Potentially Important Extracolonic Findings at Screening CT Colonography: Incidence and Outcomes Data From a Clinical Screening Program

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d2783210e116">Objective</h5> <p id="P1">The impact of detection of extracolonic findings at screening CT colonography (CTC) remains controversial. Our objective is to analyze the incidence and outcomes of unsuspected potentially significant (C-RADS extracolonic category E4) findings in a clinical CTC screening population. </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d2783210e121">Methods</h5> <p id="P2">Over 98 months (April 2004 – June 2012), 7,952 consecutive asymptomatic adults (mean age 56.7 ± 7.3 years, 3,675 men, 4,277 women) underwent first-time screening CTC. Examinations were prospectively interpreted by radiologists within our abdominal imaging section and extracolonic findings recorded and categorized. Potentially significant (ie, C-RADS extracolonic category E4) findings were retrospectively reviewed with additional analysis of follow-up and ultimate clinical outcome. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d2783210e126">Results</h5> <p id="P3">Overall, 2.5% (202/7952) of patients had a potentially significant (E4) extracolonic finding for which further imaging (55.9%, 113/202) or clinical follow-up (44.1%, 89/202) was recommended. No patients had multiple E4 findings. 22 patients were lost to follow-up. Of the remaining 180 patients, 68% (123/180) proved to have clinically significant disease, including 23% (42/180) with malignant or potentially malignant neoplasms and 32% (57/180) with abdominal aortic or other visceral artery aneurysms requiring treatment or surveillance. The most commonly involved organ systems included vascular (26.2%, 53/202), liver (14.9%, 30/202), genitourinary (13.9%, 28/202), gastrointestinal (9.9%, 20/202), lung (9.4%, 19/202), and gynecologic (6.9%, 14/202). </p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d2783210e131">Conclusions</h5> <p id="P4">Potentially significant extracolonic findings in asymptomatic adults at screening CTC are uncommon, seen in 2–3% of cases. However, the majority of these findings will prove to be clinically significant, including a number of malignancies and aneurysms requiring treatment or surveillance. </p> </div>

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Most cited references 20

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CT colonography versus colonoscopy for the detection of advanced neoplasia.

David H. K. Kim, Perry Pickhardt, Andrew J Taylor … (2007)

Advanced neoplasia represents the primary target for colorectal-cancer screening and prevention. We compared the diagnostic yield from parallel computed tomographic colonography (CTC) and optical colonoscopy (OC) screening programs. We compared primary CTC screening in 3120 consecutive adults (mean [+/-SD] age, 57.0+/-7.2 years) with primary OC screening in 3163 consecutive adults (mean age, 58.1+/-7.8 years). The main outcome measures included the detection of advanced neoplasia (advanced adenomas and carcinomas) and the total number of harvested polyps. Referral for polypectomy during OC was offered for all CTC-detected polyps of at least 6 mm in size. Patients with one or two small polyps (6 to 9 mm) also were offered the option of CTC surveillance. During primary OC, nearly all detected polyps were removed, regardless of size, according to established practice guidelines. During CTC and OC screening, 123 and 121 advanced neoplasms were found, including 14 and 4 invasive cancers, respectively. The referral rate for OC in the primary CTC screening group was 7.9% (246 of 3120 patients). Advanced neoplasia was confirmed in 100 of the 3120 patients in the CTC group (3.2%) and in 107 of the 3163 patients in the OC group (3.4%), not including 158 patients with 193 unresected CTC-detected polyps of 6 to 9 mm who were undergoing surveillance. The total numbers of polyps removed in the CTC and OC groups were 561 and 2434, respectively. There were seven colonic perforations in the OC group and none in the CTC group. Primary CTC and OC screening strategies resulted in similar detection rates for advanced neoplasia, although the numbers of polypectomies and complications were considerably smaller in the CTC group. These findings support the use of CTC as a primary screening test before therapeutic OC. Copyright 2007 Massachusetts Medical Society.

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CT colonography reporting and data system: a consensus proposal.

Alexander McFarland, N Glick, Michael Macari … (2005)

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Unsuspected extracolonic findings at screening CT colonography: clinical and economic impact.

Mary E Hanson, David J Vanness, Perry Pickhardt … (2008)

To evaluate the frequency and estimated costs of additional diagnostic workup for extracolonic findings detected at computed tomographic (CT) colonography in a large screening cohort. This retrospective HIPAA-compliant study, which had institutional review board approval, evaluated extracolonic findings in 2195 consecutive asymptomatic adults (1199 women, 996 men; age range, 40-90 years; mean age, 58.0 years +/- 8.1 [standard deviation]) undergoing low-dose CT colonographic screening performed without contrast material at a single institution over a 20-month period. All diagnostic workups generated because of extracolonic findings were reviewed. Associated costs were estimated by using 2006 Medicare average reimbursement. Testing for statistical significance was performed by using the chi(2) and t tests. Further diagnostic workup for unsuspected extracolonic findings was performed in 133 (6.1%) of 2195 patients, including 18 patients in whom additional workup was not recommended by the radiologist. Additional testing included ultrasonography (n = 64), CT (n = 59), magnetic resonance imaging (n = 11), other diagnostic imaging tests (n = 19), nonsurgical invasive procedures (n = 19), and surgical procedures (n = 22). Benign findings were confirmed in the majority of cases, but relevant new diagnoses were made in 55 (2.5%) patients, including extracolonic malignancies in nine patients. The mean cost per patient for nonsurgical procedures was $31.02 (95% confidence interval: $23.72, $38.94); that for surgical procedures was $67.54 (95% confidence interval: $38.62, $101.55). Detection of relevant unsuspected extracolonic disease at CT colonographic screening is not rare, accounting for a relatively large percentage of cases in which additional workup was recommended. Judicious handling of potential extracolonic findings is warranted to balance the cost of additional workup against the potential for early detection of important disease, because many findings will prove to be of no clinical consequence.