estimate was 4.1 ± 1.4 mSv for SD and 0.86 ± 0.17 mSv for ULD for both positions (p < 0.0001). In ULD-IMR, SD-IMR and SD-HIR, the endoluminal noise was decreased in all colonic segments compared to SD-FBP (p < 0.001). There were 27 small (6–9 mm) and 17 large (≥10 mm) colonic lesions that were classified as sessile polyps (n = 38), flat lesions (n = 3), or as a mass (n = 3). Per patient sensitivity and specificity were 0.82 and 0.93 for ULD-FBP, 0.97 and 0.97 for ULD-HIR, 0.97 and 1.0 for ULD-IMR. Per polyp sensitivity was 0.84 for ULD-FBP, 0.98 for ULD-HIR, 0.98 for ULD-IMR. Significantly less extracolonic findings were detected in ULD-FBP and ULD-HIR, but in the E4 category by C-RADS (potentially important findings), the detection was similar. Conclusion. Both HIR and IMR are suitable for sub-milliSievert ULD CTC without sacrificing diagnostic performance of the study.
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Affiliation(s)
- Lukas Lambert
- Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague , Prague , Czech Republic
| | - Petr Ourednicek
- Department of Imaging Methods, St. Anne's University Hospital in Brno , Brno , Czech Republic
| | - Jan Briza
- First Department of Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague , Prague , Czech Republic
| | - Walter Giepmans
- Clinical Science & Application Computed Tomography, Philips Healthcare , Best , The Netherlands
| | - Jiri Jahoda
- Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague , Prague , Czech Republic
| | - Lukas Hruska
- Department of Imaging Methods, St. Anne's University Hospital in Brno , Brno , Czech Republic
| | - Jan Danes
- Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague , Prague , Czech Republic
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Trilisky I, Wroblewski K, Vannier MW, Horne JM, Dachman AH. CT colonography with computer-aided detection: recognizing the causes of false-positive reader results. Radiographics 2015; 34:1885-905. [PMID: 25384290 DOI: 10.1148/rg.347130053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Computed tomography (CT) colonography is a screening modality used to detect colonic polyps before they progress to colorectal cancer. Computer-aided detection (CAD) is designed to decrease errors of detection by finding and displaying polyp candidates for evaluation by the reader. CT colonography CAD false-positive results are common and have numerous causes. The relative frequency of CAD false-positive results and their effect on reader performance on the basis of a 19-reader, 100-case trial shows that the vast majority of CAD false-positive results were dismissed by readers. Many CAD false-positive results are easily disregarded, including those that result from coarse mucosa, reconstruction, peristalsis, motion, streak artifacts, diverticulum, rectal tubes, and lipomas. CAD false-positive results caused by haustral folds, extracolonic candidates, diminutive lesions (<6 mm), anal papillae, internal hemorrhoids, varices, extrinsic compression, and flexural pseudotumors are almost always recognized and disregarded. The ileocecal valve and tagged stool are common sources of CAD false-positive results associated with reader false-positive results. Nondismissable CAD soft-tissue polyp candidates larger than 6 mm are another common cause of reader false-positive results that may lead to further evaluation with follow-up CT colonography or optical colonoscopy. Strategies for correctly evaluating CAD polyp candidates are important to avoid pitfalls from common sources of CAD false-positive results.
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Affiliation(s)
- Igor Trilisky
- From the Department of Radiology, MC2026, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL 60637 (I.T., A.H.D., M.W.V.); Department of Health Studies, University of Chicago, Chicago, Ill (K.W.); and Department of Medicine, Creighton University, Omaha, Neb (J.M.H.)
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Pickhardt PJ. CT colonography for population screening: ready for prime time? Dig Dis Sci 2015; 60:647-59. [PMID: 25492504 PMCID: PMC4629223 DOI: 10.1007/s10620-014-3454-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 11/17/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave., Madison, WI, 53792-3252, USA,
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de Haan MC, Pickhardt PJ, Stoker J. CT colonography: accuracy, acceptance, safety and position in organised population screening. Gut 2015; 64:342-50. [PMID: 25468258 DOI: 10.1136/gutjnl-2014-308696] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Colorectal cancer (CRC) is the second most common cancer and second most common cause of cancer-related deaths in Europe. The introduction of CRC screening programmes using stool tests and flexible sigmoidoscopy, have been shown to reduce CRC-related mortality substantially. In several European countries, population-based CRC screening programmes are ongoing or being rolled out. Stool tests like faecal occult blood testing are non-invasive and simple to perform, but are primarily designed to detect early invasive cancer. More invasive tests like colonoscopy and CT colonography (CTC) aim at accurately detecting both CRC and cancer precursors, thus providing for cancer prevention. This review focuses on the accuracy, acceptance and safety of CTC as a CRC screening technique and on the current position of CTC in organised population screening. Based on the detection characteristics and acceptability of CTC screening, it might be a viable screening test. The potential disadvantage of radiation exposure is probably overemphasised, especially with newer technology. At this time-point, it is not entirely clear whether the detection of extracolonic findings at CTC is of net benefit and is cost effective, but with responsible handling, this may be the case. Future efforts will seek to further improve the technique, refine appropriate diagnostic algorithms and study cost-effectiveness.
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Affiliation(s)
- Margriet C de Haan
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands Department of Radiology, University Medical Center, Utrecht, The Netherlands
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Jaap Stoker
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
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He Q, Rao T, Guan YS. Virtual gastrointestinal colonoscopy in combination with large bowel endoscopy: Clinical application. World J Gastroenterol 2014; 20:13820-13832. [PMID: 25320519 PMCID: PMC4194565 DOI: 10.3748/wjg.v20.i38.13820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/11/2014] [Accepted: 07/16/2014] [Indexed: 02/06/2023] Open
Abstract
Although colorectal cancer (CRC) has no longer been the leading cancer killer worldwide for years with the exponential development in computed tomography (CT) or magnetic resonance imaging, and positron emission tomography/CT as well as virtual colonoscopy for early detection, the CRC related mortality is still high. The objective of CRC screening is to reduce the burden of CRC and thereby the morbidity and mortality rates of the disease. It is believed that this goal can be achieved by regularly screening the average-risk population, enabling the detection of cancer at early, curable stages, and polyps before they become cancerous. Large-scale screening with multimodality imaging approaches plays an important role in reaching that goal to detect polyps, Crohn’s disease, ulcerative colitis and CRC in early stage. This article reviews kinds of presentative imaging procedures for various screening options and updates detecting, staging and re-staging of CRC patients for determining the optimal therapeutic method and forecasting the risk of CRC recurrence and the overall prognosis. The combination use of virtual colonoscopy and conventional endoscopy, advantages and limitations of these modalities are also discussed.
