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Importance of Extracolonic Findings at IV Contrast Medium-Enhanced CT

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Importance of Extracolonic Findings at IV Contrast Medium-Enhanced CT View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Bern Open Repository and Information System (BORIS) Eur Radiol (2005) 15: 2088–2095 DOI 10.1007/s00330-005-2798-6 GASTROINTESTINAL Adrian Spreng Importance of extracolonic findings at IV Peter Netzer Joerg Mattich contrast medium-enhanced CT colonography Hans-Peter Dinkel Peter Vock versus those at non-enhanced CT colonography Hanno Hoppe Abstract To compare the clinical 25% (26/102) of all patients led to Received: 11 February 2005 Revised: 24 April 2005 importance of extracolonic findings at further work up or had an impact on Accepted: 29 April 2005 intravenous (IV) contrast-enhanced therapy. Twenty-two of these patients Published online: 18 June 2005 CT colonography versus those at non- underwent CT colonography with IV # Springer-Verlag 2005 enhanced CT colonography. IV con- contrast enhancement, and four with- trast medium-enhanced (n=72) and out. The percentage of extracolonic non-enhanced (n=30) multidetector findings leading to further work up or CT colonography was performed in having an impact on therapy was 102 symptomatic patients followed by higher for IV contrast-enhanced (31%; conventional colonoscopy on the 22/72) than for non-enhanced (13%; same day. The impact of extracolonic 4/30) CT scans (P=0.12). IV contrast- findings on further work up and enhanced CT colonography produced A. Spreng . J. Mattich . H.-P. Dinkel . P. Vock . H. Hoppe (*) treatment was assessed by a review of more extracolonic findings than Institute of Diagnostic Radiology, patient records. Extracolonic findings non-enhanced CT colonography. Inselspital, University of Bern, were divided into two groups: either A substantially greater proportion Freiburgstrasse 10, leading to further work up respec- of findings on IV contrast-enhanced 3010 Bern, Switzerland e-mail: [email protected] tively having an impact on therapy or CT colonography led to further work Tel.: +41-31-6322435 not. A total of 303 extracolonic up and treatment than did non- Fax: +41-31-6324874 findings were detected. Of those, 71% enhanced CT colonography. (215/303) were found on IV contrast- P. Netzer . Department of Gastroenterology, enhanced CT, and 29% (88/303) were Keywords Extracolonic findings Inselspital, University of Bern, found on non-enhanced CT colono- Virtual colonoscopy . CT Bern, Switzerland graphy. The extracolonic findings in colonography . Abdominal CT Introduction sels, bone, and soft tissue [7]. Such findings are reported to be useful in staging cancer, explaining a patient’s present- First described by Vining et al. in 1994, CT colonography, ing symptoms, and detecting other potentially serious dis- or so-called “virtual colonoscopy,” is a rapidly evolving orders [8]. On the other hand, extracolonic findings may minimally invasive technique for examination of the entire involve phenomena already known or may lead to un- colon and detection of colorectal neoplasms [1]. Previous necessary further work up, which can be problematic for studies have shown that CT colonography has the potential both ethical and economical reasons [9, 10]. to become a valuable clinical screening method for colo- Only a few studies have examined the clinical relevance rectal neoplasms [2–6]. of extracolonic findings at CT colonography [7, 9–12]. These In contrast to other screening tools for colorectal cancer, studies examining non-enhanced CT scans of the abdomen such as conventional colonoscopy and barium enema, CT report large differences in the prevalence of extracolonic colonography allows for simultaneous visualization of ex- findings and the need for additional work up. To our tracolonic pathologies within the abdominal organs, ves- knowledge, the present study is the first to compare the 2089 clinical relevance of extracolonic findings at IV contrast- reconstructed as 2-mm slices with a 1-mm reconstruction enhanced CT colonography with those at non-enhanced interval. CT colonography. Image analysis Patients and methods Methods for polyp detection have been described else- Patients where [6]. The reconstructed supine and prone datasets were transferred to an Advantage Windows workstation One hundred and two adult patients referred to our gastro- (Version 4.0, General Electric Medical Systems, Milwau- enterology clinic for conventional colonoscopic evaluation kee, WI) running on Sun Ultra Sparc 60 hardware (Sun of symptoms (including hematochezia, positive hemoccult Microsystems, Mountain View, CA) featuring two Sun test, iron deficiency anemia, or personal or family history Ultra Sparc II 450 MHz central processing units and 2 of colonic neoplasms) were enrolled in the study. The gigabytes of random access memory. Images for extraco- study’s trial protocol was approved by the institute’s ethics lonic findings were read by a board-certified radiologist committee and performed in accordance with the revised and a radiology resident. Since the images were read during Declaration of Helsinki of 1989. Each patient provided clinical routine they were not always evaluated by the same written consent after being fully informed regarding the readers throughout the study. The supine acquisitions were study protocol. In all patients, CT colonography was fol- IV contrast enhanced in 72 patients and non-enhanced in lowed by conventional colonoscopy the same morning. 