CT虚拟结肠镜.ppt

CT虚拟结肠镜 福建医科大学附属协和医院CT室 2 前言 在美国是肿瘤发病率中居第三位2009年有近146970例新发病例占肿瘤死亡的第二位2009年全美有49920例死亡超过100万的美国人患有结肠直肠癌 3 结肠直肠癌 散发 一般危险因素 65 85 家族史 10 30 遗传性非息肉性结肠直肠癌 HNPCC 5 家族性多发性腺癌 1 罕见综合征 0 1 4 危险度因子 息肉 分类异常增生较小癌变可能腺瘤样大约90 结肠直肠癌由腺瘤样息肉发展而来 5 结肠腺瘤进展 小腺瘤 5mm 异常增殖 进展性结肠腺瘤 10mm 癌 10yrs 大多数是增生改变通常不会发展为癌症 6 筛查的优势 预防癌症切除癌前病变 恶性息肉 防止癌症发生提高生存率早期检测显著增加长期生存机会 7 筛查的优势 8 结肠直肠癌筛查率 只有40 的结肠直肠癌在早期阶段发现近一半多一点的超过50岁的美国人有进行近期的结肠直肠癌筛查 variesbasedondatasource 9 近年来光学直肠镜检查的普及率 的趋势 大于50岁的美国人 1997 2004 Aflexiblesigmoidoscopyorcolonoscopywithinthepastfiveyears Note DatafromparticipatingstatesandtheDistrictofColumbiawereaggregatedtorepresenttheUnitedStates Source BehavioralRiskFactorSurveillanceSystemCD ROM 1996 1997 1999 andPublicUseDataTape 2001 2002 2004 NationalCenterforChronicDiseasePreventionandHealthPromotion CentersforDiseaseControlandPreventionandPrevention 1999 2000 2002 2003 2005 10 近年来粪便潜血试验的普及率 的趋势 大于50岁的美国人 1997 2004 Afecaloccultbloodtestwithinthepastyear Note DatafromparticipatingstatesandtheDistrictofColumbiawereaggregatedtorepresenttheUnitedStates Source BehavioralRiskFactorSurveillanceSystemCD ROM 1996 1997 1999 andPublicUseDataTape 2001 2002 2004 NationalCenterforChronicDiseasePreventionandHealthPromotion CentersforDiseaseControlandPreventionandPrevention 1999 2000 2002 2003 2005 11 结肠直肠癌筛查率低 原因 依照患者的说法 对结肠直肠癌不重视缺乏对结肠直肠癌筛查好处的了解害怕 难为情 不舒服没时间费用高 我医生从来没跟我提到过 12 The2008CRCGuidelinesUpdatewasaJointEffortof5Organizations AmericanCancerSocietyU S Multi SocietyTaskForceonColorectalCancerAmericanGastroenterologicalAssociationAmericanCollegeofGastroenterologyAmericanSocietyofGastrointestinalEndoscopistsAmericanCollegeofRadiology 13 CRCScreeningGuidelines WhatElseisNew Twonewtestsrecommended stoolDNA sDNA andcomputerizedtomographiccolonography CTC sometimesreferredtoasvirtualcolonoscopyTheguidelines establishasensitivitythresholdforrecommendedtestsdelineateimportantquality relatedfactorsforeachformoftestingcontinuetoemphasizeoptionsfortestingAnoverridinggoalofthisupdateistoprovideapracticalguidelineforphysiciansandthepublic 14 2008CRCScreeningGuidelines Averageriskadultsage50andolderTeststhatdetectadenomatouspolypsandcancerFlexiblesigmoidoscopy FSIG every5years orColonoscopyevery10years orDoublecontrastbariumenema DCBE every5years orCTcolonography CTC every5years TeststhatprimarilydetectcancerAnnualguaiac basedfecaloccultbloodtest gFOBT withhightestsensitivityforcancer orAnnualfecalimmunochemicaltest FIT withhightestsensitivityforcancer orStoolDNAtest sDNA withhighsensitivityforcancer intervaluncertain Note Allpositivescreeningtestsshouldbefollowedupwithcolonoscopy 15 原理 16 CT虚拟结肠镜 CTColonography CTC 17 CT虚拟结肠镜 CTColonography CTC CTC图像 光学结肠镜 18 CTColonography 3 Dview Polyp 2 Dview CourtesyofBethMcFarland MD 19 CTColonography Rationale AllowsdetailedevaluationoftheentirecolonMinimallyinvasive rectaltubeforairinsufflation NosedationrequiredAnumberofstudieshavedemonstratedahighlevelofsensitivityforcancerandlargepolyps 20 CTCvs OpticalColonoscopy SensitivitiesforAllPolyps PolypSize 10mm 8mm 6mmCTC92 2 92 6 85 7 Colonoscopy88 2 89 5 90 0 Pickhardtetal NEJM2003 21 CTC AdditionalFindings CTCidentified55polypsnotseenoninitialcolonoscopy21adenomasOne11mmmalignantpolypExtra colonicfindings5asymptomaticcancersAorticaneurysmsRenalandgallbladdercalculi Pickhardtetal NEJM2003 22 CTC Follow upcolonoscopy Indicationfordiagnostic therapeuticcolonoscopyvariesmarkedlybasedonselectedpolypsizethresholdImportantimplicationsforcost effectivenessofCTC Pickhardtetal NEJM2003 23 CTColonography AdditionalEvidence AnumberofotherstudieshavedemonstratedahighlevelofsensitivityforcancerandlargepolypsFindingsfromtherecentlycompletedmulti centerACRINtrialreportedlyaresimilartothoseofPickhardtetalSomeresultsfromthistrialhavebeenreportedatmedicalmeetings buthavenotyetbeenpublishedManuscripthasbeenpreparedandiscurrentlyunderreview 24 CTColonography Limitations Requiresfullbowelprep whichmostpatientsfindtobethemostunpleasantaspectofcolonoscopy Colonoscopyisrequiredifabnormalitiesdetected sometimesnecessitatingasecondbowelprepExtra colonicfindingscanleadtoadditionaltesting mayhavebothpositiveandnegativeimplications Controversyregardingmanagementofsmallpolyps sensitivityfor flatpolyps RadiationexposureSteeplearningcurveforradiologistsLimitedavailabilitytohighqualityexamsinmanypartsofthecountryMostinsurersdonotcurrentlycoverCTCasascreeningmodality 25 2008CRCGuidelinescontinuetoemphasizeoptionsbecause Evidencedoesnotyetsupportanysingletestas best Uncertaintyexistsaboutperformanceofdifferentscreeningmethodswithregardtobenefits harms andcosts especiallyonprogrammaticbasis UptakeofscreeningremainsdisappointinglylowIndividualsdifferintheirpreferencesforonetestoranotherPrimarycarephysiciansdifferintheirabilitytooffer explain orreferpatientstoalloptionsequallyAccessisunevengeographically andintermsoftestchargesandinsurancecoverage 26 IfteststhatcanpreventCRCarepreferred whynotrecommendthemalone GreaterpatientrequirementsforsuccessfulcompletionEndoscopicandradiologicexamsrequireabowelprepandanofficeorfacilityvisitHigherpotentialforpatientinjurythanfec