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CT Colonography Reporting and Data System (C-RADS): benchmark values from a clinical screening program. AJR Am J Roentgenol 2014; 202:1232-7. [PMID: 24848819 DOI: 10.2214/ajr.13.11272] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The CT Colonography Reporting and Data System (C-RADS) is a well-recognized standard for reporting findings at CT colonography (CTC). However, few data on benchmark values for clinical performance have been published to date, especially for screening. The purpose of this study was to establish baseline C-RADS values for CTC screening. SUBJECTS AND METHODS From 2005 to 2011, 6769 asymptomatic adults (3110 men and 3659 women) 50-79 years old (mean [± SD] age, 56.7 ± 6.1 years) were enrolled for first-time CTC screening at a single center. CTC results were prospectively classified according to C-RADS for both colorectal and extracolonic findings. C-RADS classification rates and outcomes for positive patients were analyzed. RESULTS C-RADS classification rates for colorectal evaluation were C0 (0.7%), C1 (85.0%), C2 (8.6%), C3 (5.2%), and C4 (0.6%). Overall, 14.3% of subjects were positive (C2-C4), and positive findings were more frequent among men (17.5%) than women (11.6%; p < 0.0001). Positivity also increased with age, from 13.4% of patients 50-64 years old to 21.8% of patients 65-79 years old (p < 0.0001). Regarding extracolonic evaluation, 86.6% of patients were either negative for extracolonic findings or had unimportant extracolonic findings (E1 or E2). Likely unimportant but indeterminate extracolonic findings where further workup might be indicated (E3) were found in 11.3% of patients, whereas 2.1% had likely important extracolonic findings (E4). Overall, E3 and E4 rates were increased for older (p < 0.0001) and female (p = 0.008) cohorts. CONCLUSION C-RADS results from our initial experience with CTC screening may serve as an initial benchmark for program comparison and quality assurance measures.
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Pickhardt PJ. CT colonography: does it satisfy the necessary criteria for a colorectal screening test? Expert Rev Gastroenterol Hepatol 2014; 8:211-3. [PMID: 24490683 DOI: 10.1586/17474124.2014.887436] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave., Madison, WI, USA
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Jeong KE, Cairns JA. Review of economic evidence in the prevention and early detection of colorectal cancer. HEALTH ECONOMICS REVIEW 2013; 3:20. [PMID: 24229442 PMCID: PMC3847082 DOI: 10.1186/2191-1991-3-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/23/2013] [Indexed: 05/20/2023]
Abstract
This paper aims to systematically review the cost-effectiveness evidence, and to provide a critical appraisal of the methods used in the model-based economic evaluation of CRC screening and subsequent surveillance. A search strategy was developed to capture relevant evidence published 1999-November 2012. Databases searched were MEDLINE, EMBASE, National Health Service Economic Evaluation (NHS EED), EconLit, and HTA. Full economic evaluations that considered costs and health outcomes of relevant intervention were included. Sixty-eight studies which used either cohort simulation or individual-level simulation were included. Follow-up strategies were mostly embedded in the screening model. Approximately 195 comparisons were made across different modalities; however, strategies modelled were often simplified due to insufficient evidence and comparators chosen insufficiently reflected current practice/recommendations. Studies used up-to-date evidence on the diagnostic test performance combined with outdated information on CRC treatments. Quality of life relating to follow-up surveillance is rare. Quality of life relating to CRC disease states was largely taken from a single study. Some studies omitted to say how identified adenomas or CRC were managed. Besides deterministic sensitivity analysis, probabilistic sensitivity analysis (PSA) was undertaken in some studies, but the distributions used for PSA were rarely reported or justified. The cost-effectiveness of follow-up strategies among people with confirmed adenomas are warranted in aiding evidence-informed decision making in response to the rapidly evolving technologies and rising expectations.
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Affiliation(s)
- Kim E Jeong
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - John A Cairns
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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Abstract
Quantifying body fat is currently an area of active research. Recent studies have shown that the quantity and location of fat in different compartments have varying clinical significance. This information can now be obtained from computed tomography (CT) or magnetic resonance (MR), and it can inform clinical decision making for patient management. Diabetes patients with insulin resistance and hyperinsulinemia have nonalcoholic fatty liver disease (NAFLD) ranging from steatosis to nonalcoholic steatohepatitis (NASH) and cirrhosis, typically diagnosed by liver biopsy or serum markers. There is now an emerging role of noninvasive imaging tests such as MR imaging or MR spectroscopy or elastography, which can provide quantitative information and have potential to avoid biopsy. Obese patients with diabetes are also at risk for cardiovascular disease and cancer. There is an emerging role for imaging in early detection of not only structural but also functional abnormalities of myocardium at a subclinical stage. Screening for cancer is currently recommended only for breast, colon, prostate, and cervix. Given wider availability and advances in imaging techniques such as positron emission tomography/CT (faster scans with higher resolution and less ionizing radiation) and better understanding of molecular biology and risk-stratification, more and more cancers are being detected in early stages with better clinical outcomes. Concerns related to cost, overdiagnosis, and unnecessary interventions must be addressed before population-based screening for other cancers is recommended. Based on ongoing imaging research, it is expected that it will be possible to provide more precise measurement of body fat and detect cardiovascular disease and cancers earlier in their course.
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Affiliation(s)
- Kavita Garg
- Department of Radiology, University of Colorado Denver School of Medicine, Aurora, Colorado 80045, USA.