30 patients; no further IV contrast medium was adminis- tered for prone scans. Images were viewed as continuous 2- mm axial sections with regular abdominal contrast window CT colonography display settings (level 50 H, width 450 H). The window/ level settings could be adjusted manually at the worksta- On the day before the examinations, each patient was given tion. The basal portions of the lungs were also viewed a wet bowel preparation consisting of 4 l of methylcellulose using standard lung window settings (level −450 H, width as prescribed by the participating gastroenterologist. No 1,850 H). If necessary, additional multiplanar reformatting oral contrast medium was administered. CT colonography was performed using the workstation. Both readers were was performed with an Asteion four-channel multidetector unaware of the patients’ medical history, but knew that the CT scanner (Toshiba, Tokyo, Japan). A flexible rubber cath- examined patient cohort consisted of symptomatic pa- eter with a rectal balloon was inserted into the rectum by tients. One radiologist per study was responsible for dic- the investigating radiologist. The patient’s colon was then tating an official CT colonography report, which included insufflated with room air according to the patient’s toler- both intra- and extracolonic findings plus suggestions for ance. The catheter was clamped and left in the rectum, possible work-up procedures. The report was sent to the and a single supine scout CT image was obtained to verify referring clinician. adequate bowel distension. If bowel distension was in- adequate, additional air was insufflated into the rectum. Once bowel distension was adequate, CT colonography Definitions was performed. In 72 of the 102 patients, 120 ml (flow-rate: 3 ml/s; scan delay: 60 s) of iopromide IV contrast medium Extracolonic findings were divided into two groups: either containing 300 mg/ml iodine (Ultravist 300, Berlex Labo- leading to further work-up respectively having an impact ratories, Montville, USA) was power injected, followed on therapy or not. Extracolonic findings were classified first by CT colonography in the supine position in a cranio- by organ system as hepatic (lesion, fatty liver), vascular caudal direction to image the entire region of the colon and (aneurysm, thrombosis, sclerosis, varices), gallbladder (cho- rectum, then by examination in the prone position without lecystitis, polyps) or cholangio (cholestasis), pulmonary (nod- additional injection of contrast medium. In 30 of the 102 ule, infiltrate, emphysema, fibrosis) or pleural (pleuritis, patients, administration of IV contrast medium was con- effusion, calcification, thickening), musculoskeletal(mass traindicated due to an elevated creatinine level, known renal including hematoma or lipoma, osteolysis, arthrosis), urogen- insufficiency, or contrast media allergy. ital (renal mass, renal cyst, renal duplication, nephrolithia- CT parameters included 4×2-mm detector collimation, sis, adrenal mass, prostatic enlargement, testicular hydrocele, 120 kV, 0.75-s gantry rotation, 200 mAs and a pitch of uterine myoma, any calcification), cardiac (pericardial effu- 1.375. The entire abdomen and pelvis were scanned during sion, coronary artery calcification, cardiomegaly), splenic a breath hold of approximately 30 s. Axial CT images were (lesion, splenomegaly, accessory spleen), pancreatic (mass, 2090 Table 1 The number of extra- Finding No. of No. of previously known findings Findings on IV Findings on colonic findings at CT colonog- raphy in 102 patients, number of findings IV contrast Non-enhanced contrast-enhanced non-enhanced previously known findings, and CT scans CT scans corresponding numbers of find- ings on CT scans with and Hepatic 40 3 2 30 10 without IV contrast Vascular 48 6 0 33 15 enhancement Gallbladder/cholangio 18 0 0 13 5 Pulmonary/pleural 32 3 0 24 8 Musculoskeletal 13 1 0 9 4 Urogenital 65 2 0 48 17 Cardiac 15 0 0 7 8 Splenic 8 0 0 6 2 Pancreatic 3 1 0 2 1 Hernia 20 1 0 14 6 Other 41 2 0 29 12 A patient could have more than Total no. of findings 303 19 2 215 88 one finding pancreatitis, calcification), hernia (inguinalhernia, hiatal her- or chi-squared test, respectively. A P-value of less than nia), or other (enlarged lymph nodes, ascites, esophageal or 0.05 was considered significant. gastric mass). The definition of a fatty liver on non-con- trast-enhanced CT was mean CT Hounsfield units lower in the liver than in the spleen or on contrast-enhanced CT if Results the liver is less attenuating than muscle, since comparison with the spleen is not accurate on contrast-enhanced CT One hundred and two subjects were enrolled in the study scans [13]. Prostate enlargement was defined as a prostate (63 men, 39 women; age range: 20–91 years; mean age: 66 volume larger than 25 ml.
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