ENDOSCOPY IN COMPETITION DIAGNOSTICS. Dr. med. Dirk Hartmann Klinikum Ludwigshafen

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1 Falk Symposium 166 GI Endoscopy Standards and Innovations Mainz, September 2008 ENDOSCOPY IN COMPETITION DIAGNOSTICS Dr. med. Dirk Hartmann Klinikum Ludwigshafen

2 ENDOSCOPY IN COMPETITION Competing methods EUS versus CT ERCP versus MRCP Colonoscopy versus virtual Colonoscopy

3 EUS VERSUS CT Pancreatic Cancer - Survival Overall 5-year relative survival rate for : 5% Ries et al., SEER Cancer Statistics Review , National Cancer Institute 2006

4 EUS VERSUS CT Endoscopic Ultrasound Frequency: 5-20 MHz (scopes) up to 30 MHz (probes) Minimal detection size: 2-3 mm Tissue sampling: FNA (fine needle aspiration) TNB (trucut needle biopsy)

5 EUS VERSUS CT Pancreatic Cancer - EUS Sensitivity and diagnostic accuracy of EUS in the detection of pancreatic cancer sensitivity accuracy Dufour et al., Gastroenterol Clin Biol % 71% Legmann et al., Am J Roentgenol % 93% Akahoshi et al., Brit J Radiol % 94% Cannon et al., Gastrointest Endosc % Rösch et al., Am J Gastroenterol % Ahmad et al., Gastrointest Endosc % Meining et al., GUT % Soriano et al., Am J Gastroenterol %

6 EUS VERSUS CT Pancreatic Cancer EUS-FNA Prospective evaluation of endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer (n=158) Results: Sensitivity = 84% Specificity = 97% PPV = 99% NPV = 64% Accuracy = 84% Problem: Low NPV if FNA is negative, a carcinoma can not be excluded with positive or negative FNA next step will be operation Eloubeidi et al., Am J Gastroenterol 2003

7 EUS VERSUS CT Pancreatic cancer Competing methods Sensitivity (%) of different imaging modalities: EUS CT MRI A Locoregional extension Lymph node involvement Vascular invasion Distant metastases Assessment of Tumor TNM-Stage (%) Accuracy Overstaging Understaging EUS CT MRI Soriano et al., Am J Gastroenterol 2004

8 EUS VERSUS CT Pancreatic cancer Competing methods Assessment of Tumor Resectability (%) Sensitivity Specificity PPV NPV Accuracy EUS CT CT + EUS CT + EUS: combined strategy, with CT and EUS performed in all patients Soriano et al., Am J Gastroenterol 2004

9 EUS VERSUS CT Pancreatic cancer EUS Follow-up of patients with clinically indeterminate suspicion of pancreatic cancer and normal EUS Catanzaro et al., Gastrointest Endoscopy patients with a mean follow-up period of 23.9 months No patients developed pancreatic cancer during the follow-up period Klapman et al., Am J Gastroenterol patients with a mean follow-up period of 25 months No patients developed pancreatic cancer during the follow-up period A normal EUS has a high NPV

10 EUS VERSUS CT Pancreatic cancer EUS versus CT EUS +/- FNA has a high sensitivity, even for small cancers CT has the highest accuracy in assessing extent of primary tumor, tumor TNM stage and tumor resectability Normal EUS examination excludes a pancreatic cancer with a high probability Combination of CT and EUS proved to be the method with highest accuracy in the evaluation of tumor resectability

11 ERCP VERSUS MRCP Biliary obstruction - stone -tumor - stricture MRCP Indications Diseases of the pancreatic and bile duct - primary sclerosing cholangitis - chronic pancreatitis - intraductal papillary mucinous tumor Anomalies and anatomic variants -cysts - pancreas divisum - after hepato-biliary surgery