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Abstract
Simulation modeling is extensively applied to CT colonography (CTC) to define its long-term efficacy and cost-effectiveness for colorectal cancer (CRC) screening. CTC is effective in reducing CRC incidence and mortality (40%-77% and 58%-84%, respectively). Several factors may explain this variability. CTC is cost-effective compared with no screening, indicating that it represents an attractive test noncompliance with the available options. CTC needs to achieve a higher attendance rate or cost less than colonoscopy to be cost-effective relative to colonoscopy. Fortunately, both conditions appear to be achievable if CTC becomes a widely utilized and reimbursed screening tool.
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Affiliation(s)
- Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Roma 00153, Italy.
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Hassan C, Pickhardt PJ. Management of subcentimetric polyps detected by CT colonography. Nat Rev Gastroenterol Hepatol 2013; 10:119-24. [PMID: 23165237 DOI: 10.1038/nrgastro.2012.222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The advent of CT colonography (CTC) has generated conservative policies for the management of diminutive (<5 mm) and small (6-9 mm) polyps to prevent inefficient duplication of screening tests. The effect of not referring subcentimetric polyps for polypectomy on the efficacy of colorectal cancer screening is still uncertain but depends on the natural history of diminutive and small polyps, as well as on the distribution of advanced neoplasia within these lesions. Simulation modelling enables the efficacy and cost-effectiveness of conservative strategies for the management of subcentimetric lesions to be tested (such as nonreferral to polypectomy for diminutive polyps and early CTC surveillance for small polyps). These policies might be further refined by the inclusion of patient and polyp-related predictive factors for advanced neoplasia, enabling a patient-tailored approach for the management of these lesions.
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Affiliation(s)
- Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Via Morosini 30, 00153 Rome, Italy.
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Laghi A, Rengo M, Graser A, Iafrate F. Current status on performance of CT colonography and clinical indications. Eur J Radiol 2012; 82:1192-200. [PMID: 22749108 DOI: 10.1016/j.ejrad.2012.05.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 05/23/2012] [Indexed: 02/07/2023]
Abstract
CT colonography (CTC) is a robust and reliable imaging test of the colon. Accuracy for the detection of colorectal cancer (CRC) is as high as conventional colonoscopy (CC). Identification of polyp is size dependent, with large lesions (≥10mm) accurately detected and small lesions (6-9mm) identified with moderate to good sensitivity. Recent studies show good sensitivity for the identification of nonpolypoid (flat) lesions as well. Current CTC indications include the evaluation of patients who had undergone a previous incomplete CC or those who are unfit for CC (elderly and frail individuals, patients with underlying severe clinical conditions, or with contraindication to sedation). CTC can also be efficiently used in the assessment of diverticular disease (excluding patients with acute diverticulitis, where the exam should be postponed), before laparoscopic surgery for CRC (to have an accurate localization of the lesion), in the evaluation of colonic involvement in the case of deep pelvic endometriosis (replacing barium enema). CTC is also a safe procedure in patients with colostomy. For CRC screening, CTC should be considered an opportunistic screening test (not available for population, or mass screening) to be offered to asymptomatic average-risk individuals, of both genders, starting at age 50. The use in individuals with positive family history should be discussed with the patient first. Absolute contraindication is to propose CTC for surveillance of genetic syndromes and chronic inflammatory bowel diseases (in particular, ulcerative colitis). The use of CTC in the follow-up after surgery for CRC is achieving interesting evidences despite the fact that literature data are still relatively weak in terms of numerosity of the studied populations. In patients who underwent previous polypectomy CTC cannot be recommended as first test because debate is still open. It is desirable that in the future CTC would be the first-line and only diagnostic test for colonic diseases, leaving to CC only a therapeutic role.
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Affiliation(s)
- Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology Sapienza - Università di Roma, Polo Pontino, I.C.O.T. Hospital, Via Franco Faggiana 43, 04100 Latina, Italy.
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Neri E, Faggioni L, Vagli P, Cerri F, Picano E, Angeli S, Cini L, Bartolozzi C. Patients' preferences about follow-up of medium size polyps detected at screening CT colonography. ACTA ACUST UNITED AC 2012; 36:713-7. [PMID: 21161217 DOI: 10.1007/s00261-010-9671-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To evaluate patients' preferences regarding follow-up of medium size polyps detected at screening CT colonography (CTC). METHODS AND MATERIALS 193 C-RADS2 asymptomatic patients were asked to fill in a form explaining the indications, technique and potential complications of CTC, and were invited to choose their preferred examination technique (CTC or optical colonoscopy: OC) and their follow-up interval by repeated consultations at 3-month intervals. The follow-up interval for CTC and OC was recorded. RESULTS 87/193 C-RADS2 patients (45.1%) accepted follow-up. Average time interval for follow-up was comparable between CTC and OC (9.00 ± 4.24 vs. 9.00 ± 4.39 months, respectively; P = 0.7188). No patients chose to undergo a 3-year follow-up with either CTC or OC. Most patients elected to have follow-up with either CTC or OC before 18 months rather than later (P = 0.0004). CONCLUSIONS A substantial fraction of C-RADS2 patients prefer to undergo immediate OC and polyp removal rather than follow-up, and the majority of those accepting follow-up are willing to wait for less than 18 months. Such findings may suggest a revision of the proposed C-RADS2 category.
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Affiliation(s)
- Emanuele Neri
- Diagnostic and Interventional Radiology, Department of Oncology, Transplants and Advanced Technologies in Medicine, University of Pisa, Via Paradisa, 2, 56100, Pisa, Italy.
