CT-Colonography clinical indications

Emanuele NeriDiagnostic and Interventional RadiologyPisa, Italy

ESGAR – ESGE ConsensusClinical indications for computed tomographic colonography: European Society of Gastrointestinal Endoscopy (ESGE) and

European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline.

Spada C, Stoker J, Alarcon O, Barbaro B, Bellini D, Bretthauer M, De Haan MC, Dumonceau JM, Ferlitsch M, Halligan S, Helbren E, Hellstrom M, Kuipers EJ, Lefere P, Mang T, Neri E, Petruzziello L,

Plumb A, Regge D, Taylor SA, Hassan C, Laghi A.

Endoscopy. 2014 Oct;46(10):897-915. doi: 10.1055/s-0034-1378092. Epub 2014 Sep 30

Methods

• The guideline is based on a targeted literature search to evaluate the evidence supporting the use CTC in clinical practice. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence.

GuidelinesMain recommendations

1. ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. ESGE/ESGAR do not recommend barium enema in this setting (strong recommendation, high quality evidence).

2. ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. Delay of CTC should be considered following endoscopic resection. In the case of obstructing colorectal cancer, preoperative contrast-enhanced CTC may also allow location or staging of malignant lesions (strong recommendation, moderate quality evidence).

3. When endoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with symptoms suggestive of colorectal cancer (strong recommendation, high quality evidence).

CTC vs BE• CTC can be considered the best non

invasive test for colorectal cancer• CTC results for both CRC and significant

polyps similar to CC in symptomatic and asymptomatic patients and clearly superior to Barium Enema diagnosis.

• Routine use of BE is not recommended

BE sens and specclearly inferior to CTC

Polyps of any size 38% and 86%

41% and 82%

S. J. Winawer, et alA comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy.

National Polyp Study Work Group. The New England journal of medicine 342, 1766-1772 (2000)

Polyps >5mm

D. C. Rockey, et al, Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective

comparison. Lancet 365, 305-311 (2005)

Main recommendations

1. ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. ESGE/ESGAR do not recommend barium enema in this setting (strong recommendation, high quality evidence).

2. ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. Delay of CTC should be considered following endoscopic resection. In the case of obstructing colorectal cancer, preoperative contrast-enhanced CTC may also allow location or staging of malignant lesions (strong recommendation, moderate quality evidence).

3. When endoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with symptoms suggestive of colorectal cancer (strong recommendation, high quality evidence).

Incomplete colonoscopy

• In case imaging will be performed, in patients with incomplete colonoscopy, CTC is the most effective and efficient option.

• All studies show a high technical feasibility of CTC, a relatively high diagnostic yield, and an adequate PPV, especially at 10 mm cut-off.

H. J. Pullens, M. S. van Leeuwen, R. J. Laheij, F. P. Vleggaar, P. D. Siersema, CT-colonography after incomplete colonoscopy: what is the diagnostic yield? Diseases of the colon and rectum 56, 593-599 (2013);

M. Neerincx, J. S. Terhaar sive Droste, C. J. Mulder, M. Rakers, J. F. Bartelsman, R. J. Loffeld, H. A. Tuynman, R. M. Brohet, R. W. van der Hulst, Colonic work-up after incomplete colonoscopy: significant new findings during follow-up. Endoscopy 42, 730-735 (2010);

F. Iafrate, C. Hassan, A. Zullo, A. Stagnitti, R. Ferrari, A. Spagnuolo, A. Laghi, CT colonography with reduced bowel preparation after incomplete colonoscopy in the elderly. Eur Radiol 18, 1385-1395 (2008)

L. Copel, J. Sosna, J. B. Kruskal, V. Raptopoulos, R. J. Farrell, M. M. Morrin, CT colonography in 546 patients with incomplete colonoscopy. Radiology 244, 471-478 (2007);

M. M. Morrin, J. B. Kruskal, R. J. Farrell, S. N. Goldberg, J. B. McGee, V. Raptopoulos, Endoluminal CT colonography after an incomplete endoscopic colonoscopy. AJR. American journal of roentgenology 172, 913-918 (1999); published online EpubApr (10.2214/ajr.172.4.10587120).

C. Yucel, A. S. Lev-Toaff, N. Moussa, H. Durrani, CT colonography for incomplete or contraindicated optical colonoscopy in older patients. AJR Am J Roentgenol 190, 145-150 (2008); published online EpubJan (10.2214/AJR.07.2633).

M. Macari, P. Berman, M. Dicker, A. Milano, A. J. Megibow, Usefulness of CT colonography in patients with incomplete colonoscopy. AJR. American journal of roentgenology 173, 561-564 (1999); published online EpubSep (10.2214/ajr.173.3.10470879).

E. Neri, P. Giusti, L. Battolla, P. Vagli, P. Boraschi, R. Lencioni, D. Caramella, C. Bartolozzi, Colorectal cancer: role of CT colonography in preoperative evaluation after incomplete colonoscopy. Radiology 223, 615-619 (2002);

M. Luo, H. Shan, K. Zhou, CT virtual colonoscopy in patients with incomplete conventional colonoscopy. Chinese medical journal 115, 1023-1026 (2002);

C. Lai, T. Sammour, G. Roadley, G. Wilton, A. G. Hill, CT colonography in a rural New Zealand hospital. The New Zealand medical journal 122, 67-73 (2009)

FOBT/FIT positive with incomplete colonoscopy

• ESGE/ESGAR strongly recommend CTC in the case of positive FOBT/FIT with incomplete or unfeasible colonoscopy within organized population screening programs. (Recommendation: Strong; Evidence Level: Low).