12 ERCP VERSUS MRCP MRCP Stones

13 ERCP VERSUS MRCP MRCP Bile duct Prospective comparison of MRCP and ERCP in patients with suspected bile duct obstruction (n=60) all findings malignant findings Sensitivity (%) 89 /42/47) 81(22/27) Specificity (%) 92 (12/13) 100 (33/33) PPV (%) 98 (42/43) 100 (22/22) Adamek et al., Gut 1998

14 ERCP VERSUS MRCP MRCP Bile duct Meta-analysis of test performance in suspected biliary disease (n=4711) sensitivity (%) specificity (%) presence of obstruction 97 (91-99) 98 (91-99) level of obstruction 98 (94-99) 98 (94-100) stone detection 92 (80-97) 97 (90-95) malignancy detection 88 (70-96) 95 (82-95) overall 95 (75-99) 97 (86-99) Romagnuolo et al., Ann Intern Med 2003

15 ERCP VERSUS MRCP MRCP Primary sclerosing cholangitits (PSC)

16 ERCP VERSUS MRCP MRCP PSC Comparison of MRC and ERC in patients with primary sclerosing cholangitis Categories of visualization: 1=excellent to 4=nondepiction N = 66 MRC ERC p Extrahepatic First-order intrahepatic Second-order intrahepatic Third-order intrahepatic Gall bladder Berstad et al., Clin Gastroenterol Hepatol 2006

17 ERCP VERSUS MRCP MRCP Pancreas Comparison of MRCP and ERCP in the detection of pancreatic tumors (n=124) Final diagnosis N Correct diagnosis (n) No findings 13 MRCP (12) ERCP (13) Pancreatic cancer 37 MRCP (31) ERCP (26) Chronic pancreatitis 57 MRCP (50) ERCP (51) Ampullary tumor 9 MRCP (7) ERCP (9) Cystic neopalsm 6 MRCP (6) ERCP (5) Neuroendocrine tumor 2 MRCP (1) ERCP (0) Sensitivity (%) 92, ,3 70,3 87,7 89,5 77, ,3 - - Specificity (%) 97,3 96,4 96,4 94,3 94,0 91,0 99,1 99, Adamek et al., Lancet 2000

18 ERCP VERSUS MRCP MRCP Secretin Grade 0: no fluid in the duodenum Grade 1: fluid limited to the duodenal bulb Grade 2: fluid filling up to the Genu inferius Grade 3: duodenal filling beyound the Genu inferius 1 clinical unit/kg; 0,1 ml / kg KG secretin Matos et al., Radiology 1997

19 ERCP VERSUS MRCP MRCP Secretin Improvement of diagnostic accuracy of secretinenhanced MRCP compared with conventional MRCP (n = 95) Diagnosis without secretin with secretin Pancreas divisum 8 13 Chronic pancreatitis Strictures 4 7 Papillary stenosis 4 7 Pancreatic stones 4 4 Sensitivity without secretin: 77% Sensitivity with secretin: 89% Hellerhoff et al, AJR 2002

20 ERCP VERSUS MRCP MRCP Pancreas divisum

21 ERCP VERSUS MRCP Algorithm for triage to MRCP Suspected pancreatico-biliary disease Low therapeutic group: MRCP 1. Gallstones, no biliary dilatation and abnormal LFTs 2. Cholecystectomy, recurrent abdominal pain, normal LFTs 3. Abdominal pain, biliary dilatation, no gallstones and normal LFTs 4. No pain, normal biliarytree, no gallstones and abnormal LFTs High therapeutic group: ERCP 1. Gallstones; biliary dilatation and abnormal LFTs 2. Cholecystectomy, recurrent pain and abnormal LFTs 3. Jaundice and biliary dilatation 4. Postcholecystectomy leak 5. Gallstone pancreatitis 5. Recurrent pancreatitis 6. Non gallstone pancreatitis Parnaby et al, Surg Endosc 2008

22 ERCP VERSUS MRCP Algorithm for triage to MRCP Low therapeutic group: MRCP n=52 High therapeutic group: ERCP n=51 ERCP n=8 No ERCP n=44 Therapeutic ERCP n=47 Therapeutic ERCP n=3 Diagnostic ERCP n=4 Parnaby et al, Surg Endosc 2008