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Chang MS, Shah JP, Amin S, Gonzalez S, Prowda JC, Cheng JM, Verna EC, Rockey DC, Frucht H. Physician knowledge and appropriate utilization of computed tomographic colonography in colorectal cancer screening. ABDOMINAL IMAGING 2011; 36:524-531. [PMID: 21318376 DOI: 10.1007/s00261-011-9698-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
GOALS To assess physician understanding of computed tomographic colonography (CTC) in colorectal cancer (CRC) screening guidelines in a pilot study. BACKGROUND CTC is a sensitive and specific method of detecting colorectal polyps and cancer. However, several factors have limited its clinical availability, and CRC screening guidelines have issued conflicting recommendations. STUDY A web-based survey was administered to physicians at two institutions with and without routine CTC availability. RESULTS 398 of 1655 (24%) participants completed the survey, 59% was from the institution with routine CTC availability, 52% self-identified as trainees, and 15% as gastroenterologists. 78% had no personal experience with CTC. Only 12% was aware of any current CRC screening guidelines that included CTC. In a multiple regression model, gastroenterologists had greater odds of being aware of guidelines (OR 3.49, CI 1.67-7.26), as did physicians with prior CTC experience (OR 4.81, CI 2.39-9.68), controlling for institution, level of training, sex, and practice type. Based on guidelines that recommend CTC, when given a clinical scenario, 96% of physicians was unable to select the appropriate follow-up after a CTC, which was unaffected by institution. CONCLUSIONS Most physicians have limited experience with CTC and are unaware of recent recommendations concerning CTC in CRC screening.
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Affiliation(s)
- Matthew S Chang
- Muzzi Mirza Pancreatic Cancer Prevention and Genetics Program, Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Almond LM, Bowley DM, Karandikar SS, Roy-Choudhury SH. Role of CT colonography in symptomatic assessment, surveillance and screening. Int J Colorectal Dis 2011; 26:959-66. [PMID: 21424390 DOI: 10.1007/s00384-011-1178-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION When 'whole colonic imaging' is indicated, clinicians must decide between optical colonoscopy, barium enema and CT colonography (CTC). CTC is a relatively new technique which has become increasingly accessible in the UK over the past 5 years. As radiologists have gained experience and scanning parameters have standardised, there have been substantial improvements in both the accuracy and safety of CTC. METHODS We review evidence from observational studies and randomised trials, and draw on expert opinion, to provide a comprehensive discussion of the current role of CTC in both symptomatic and asymptomatic individuals. CONCLUSIONS The emergence of CTC could soon entirely obviate the need for barium enema. CTC now has a complementary role alongside colonoscopy in symptomatic patients and a possible future role in colorectal cancer screening in the UK.
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Affiliation(s)
- L Maximilian Almond
- Department of Colorectal Surgery, Heart of England NHS Foundation Trust, Birmingham, Birmingham, UK.
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Decreased-Purgation CT Colonography: State of the Art. CURRENT COLORECTAL CANCER REPORTS 2011. [DOI: 10.1007/s11888-010-0085-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Computed tomographic (CT) colonography is a noninvasive method to evaluate the colon and has received considerable attention in the last decade as a colon-imaging tool. The technique has also been proposed as a potential primary colon cancer-screening method in the United States. The accuracy of the technique for the detection of large lesions seems to be high, perhaps in the range of colonoscopy. Overall, the field is rapidly evolving. Available data suggest that CT colonography, although a viable colon cancer screening modality in the United States, is not ready for widespread implementation, largely because of the lack of standards for training and reading and the limited number of skilled readers.
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Affiliation(s)
- Don C Rockey
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8887, USA.
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Cost-effectiveness of colorectal cancer screening with computed tomography colonography or fecal blood tests. Eur J Gastroenterol Hepatol 2010; 22:1372-9. [PMID: 20802341 DOI: 10.1097/meg.0b013e32833eaa71] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To assess the cost-effectiveness of colorectal cancer screening using computed tomography colonography (CTC) and immunological fecal occult blood test (iFOBT). METHODS CTC and iFOBT strategies were compared with Nn screening or guaiac FOBT (gFOBT) using Markov modeling. CTC was proposed at 50, 60, and 70 years, whereas gFOBT and iFOBT were performed every 2 years beginning at 50 years until 74 years of age with a 30-year time horizon. We calculated incremental cost-effectiveness ratios and efficiency ratios (ERs). Then, we performed univariate and probabilistic sensitivity analyses. RESULTS With gFOBT as reference, colorectal cancer prevention rate was 18% for CTC and 11% for iFOBT. The incremental cost-effectiveness ratio of CTC and iFOBT were respectively 3204 and 5458 euro per life years gained (LYG), the ER for CTC was 0.22 and the ER for iFOBT was 2.08 colonoscopies per LYG. Cost-effectiveness results were sensitive to CTC cost. In the probabilistic sensitivity analysis, compared with CTC, iFOBT strategy was cost-effective for 84.6% of simulations when we assumed a willingness to pay (WTP) of 20,000 euro/LYG. CONCLUSION CTC requires substantially less colonoscopies than iFOBT and is cost-effective for low values of WTP. However, iFOBT is the preferred screening strategy for a WTP greater than 6207 euro/LYG.
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Pohl H, Robertson DJ. Colorectal cancers detected after colonoscopy frequently result from missed lesions. Clin Gastroenterol Hepatol 2010; 8:858-64. [PMID: 20655393 DOI: 10.1016/j.cgh.2010.06.028] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/11/2010] [Accepted: 06/28/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal cancers (CRCs) that are detected in patients who have received colonoscopies (interval cancers) arise from missed lesions, incomplete resections of adenomas, or de novo. We estimated rates of interval cancer from missed lesions. METHODS Adenoma miss rates, cancer prevalence among patients with adenoma (based on size), and rates of adenoma-to-cancer transitions were estimated from the literature. We used a model to apply these risk estimates to a hypothetical average-risk population that received screening colonoscopies. We calculated the proportion of individuals with tumors missed at the baseline colonoscopy and tumors that arose from missed adenomas during a 5-year follow-up period. Sensitivity analyses were performed to assess robustness. RESULTS We found that 0.7 per 1000 persons undergoing a screening colonoscopy had a cancer that was missed at the baseline colonoscopy and an additional 1.1 per 1000 subsequently developed cancer from a missed adenoma. Therefore, the expected rate of individuals with CRC, based on missed adenomas, was 1.8 per 1000 persons within 5 years. By using the most conservative assumptions-a low miss rate and low prevalence of cancer in adenomas-0.5 per 1000 persons would have a detectable CRC within 5 years after a screening colonoscopy. In contrast, using the highest reported miss rates and cancer prevalence, CRCs from missed lesions would occur in 3.5 per 1000 screened persons. CONCLUSIONS A significant number of patients undergoing a screening colonoscopy that did not detect cancer actually have a malignant lesion or adenoma that could progress in a short interval. Most interval cancers might reflect missed rather than new lesions. Improving adenoma detection could reduce the rate of interval cancers.