• High PPV– 77% for 6-9mm polyps– 83% for >10 mm polyps

The Positive predictive value is the probability that subjects with a positive screening test truly have the disease.

CTC timing• CTC after incomplete colonoscopy

needs a different approach compared to primary CTC, in case the patient underwent a colonic biopsy and/or polypectomy or mucosectomy.

• In case of polypectomy/mucosectomy it is cautious to consider a delay of 2 weeks before performing CTC.

Obstructing colorectal cancer

• pre-operative full colorectal imaging assessment is needed

• equivalent sensitivity  for colon cancer between colonoscopy and CTC  

Main recommendations

1. ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. ESGE/ESGAR do not recommend barium enema in this setting (strong recommendation, high quality evidence).

2. ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. Delay of CTC should be considered following endoscopic resection. In the case of obstructing colorectal cancer, preoperative contrast-enhanced CTC may also allow location or staging of malignant lesions (strong recommendation, moderate quality evidence).

3. When endoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with symptoms suggestive of colorectal cancer (strong recommendation, high quality evidence).

Symptomatic patients• first randomised trial to compare CTC and

colonoscopy for investigation of patients with symptoms suggestive of colorectal cancer.

• data suggest that CTC and colonoscopy have similar sensitivity for CRC and large polyps in symptomatic patients, suggesting either may be chosen to exclude important colonic neoplasia.

• 4. ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥ 6 mm in diameter detected at CTC.

• CTC surveillance may be clinically considered if patients do not undergo polypectomy (strong recommendation, moderate quality evidence).

• 5. ESGE/ESGAR do not recommend CTC as a primary test for population screening or in individuals with a positive first-degree family history of colorectal cancer (CRC). However, it may be proposed as a CRC screening test on an individual basis providing the screenee is adequately informed about test characteristics, benefits, and risks (weak recommendation, moderate quality evidence).

Guidelines

The issues of diminutive (<6mm) and intermediate (6-9mm) polyps• Most of the colorectal lesions at

endoscopy concern <5 mm (i.e. diminutive) polyps.

• Approximately only half of these diminutive polyps are adenomatous and therefore precancerous lesions.

Relative prevalence of adenomatous histotype among diminutive and small lesions in large

cohorts of subjects undertaking endoscopic or CT colonography screening.

6-9 mm (i.e. small) polyps represent about 15% of all the polyps detected in screening population

Natural history of 6-9 mm polyps• Recently, natural history of 6-9 mm CTC-

detected lesions has been addressed in a longitudinal study.

• In detail, 243 adults with 306 CTC-detected small polyps underwent a new CTC after a 2-3 year follow up.

• Overall, 22% of these polyps progressed, with only 6% exceeding 10 mm at follow-up.

P. J. Pickhardt, et al.Assessment of volumetric growth rates of small colorectal polyps with CT colonography: a

longitudinal study of natural history. The lancet oncology, (2013)

• 4. ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥ 6 mm in diameter detected at CTC.

• CTC surveillance may be clinically considered if patients do not undergo polypectomy (strong recommendation, moderate quality evidence).

• 5. ESGE/ESGAR do not recommend CTC as a primary test for population screening or in individuals with a positive first-degree family history of colorectal cancer (CRC). However, it may be proposed as a CRC screening test on an individual basis providing the screenee is adequately informed about test characteristics, benefits, and risks (weak recommendation, moderate quality evidence).

Guidelines

BREAKING NEWS: March 5th 2008

Screening on individual basis

Screening

• On an individual basis “CTC is currently a credible alternative screening method and should be considered as a reasonable alternative to the other CRC screening tests…”

• In a mass screening programme screening CTC is probably safer and more cost effective than other screening tests if a 6 mm reporting threshold is proposed.

• However participation rate and advanced adenoma detection rate a need to be verified in randomized clinical trials.

SAFE: VC vs FOBT

COCOS: VC vs Colonoscopy

PROTEUS: VC vs Colonoscopy

SIGGAR: VC vs Colonoscopy,- VC vs BE (symptomatic)

Mass Screening

COCOS trial (Netherlands)– Results of the COCOS trial (Rand CTC versus

colonoscopy, > 982-1276 cases).

– Referral to colonoscopy 9% of whom 6% with advanced neoplasia. In the colonoscopy arm 9% with advanced neoplasia.

– Participation rate: 34% CTC versus 22% colonoscopy

Mass Screening

Indications

Current• Incomplete colonoscopy• Refused to perform

colonoscopy• Diverticular disease• Fragile patients• Staging of patients with

CRC (one step)• Opportunistic screening

New and potential• Mass screening (patients

with +FIT that refuse colonoscopy)

• Individual with non specific symptoms (dd with irritable bowel syndrome).

• SurveillanceSpecific clinical situations• Deep pelvic endometriosis• Inflammatory bowel disease

• Diverticular disease. Significantly higher number of patients are diagnosed with diverticular disease with CTC in respect to colonoscopy (54% versus 35%). SIGGAR Lancet 2013

Endometriosis

32 year old female, no family history for CRC, constipation, one episode of occlusion, refused OC

Endometriosis

Take home messages

• Indications to CTC are increasing

• CTC is recommended in all cases of unfeasibility of colonoscopy

• CTC is not ready for mass screening but is ideal for screening on an individual basis.