23 ERCP VERSUS MRCP MRCP versus ERCP Low therapeutic probability MRCP ERCP High therapeutic probability

24 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY 76% -90% reduction of carcinoma incidence by polypectomy 1 In October 2002 screening colonoscopy was introduced into the National Cancer Prevention Program in Germany Until 2006 ~ 2,2 millions of screening colonoscopies ~ 8-10% of the claimants/eligable persons p.a. Acceptance of screening too low no findings 71,3% hyperplastic polyps 9,0% tubulare adenomas 16,2% villous adenomas 3,8% carinomas 0,7% UICC I 48% UICC II 22% UICC III 20% UICC IV 10% Results 2 1 National Polyp Study; Winawer et al., N Engl J Med Sieg et al., Dtsch Med Wochenschr 2006

25 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY Possible reasons for the low acceptance of screening Lack of prevention consciousness? Fear of consequence? Stigma of painful examination? Invasive examination? } Education Additional screening offers smart methods Increasing acceptance of screening? - Virtual Colonoscopy - Colon Capsule - New smart systems for colonoscopy -Aer-o-scope -NeoGuide -ColonoSight -Invendo system

26 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY CT-Colonography

27 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY CT-Colonography > 10 mm n Polypensens. (%) Patientenbezogene Sens. (%) Spez. (%) Johnson Pickhardt Cotton Rockey mm n Polypensens. (%) Patientenbezogene Sens. (%) Spez. (%) Johnson Pickhardt Cotton Rockey

28 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY CT-Colonography

29 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY CT-Colonography Excerpt of the results from the BFS (Bundesamt für Strahlenschutz) expert meeting on May 23rd 2005 on the Multislice- CT- Scan as screening method Valuation of CT- Colonoscopy A screening- program is not recommended. Colonoscopy is the screening method of choice for early diagnosis of colon cancer and preliminary stages. CT-Colonography is not justified as primary examination of individual early diagnosis. CT-Colonography maybe justified in patients with incomplete colonoscopy.

30 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY MR-Colonography per polyp Sensitivity per patient sensitivity Autor n 6-9mm 10 mm 6-9mm 10 mm Luboldt Pappalardo Ajaj /18 11/ Hartmann comparable results to CT not enough data LUVIC 1 Hartmann et al, Radiology 2006

31 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY MR-Colonography LUVIC Ludwigshafen Virtual Colonoscopy study - National multicenter study - Screening population - Comparison of MR-colonography and colonoscopy patients - Centers Klinikum Ludwigshafen (study coordination), Uni-Klinik Regensburg, Robert-Bosch-KH Stuttgart, Uni-Klinik Ulm, Charite Berlin, St. Josefs-KH Dortmund, Uni-Klinik Mannheim

32 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY MR-colonography incomplete colonoscopy 32 patients with incomplete colonoscopy 26 Patienten with high-grade stenosis 6 Patienten mit incomplete colonoscopy for other reasons Surgery (n=19) MRC: 9 polyps in proximal colonic segments in 14 patients colonoscopy after surgery (n=14) MRC postop. colonosc 1-5 mm mm 6 7 >10mm 1 1 All 9 10 Hartmann et al, Endoscopy 2005

33 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY MR-Colonography - acceptance MR-colonography bowel cleansing 1 10 comfort / discomfort scale from 1 bis 10 (1 = pleasant; 10 = unpleasant) colonoscopy Question: Which part do you feel most discomfort? n=100 percent bowel cleansing colonoscopy MRC Hartmann et al, DMW 2006

34 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY Virtual colonoscopy tandem concept virtual colonoscopy colonoscopy Same day virtual colonoscopy in patients with incomplete conventional colonoscopy Same day conventional colonoscopy in patients with positive findings

35 COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY Virtual colonoscopy future perspectives Virtual colonoscopy The end of conventional screening colonoscopy? Not competing methods, but additional offers? Vision: Increasing acceptance of colorectal cancer screening