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Affiliation(s)
- Heiko Pohl
- Outcomes Group, VA Medical Center, White River Junction, Vermont 05009, USA.
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Abstract
Computed tomography colonography (CTC) in colorectal cancer (CRC) screening has two roles: one present and the other potential. The present role is, without any further discussion, the integration into established screening programs as a replacement for barium enema in the case of incomplete colonoscopy. The potential role is the use of CTC as a first-line screening method together with Fecal Occult Blood Test, sigmoidoscopy and colonoscopy. However, despite the fact that CTC has been officially endorsed for CRC screening of average-risk individuals by different scientific societies including the American Cancer Society, the American College of Radiology, and the US Multisociety Task Force on Colorectal Cancer, other entities, such as the US Preventive Services Task Force, have considered the evidence insufficient to justify its use as a mass screening method. Medicare has also recently denied reimbursement for CTC as a screening test. Nevertheless, multiple advantages exist for using CTC as a CRC screening test: high accuracy, full evaluation of the colon in virtually all patients, non-invasiveness, safety, patient comfort, detection of extracolonic findings and cost-effectiveness. The main potential drawback of a CTC screening is the exposure to ionizing radiation. However, this is not a major issue, since low-dose protocols are now routinely implemented, delivering a dose comparable or slightly superior to the annual radiation exposure of any individual. Indirect evidence exists that such a radiation exposure does not induce additional cancers.
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Pickhardt PJ, Hain KS, Kim DH, Hassan C. Low rates of cancer or high-grade dysplasia in colorectal polyps collected from computed tomography colonography screening. Clin Gastroenterol Hepatol 2010; 8:610-5. [PMID: 20304097 DOI: 10.1016/j.cgh.2010.03.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 03/09/2010] [Accepted: 03/09/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with polyps detected at computed tomography colonography (CTC) screening, management decisions are influenced by the likelihood of important polyp histology. We assess the rates of cancer and high-grade dysplasia among patients found to have small (6-9 mm) and large (>or=10 mm) colorectal polyps at CTC. METHODS We reviewed results from 5124 consecutive adults (mean age, 56.9 y; 2792 women) who received CTC screening at 1 institution over a 52-month period. All nondiminutive lesions confirmed at subsequent colonoscopy were grouped by size and histology features. Rates of cancer and high-grade dysplasia were calculated for various sizes. Adenomas were classified as advanced if they were 10 mm or greater and/or contained high-grade dysplasia or a prominent villous component. RESULTS A total of 755 polyps 6 mm or greater were identified during colonoscopy examinations in 479 patients. The rate of malignancy, according to polyp size, was 0% (0 of 464) for polyps 6 to 9 mm, 0.9% (2 of 216) for polyps 10 to 19 mm, 6.1% (2 of 33) for polyps 20 to 29 mm, and 38.1% (16 of 42) for polyps 30 mm or greater. High-grade dysplasia was observed in 0.4% (2 of 464) of 6- to 9-mm polyps and 7.9% (23 of 291) of lesions 10 mm or greater. A prominent villous component was seen in 3.4% (16 of 464) of 6- to 9-mm polyps. The overall rate of advanced histology in small polyps was 3.9% (18 of 464). CONCLUSIONS Small (6-9 mm) polyps rarely contained high-grade dysplasia (0.4%); none was malignant. The malignancy rate for large (1-2 cm) colorectal polyps was less than 1%. These findings indicate the potential for less aggressive management of lesions detected by CTC.
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Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792-3252, USA.
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Cost-effectiveness of colorectal cancer screening with computed tomography colonography according to a polyp size threshold for polypectomy. Eur J Gastroenterol Hepatol 2010; 22:716-23. [PMID: 19574924 DOI: 10.1097/meg.0b013e32832c76f6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Computed tomography colonography (CTC) has an acceptable accuracy in detecting colonic lesions, especially for polyps at least 6 mm. The aim of this analysis is to determine the cost-effectiveness of population-based screening for colorectal cancer (CRC) using CTC with a polyp size threshold. METHODS The cost-effectiveness ratios of CTC performed at 50, 60 and 70 years old, without (PL strategy) or with (TS strategy) polyp size threshold were compared using a Markov process. Incremental cost-effectiveness ratios (ICER) were calculated per life-years gained (LYG) for a time horizon of 30 years. RESULTS The ICER of PL and TS strategies were 12 042 and 2765 euro/LYG associated to CRC prevention rates of 37.9 and 36.5%. The ICER of PL and TS strategies dropped to 9687 and 1857 euro/LYG when advanced adenoma (AA) prevalence increased from 6.9 to 8.6% for male participants and 3.8-4.9% for female participants or to 9482 and 2067 euro/LYG when adenoma and AA annual recurrence rates dropped to 3.2 and 0.25%. The ICER for PL and TS strategies decreased to 7947 and 954 euro/LYG or when only two CTC were performed at 50 and 60-years-old. Conversely, the ICER did not significantly change when varying population participation rate or accuracy of CTC. CONCLUSION CTC with a 6 mm threshold for polypectomy is associated to a substantial cost reduction without significant loss of efficacy. Cost-effectiveness depends more on the AA prevalence or transition rate to CRC than on CTC accuracy or screening compliance.
