Falk Symposium 166 GI Endoscopy Standards and Innovations Mainz, 18. 19. September 2008 ENDOSCOPY IN COMPETITION DIAGNOSTICS Dr. med. Dirk Hartmann Klinikum Ludwigshafen
ENDOSCOPY IN COMPETITION Competing methods EUS versus CT ERCP versus MRCP Colonoscopy versus virtual Colonoscopy
EUS VERSUS CT Pancreatic Cancer - Survival Overall 5-year relative survival rate for 1996-2002: 5% Ries et al., SEER Cancer Statistics Review 1975-2003, National Cancer Institute 2006
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)
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 1997 88% 71% Legmann et al., Am J Roentgenol 1998 100% 93% Akahoshi et al., Brit J Radiol 1998 89% 94% Cannon et al., Gastrointest Endosc 1999 78% Rösch et al., Am J Gastroenterol 2000 86% Ahmad et al., Gastrointest Endosc 2000 69% Meining et al., GUT 2002 72% Soriano et al., Am J Gastroenterol 2004 63%
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
EUS VERSUS CT Pancreatic cancer Competing methods Sensitivity (%) of different imaging modalities: EUS CT MRI A Locoregional extension 44 66 53 - Lymph node involvement 36 37 15 - Vascular invasion 42 67 59 21 Distant metastases 0 55 30 42 Assessment of Tumor TNM-Stage (%) Accuracy Overstaging Understaging EUS 40 5 56 CT 46 8 46 MRI 36 7 57 Soriano et al., Am J Gastroenterol 2004
EUS VERSUS CT Pancreatic cancer Competing methods Assessment of Tumor Resectability (%) Sensitivity Specificity PPV NPV Accuracy EUS 23 100 100 64 67 CT 67 97 95 77 83 CT + EUS 71 97 82 94 87 CT + EUS: combined strategy, with CT and EUS performed in all patients Soriano et al., Am J Gastroenterol 2004
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 2003 76 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 2005 135 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
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
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
ERCP VERSUS MRCP MRCP Stones
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
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
ERCP VERSUS MRCP MRCP Primary sclerosing cholangitits (PSC)
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 1.80 1.67 0.33 First-order intrahepatic 1.95 1.56 0.01 Second-order intrahepatic 2.56 2.20 0.001 Third-order intrahepatic 2.96 2.54 0.0001 Gall bladder 1.16 2.56 0.0001 Berstad et al., Clin Gastroenterol Hepatol 2006
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 (%) 92,3 100 83,3 70,3 87,7 89,5 77,8 100 100 83,3 - - Specificity (%) 97,3 96,4 96,4 94,3 94,0 91,0 99,1 99,1 100 100 - - Adamek et al., Lancet 2000
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
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 20 23 Strictures 4 7 Papillary stenosis 4 7 Pancreatic stones 4 4 Sensitivity without secretin: 77% Sensitivity with secretin: 89% Hellerhoff et al, AJR 2002
ERCP VERSUS MRCP MRCP Pancreas divisum
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
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
ERCP VERSUS MRCP MRCP versus ERCP Low therapeutic probability MRCP ERCP High therapeutic probability
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 1993 2 Sieg et al., Dtsch Med Wochenschr 2006
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
COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY CT-Colonography
COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY CT-Colonography > 10 mm n Polypensens. (%) Patientenbezogene Sens. (%) Spez. (%) Johnson 703 34-73 46-69 95-98 Pickhardt 1233 92 94 96 Cotton 615 52 55 96 Rockey 614 53 59 96 6-9 mm n Polypensens. (%) Patientenbezogene Sens. (%) Spez. (%) Johnson 703 29-57 41-69 86-95 Pickhardt 1233 86 89 80 Cotton 615 23 39 90 Rockey 614 47 51 89
COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY CT-Colonography
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.
COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY MR-Colonography per polyp Sensitivity per patient sensitivity Autor n 6-9mm 10 mm 6-9mm 10 mm Luboldt 132 61 96 93 Pappalardo 70 96 100 96 Ajaj 122 16/18 11/11 - - Hartmann 1 100 84 100 84 100 comparable results to CT not enough data LUVIC 1 Hartmann et al, Radiology 2006
COLONOSCOPY VERSUS VIRTUAL COLONOSCOPY MR-Colonography LUVIC Ludwigshafen Virtual Colonoscopy study - National multicenter study - Screening population - Comparison of MR-colonography and colonoscopy - 1267 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
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 2 2 6-10 mm 6 7 >10mm 1 1 All 9 10 Hartmann et al, Endoscopy 2005
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 100 90 80 70 60 50 40 30 20 10 0 bowel cleansing colonoscopy MRC Hartmann et al, DMW 2006
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
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