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CT Colonography vs Colonoscopy for the Detection of Advanced Neoplasia

CT Colonography vs Colonoscopy for the Detection of Advanced Neoplasia

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CT Colonography vs Colonoscopy for the Detection of Advanced Neoplasia

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  1. CT Colonography vs Colonoscopy for the Detection of Advanced Neoplasia David H. Kim, M.D., Perry J. Pickhardt, M.D., Andrew J. Taylor, M.D., Winifred K. Leung, M.D., Thomas C. Winter, M.D., J. Louis Hinshaw, M.D., Deepak V. Gopal, M.D., Mark Reichelderfer, M.D., Richard H. Hsu, M.D., and Patrick R. Pfau, M.D. NEJM Oct 4, 2007 Volume 357:1403-1412

  2. Background

  3. Ct Colonography http://www.radiologyinfo.org/en/photocat/photos_pc.cfm?image=vcoloMovie.jpg&pg=ct_colo

  4. Colorectal cancer: • A major cause of cancer-related mortality in the US (55,000 deaths/yr) • Preventable by detection and removal of its precursor: advanced colonic adenoma

  5. Colonic adenoma progression Advance colonic adenomas >10mm Small adenomas < 5mm dysplasia Cancer 10 yrs Most likely Hyperplastic Usually do not progress to cancer

  6. Study Objective

  7. Optical colonoscopy (OC) is currently the preferred screening and preventive strategy of CRC by AGS • CT colonography (CTC) is a non-invasive promising alternative screening method • Most trials examining CTC had failed to show comparative sensitivity/specificity to OC.

  8. Methods

  9. Study design: Single center, non randomize clinical trial comparing CTC vs OC screening in a 25 month period Study population: 6283 pt referred by primary care providers. • 3120 CTC screening • 3163 OC screening

  10. Inclusion/Exclusion criteria • Inclusion • Asymptomatic and average risk for colorectal CA • Exclusion • Prior polyp surveillance • History of bowel disorder (IBD, polyposis syndromes, hereditary non polyposis colorectal cancer syndrome)

  11. Screening Methods • Pt identified with advanced neoplasm (mass/polyps > 6mm) by CTC were given the option of surveillance with CTC or removal of the polyp by OC. • In the OC group, All polyps/masses found were removed, regardless of size or significance. • All removed masses were evaluated for location relative to the splenic flexure, morphologic characteristics, and histology.

  12. Screening Methods • Lesions were divided into two categories: • Polyps • Large: > 10mm • Small: 6-9 mm • Diminutive: 5mm or less • Invasive mass

  13. Statistics • A positive test was defined as detection of polyps of any size in the OC group and polyps of >6mm in the CTC group. • The two tests were compared using student’s T-test and Chi square analyses

  14. Results

  15. Optical colonoscopy A sessile polyp An adenomatous polyp http://www.murrasaca.com/colonoscopy.htm

  16. 3120 Patients were enrolled in CTC screening 2716 (87.1%) had negative findings 404 (12.9%) had positive findings Routine follow-up in 5 yrs 246 (7.9%) underwent OC with polypectomy 158 (5.1%) chose ongoing imaging surveillance With 193 polyps With 394 polyps (>6mm) 227 adenomas 14 Cancers 153 non-neoplastic tumors 123 Advanced neoplastic lesions

  17. More Information

  18. Summary of Results • Both CTC and OC had comparative diagnostic yield for both types of advance neoplasia (p= 0.81) • CTC had an advantage of safety, no requirement for sedation, and detecting extra-colonic abnormalities • There were larger number of polypectomies in the OC (2434) vs. in the CTC (561) while total advance neoplasias were similar in both (121/2434 vs 123/561)

  19. PPV for advance neoplasia • TP / TP+FP • CTC 123 / 561 • OC 121 / 2434

  20. Discussion

  21. Study Strength • Large sample size, similar baseline characteristics • Relevant exclusion criteria • Detailed pathological characterization of tissues in addition to imaging to establish comparative detection • Could have significant clinical and economical impact on current practice of colon CA screening

  22. Weakness • Non blinded/non-randomized (selection bias) • single Center • Technical advancement may vary between centers for effective CTC screening • True negatives in pts with lesions < 5mm in the CTC group is not determined

  23. Clinical Practice Relevance • Offers CTC as a non-invasive alternative to OC for comparative detection of colonic neoplasias • Eliminates the need for a large number of unnecessary colonoscopies and polypectomies • Due to variability in technical resources CTC may not yet be a potential replacement for OC in many practice settings

  24. Thank you

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