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Pickhardt PJ, Kim DH, Robbins JB. Flat (nonpolypoid) colorectal lesions identified at CT colonography in a U.S. screening population. Acad Radiol 2010; 17:784-90. [PMID: 20227304 DOI: 10.1016/j.acra.2010.01.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 01/05/2010] [Accepted: 01/07/2010] [Indexed: 12/11/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to investigate the clinical importance and height definition of flat (nonpolypoid) colorectal lesions detected on screening computed tomographic colonography (CTC). MATERIALS AND METHODS Results from prospective screening CTC in 5107 consecutive asymptomatic adults (mean age, 56.9 years) at a single center were analyzed. All detected colorectal lesions > or = 6 mm were prospectively categorized as polypoid or flat (nonpolypoid). The maximal height of all flat lesions was measured to assess the suggested 3-mm threshold definition. RESULTS Of 954 polyps measuring > or = 6 mm identified on screening CTC, 125 lesions (13.1%) in 106 adults were prospectively categorized as flat, with a mean size of 12.7 mm (range, 6-80 mm), including 73 lesions 6 to 9 mm, 42 lesions 10 to 29 mm, and 10 lesions > or = 3 cm (carpet lesions). For polyps between 6 and 30 mm in size, flat lesions were less likely than polypoid lesions to be neoplastic (25.0% vs 60.3%, P < .001), histologically advanced (5.4% vs 12.1%, P = .07) or malignant (0% vs 0.5%, P = NS). Two of 10 carpet lesions (20%) were malignant, compared to 50% of polypoid masses > or = 3 cm. Of nine flat lesions seen only on colonoscopy (false-negatives on CTC), two were neoplastic (tubular adenomas), and none was histologically advanced. For all flat lesions between 6 and 30 mm, the maximal height averaged 2.2 mm and was < or =3 mm in 86.1%, including 93.2% of small 6-mm to 9-mm flat lesions. CONCLUSION In a US screening population, flat colorectal lesions detected on CTC demonstrated less aggressive histologic features compared to polypoid lesions. Excluding carpet lesions, a maximal height of 3 mm appears to be a reasonable definition.
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Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-3252, USA.
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Pickhardt PJ, Kim DH. Performance of CT colonography for detecting small, diminutive, and flat polyps. Gastrointest Endosc Clin N Am 2010; 20:209-26. [PMID: 20451811 DOI: 10.1016/j.giec.2010.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The primary goal of colorectal cancer screening and prevention is the detection and removal of advanced neoplasia. Computerized tomography (CT) colonography is now well established as an effective screening test. Areas of greater uncertainty include the performance characteristics of CT colonography for detecting small (6-9 mm), diminutive (< or =5 mm), and flat (nonpolypoid) lesions. However, the actual clinical relevance of small, diminutive, and flat polyps has also been the source of debate. This article addresses these controversial and often misunderstood issues.
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Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-3252, USA.
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Abstract
Computed tomography colonography (CTC) has the potential to become a major component of colorectal cancer (CRC) screening programs and to have a significant effect on CRC prevention. This article describes the potential role of CTC within the framework of colorectal cancer screening. Current screening recommendations and traditional screening tests are reviewed, followed by a summary of recent study results on the use of CTC as a screening tool. Several factors that are affecting the acceptance and adoption of CTC are outlined. Although CTC is valuable and holds considerable promise as a way to increase the use of CRC screening, these issues need to be addressed before CTC becomes more widely disseminated as a screening modality.
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Sonnenberg A. Inflationary caution in GI endoscopy. Gastrointest Endosc 2010; 71:789-91. [PMID: 20363420 DOI: 10.1016/j.gie.2009.12.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 12/30/2009] [Indexed: 02/08/2023]
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Bretagne JF, Manfredi S, Piette C, Hamonic S, Durand G, Riou F. Yield of high-grade dysplasia based on polyp size detected at colonoscopy: a series of 2295 examinations following a positive fecal occult blood test in a population-based study. Dis Colon Rectum 2010; 53:339-45. [PMID: 20173483 DOI: 10.1007/dcr.0b013e3181c37f9c] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim was to determine the rate of high-grade dysplasia among patients with all adenomas, and its prevalence in patients with adenomas of different sizes in a well-defined population-based study. POPULATION AND METHODS We performed a secondary analysis of the 2295 colonoscopies performed following a positive fecal occult blood test result during the first round of colorectal cancer screening in one French district. The rates of high-grade dysplasia were calculated for 3 size categories of adenoma (diminutive, <or=5 mm; small, 6-9 mm; large, >or=10 mm). Predictive factors for high-grade dysplasia were assessed by univariate and multivariate analyses. RESULTS A total of 1284 adenomas were detected in 784 subjects. High-grade dysplasia was present in 32.1% of the 784 subjects and in 2.7%, 16.0%, and 51.1% of those whose adenomas were diminutive, small, and large, respectively. Among subjects with no more than 2 small adenomas, the proportion of those with high-grade dysplasia was 12.4%. Both adenoma size and a villous component within adenomas were found to be independent predictive factors for high-grade dysplasia by multivariate analysis. CONCLUSIONS Because of the high rate of high-grade dysplasia among small adenomas, our results reinforce the need to remove all small adenomas detected at colonoscopy. Furthermore, the results suggest that opting for CT colonography surveillance instead of colonoscopic removal among subjects with one or 2 small polyps revealed by CT colonography would have led to missed high-grade dysplasia in 12.4% of them.
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Affiliation(s)
- Jean-François Bretagne
- Service des Maladies de l'Appareil Digestif, Centre hospitalo-universitaire, Rennes, France.
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CT colonography with decreased purgation: balancing preparation, performance, and patient acceptance. AJR Am J Roentgenol 2010; 193:1531-9. [PMID: 19933644 DOI: 10.2214/ajr.09.2342] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Reduction or elimination of catharsis with fecal tagging enhances the tolerability of CT colonography (CTC) and may increase compliance with colorectal cancer (CRC) screening recommendations. We systematically reviewed studies that prospectively evaluated performance and patient satisfaction with decreased-purgation CTC and with optical colonoscopy. CONCLUSION The nine studies reviewed showed moderate-to-good performance for decreased-purgation CTC; however, data are limited, and study design and data presentation are inconsistent. Further study of decreased-purgation CTC and standardization of terminology are needed.
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McFarland EG, Fletcher JG, Pickhardt P, Dachman A, Yee J, McCollough CH, Macari M, Knechtges P, Zalis M, Barish M, Kim DH, Keysor KJ, Johnson CD. ACR Colon Cancer Committee white paper: status of CT colonography 2009. J Am Coll Radiol 2010; 6:756-772.e4. [PMID: 19878883 DOI: 10.1016/j.jacr.2009.09.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 09/02/2009] [Indexed: 12/21/2022]
Abstract
PURPOSE To review the current status and rationale of the updated ACR practice guidelines for CT colonography (CTC). METHODS Clinical validation trials in both the United States and Europe are reviewed. Key technical aspects of the CTC examination are emphasized, including low-dose protocols, proper insufflation, and bowel preparation. Important issues of implementation are discussed, including training and certification, definition of the target lesion, reporting of colonic and extracolonic findings, quality metrics, reimbursement, and cost-effectiveness. RESULTS Successful validation trials in screening cohorts both in the United States with ACRIN and in Germany demonstrated sensitivity > or = 90% for patients with polyps >10 mm. Proper technique is critical, including low-dose techniques in screening cohorts, with an upper limit of the CT dose index by volume of 12.5 mGy per examination. Training new readers includes the requirement of interactive workstation training with 2-D and 3-D image display techniques. The target lesion is defined as a polyp > or = 6 mm, consistent with the American Cancer Society joint guidelines. Five quality metrics have been defined for CTC, with pilot data entered. Although the CMS national noncoverage decision in May 2009 was a disappointment, multiple third-party payers are reimbursing for screening CTC. Cost-effective modeling has shown CTC to be a dominant strategy, including in a Medicare cohort. CONCLUSION Supported by third-party payer reimbursement for screening, CTC will continue to further transition into community practice and can provide an important adjunctive examination for colorectal screening.
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Hassan C, Hunink MGM, Laghi A, Pickhardt PJ, Zullo A, Kim DH, Iafrate F, Di Giulio E. Value-of-Information Analysis to Guide Future Research in Colorectal Cancer Screening. Radiology 2009; 253:745-52. [DOI: 10.1148/radiol.2533090234] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
Every year more than one million new patients are diagnosed with colon cancer worldwide. Although multiple prospective randomized trials and observational studies have demonstrated that mortality from colon cancer can be reduced with screening and removal of adenomatous polyps, compliance with screening guidelines remains low. Recent CT colonography (CTC) trials have shown that CTC is capable of demonstrating adenomatous polyps ≥10 mm (and in most cases ≥6 mm) with sensitivities comparable to those for optical colonoscopy. Based on these results, at least two expert panels have recommended CTC as an option for colorectal cancer screening. Despite these endorsements, the Centers for Medicare and Medicaid Services (CMS) in the United States recently decided to deny coverage of CTC for colorectal cancer screening. This article addresses the reservations raised by CMS and provides a perspective on whether CTC is ready for routine use as a colorectal cancer screening test.
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Affiliation(s)
- Jay P Heiken
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, St Louis, MO 63110, USA.
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Pickhardt PJ. Colorectal cancer: Management of small polyps detected by CT colonography. Nat Rev Gastroenterol Hepatol 2009; 6:568-70. [PMID: 19789572 DOI: 10.1038/nrgastro.2009.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-3252, USA.
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Colorectal cancer screening with CT colonography: key concepts regarding polyp prevalence, size, histology, morphology, and natural history. AJR Am J Roentgenol 2009; 193:40-6. [PMID: 19542393 DOI: 10.2214/ajr.08.1709] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this article is to provide a timely update on a variety of key polyp topics to construct a proper framework for physicians who are interested in providing CT colonography screening as a clinical service. CONCLUSION As the medical community considers the expansion of CT colonography for screening, we believe it is prudent to update and review several key concepts regarding colorectal polyps. In particular, it is important to replace the older literature derived from high-risk and symptomatic cohorts with the wealth of newer and more applicable data from average-risk and asymptomatic screening cohorts. Familiarity with current concepts regarding flat (nonpolypoid) lesions and the natural history of small colorectal polyps is also vital to the effective application of this technique.
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Rockey DC, Chen MH, Herman BA, Johnson CD, Toledano A, Dachman AH, Hara AK, Fidler JL, Menias CO, Coakley KJ, Kuo M, Horton KM, Cheema J, Iyer R, Siewert B, Yee J, Obregon R, Zimmerman P, Halvorsen R, Casola G, Morrin M. Computed tomographic colonography: current perspectives and future directions. Gastroenterology 2009; 137:7-14. [PMID: 19450595 DOI: 10.1053/j.gastro.2009.05.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Computed tomographic (CT) colonography, also known as virtual colonoscopy or CT colography, is capable of detecting colon polyps and cancers. It is emerging rapidly and has gained great momentum over the past several years, to the point where it has been proposed to be a viable primary colon cancer screening option. Despite the current publicity, many issues concerning CT colonography remain. As of 2009, the following topics are of paramount importance: (1) accuracy, including both sensitivity and specificity, (2) bowel preparation, (3) safety, (4) extracolonic findings, (5) patient acceptability, (6) training and standardization, and (7) implementation of CT colonography. Although much about CT colonography has already been learned, more remains to be learned in the future.
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Affiliation(s)
- Don C Rockey
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA.
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Shah JP, Hynan LS, Rockey DC. Management of small polyps detected by screening CT colonography: patient and physician preferences. Am J Med 2009; 122:687.e1-9. [PMID: 19559172 DOI: 10.1016/j.amjmed.2009.01.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Revised: 12/19/2008] [Accepted: 01/05/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Management of small polyps found on computed tomography (CT) colonography is controversial and critical to both cancer outcomes and cost. Patient and physician behavior are influenced by personal beliefs and prior experience. Thus, we aimed to understand patient and physician preferences after finding polyps on CT colonography. METHODS Patients were given a validated handout and survey asking for their preference for evaluation of a "pea-sized" polyp found on CT colonography. By using an Internet survey, physicians were asked how they would manage a 5-mm, 8-mm, or 12-mm polyp, or three 5-mm polyps found by CT colonography in a hypothetical 52-year-old patient of average colorectal cancer risk. Survey reliability was assessed using Cronbach's coefficient alpha. RESULTS Of the 305 patient respondents, 95% wanted to know if the polyp found on CT colonography was precancerous, 86% stated they would request endoscopic evaluation, and 85% wanted polypectomy. Of the 277 primary care physicians, 71% would refer a 5-mm sigmoid polyp for endoscopy, 86% would refer an 8-mm polyp, 97% would refer a 12-mm polyp, and 91% would refer three 5-mm polyps. Of the 461 gastroenterologists, 83% would refer a 5-mm sigmoid polyp for endoscopy, 96% would refer an 8-mm polyp, 97% would refer a 12-mm polyp, and 93% would refer three 5-mm polyps. Overall, 75% of physicians indicated the fear of missing a precancerous lesion would prompt referral for colonoscopy. CONCLUSION Both patients and physicians overwhelmingly preferred to follow up small polyps identified by CT colonography with endoscopy, suggesting that population-based CT colonography screening programs in which polyps are not removed might require significant patient and physician education before implementation.
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Affiliation(s)
- Jessica P Shah
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX 75390-8887, USA
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CT colonography to screen for colorectal cancer and aortic aneurysm in the Medicare population: cost-effectiveness analysis. AJR Am J Roentgenol 2009; 192:1332-40. [PMID: 19380558 DOI: 10.2214/ajr.09.2646] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE CT colonography (CTC) is a recommended test for colorectal cancer (CRC) screening according to the updated 2008 American Cancer Society guidelines. CTC can also accurately detect abdominal aortic aneurysm (AAA). This collaborative gastroenterology-radiology project evaluated the cost-effectiveness and clinical efficacy of CTC in the Medicare population. MATERIALS AND METHODS A computerized Markov model simulated the development of CRC and AAA in a hypothetical cohort of 100,000 U.S. adults > or = 65 years old. Screening with CTC at 5- and 10-year intervals using a 6-mm size threshold for polypectomy was compared with primary optical colonoscopy screening every 10 years and with no screening. Base case costs for CTC and optical colonoscopy were $674 and $795, respectively. The costs of the imaging workup for extracolonic findings at CTC were also included. RESULTS CTC resulted in 7,786 and 7,027 life-years gained at 5- and 10-year intervals, respectively, compared with 6,032 life-years gained with 10-year optical colonoscopy. The increase in overall efficacy with CTC was primarily due to prevention of AAA rupture because CRC prevention and CRC detection rates were similar for CTC and optical colonoscopy. All three strategies were highly cost-effective compared with no screening, with an incremental cost-effectiveness ratio (ICER) of $6,088, $1,251, and $1,104 per life-year gained for 5-year CTC, 10-year CTC, and 10-year optical colonoscopy strategies, respectively. The ICER of 5-year CTC and 10-year CTC versus optical colonoscopy was $23,234 and $2,144 per life-year gained, respectively. CONCLUSION Because of its ability to simultaneously screen for both CRC and AAA, CTC is a highly cost-effective and clinically efficacious screening strategy for the Medicare population.
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El-Maraghi RH, Kielar AZ. CT colonography versus optical colonoscopy for screening asymptomatic patients for colorectal cancer a patient, intervention, comparison, outcome (PICO) analysis. Acad Radiol 2009; 16:564-71. [PMID: 19345897 DOI: 10.1016/j.acra.2009.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Revised: 12/26/2008] [Accepted: 01/06/2009] [Indexed: 01/06/2023]
Abstract
RATIONALE AND OBJECTIVES The American College of Radiology has recently endorsed the use of computed tomographic colonography (CTC) for colon cancer screening. With advances in technology and postprocessing software, the quality of computed tomographic colonographic studies has improved, and new techniques are being developed to reduce radiation exposure and increase patient acceptance of the procedure. The aim of colorectal cancer screening is to reduce the incidence of malignancy by identifying and removing presymptomatic lesions. The aim of this study was to answer the clinical question: In an asymptomatic patient at average risk for colon cancer, is CTC equivalent to optical colonoscopy (OC) for detecting clinically significant polyps? MATERIALS AND METHODS A systematic literature review was conducted to evaluate CTC compared to OC, using the patient, intervention, comparison intervention, outcome (PICO) search strategy. The PubMed search used Medical Subject Headings, including the terms "computed tomography colonography," "colonoscopy," "screening," and "polyp." Each of the retrieved articles was assigned a level of evidence using the Centre for Evidence-Based Medicine's hierarchy of validity for diagnostic studies. RESULTS PICO search criteria and review of abstracts identified 16 relevant studies. Using the Centre for Evidence-Based Medicine's hierarchy of validity, there were three level 1c studies, two level 2a studies, three level 2b studies, four level 3b studies, two level 4 studies, and two level 5 studies. All relevant studies demonstrated that CTC had high or moderately high per patient and per polyp sensitivity and specificity compared to OC for clinically relevant polyps (>5 mm). CONCLUSIONS The majority of evidence suggests that CTC is an acceptable alternative to OC, particularly in the group of patients who are either unwilling or unable to undergo OC. The results of the large, multicenter American College of Radiology Imaging Network study are pending. This trial presented preliminary results in 2007 suggesting that the sensitivity and specificity of CTC are high and comparable to those of OC.
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Hassan C, Pickhardt PJ, Laghi A, Zullo A, Kim DH, Iafrate F, Cristofari F, Di Giulio E. The diminutive lesion versus the advanced adenoma: Which is the real target of CT colonography screening? Int J Cancer 2009; 125:1238; author reply 1239-40. [DOI: 10.1002/ijc.24478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Farraye FA, Adler DG, Chand B, Conway JD, Diehl DL, Kantsevoy SV, Kwon RS, Mamula P, Rodriguez SA, Shah RJ, Wong Kee Song LM, Tierney WM. Update on CT colonography. Gastrointest Endosc 2009; 69:393-8. [PMID: 19231482 DOI: 10.1016/j.gie.2008.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 10/09/2008] [Indexed: 02/08/2023]
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