CT虛擬結(jié)腸鏡課件

1、CT虛擬(xn)結(jié)腸鏡福建醫(yī)科大學(xué)附屬福建醫(yī)科大學(xué)附屬(fsh)協(xié)和醫(yī)院協(xié)和醫(yī)院 CT室室第一頁，共二十七頁。CT虛擬結(jié)腸鏡2前 言 在美國是腫瘤發(fā)病率中居第三位 2009年有近146970例新發(fā)病例(bngl) 占腫瘤死亡的第二位 2009年全美有49920例死亡 超過100萬的美國人患有結(jié)腸直腸癌第二頁，共二十七頁。CT虛擬結(jié)腸鏡3結(jié)腸(jichng)直腸癌 遺傳性非息肉(xru)性結(jié)腸直腸癌家族性多發(fā)性腺癌CENTERS FOR DISEASE CONTROLAND PREVENTION第三頁，共二十七頁。CT虛擬結(jié)腸鏡4危險度因子(ynz)- 息肉分類 異常增生 較小癌變可能 腺瘤樣

2、大約90%結(jié)腸直腸癌由腺瘤樣息肉(xru)發(fā)展而來第四頁，共二十七頁。CT虛擬結(jié)腸鏡5結(jié)腸(jichng)腺瘤進展小腺瘤 10mm 癌10 yrs 大多數(shù)是增生改變通常不會發(fā)展為癌癥第五頁，共二十七頁。CT虛擬結(jié)腸鏡6篩查的優(yōu)勢(yush) 預(yù)防癌癥 切除癌前病變（惡性息肉）防止癌癥發(fā)生 提高生存率早期檢測顯著增加長期(chngq)生存機會第六頁，共二十七頁。CT虛擬結(jié)腸鏡7篩查的優(yōu)勢(yush)第七頁，共二十七頁。CT虛擬結(jié)腸鏡8結(jié)腸(jichng)直腸癌篩查率 只有40%的結(jié)腸直腸癌在早期(zoq)階段發(fā)現(xiàn) 近一半多一點的超過50歲的美國人有進行近期的結(jié)腸直腸癌篩查。*varies bas

3、ed on data source第八頁，共二十七頁。CT虛擬結(jié)腸鏡9近年來光學(xué)(gungxu)直腸鏡檢查的普及率 (%)的趨勢, 大于50歲的美國人, 1997-2004*A flexible sigmoidoscopy or colonoscopy within the past five years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor

4、Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005. 第九頁，共二十七頁。CT虛擬結(jié)腸鏡10近年來糞便潛血試驗(shyn)的普及率 (%)的趨勢, 大于50歲

5、的美國人, 1997-2004*A fecal occult blood test within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004), N

6、ational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005. 第十頁，共二十七頁。CT虛擬結(jié)腸鏡11結(jié)腸(jichng)直腸癌篩查率低:原因 (依照患者的說法) 對結(jié)腸直腸癌不重視 缺乏對結(jié)腸直腸癌篩查好處(ho chu)的了解 害怕, 難為情, 不舒服 沒時間 費用高 “我醫(yī)生從來沒跟我提到過!”第十一頁，共二十七頁。CT虛擬結(jié)腸鏡12The

7、2008 CRC Guidelines Update was a Joint Effort of 5 Organizations American Cancer Society U. S. Multi-Society Task Force on Colorectal Cancer American Gastroenterological AssociationAmerican College of GastroenterologyAmerican Society of Gastrointestinal Endoscopists American College of Radiology第十二頁

8、，共二十七頁。CT虛擬結(jié)腸鏡13CRC Screening Guidelines: What Else is New? Two new tests recommended: stool DNA (sDNA) and computerized tomographic colonography (CTC) sometimes referred to as virtual colonoscopyThe guidelines: establish a sensitivity threshold for recommended testsdelineate important quality-relat

9、ed factors for each form of testing continue to emphasize options for testing An overriding goal of this update is to provide a practical guideline for physicians and the public第十三頁，共二十七頁。CT虛擬結(jié)腸鏡142008 CRC Screening GuidelinesAverage risk adults age 50 and olderTests that detect adenomatous polyps a

10、nd cancer Flexible sigmoidoscopy (FSIG) every 5 years*, or Colonoscopy every 10 years, or Double contrast barium enema (DCBE) every 5 years*, or CT colonography (CTC) every 5 years* Tests that primarily detect cancer Annual guaiac-based fecal occult blood test (gFOBT)* with high test sensitivity for

11、 cancer, or Annual fecal immunochemical test (FIT)* with high test sensitivity for cancer, or Stool DNA test (sDNA)*, with high sensitivity for cancer, interval uncertain *Note: All positive screening tests should be followed up with colonoscopy第十四頁，共二十七頁。CT虛擬結(jié)腸鏡15原 理第十五頁，共二十七頁。CT虛擬結(jié)腸鏡16CT虛擬(xn)結(jié)腸鏡

12、( CT Colonography，CTC)第十六頁，共二十七頁。CT虛擬結(jié)腸鏡17CT虛擬(xn)結(jié)腸鏡 ( CT Colonography，CTC)CTC 圖像(t xin)光學(xué)(gungxu)結(jié)腸鏡第十七頁，共二十七頁。CT虛擬結(jié)腸鏡18CT Colonography 3-D viewPolyp2-D viewCourtesy of Beth McFarland, MD第十八頁，共二十七頁。CT虛擬結(jié)腸鏡19CT Colonography: Rationale Allows detailed evaluation of the entire colon Minimally invasiv

13、e (rectal tube for air insufflation) No sedation required A number of studies have demonstrated a high level of sensitivity for cancer and large polyps第十九頁，共二十七頁。CT虛擬結(jié)腸鏡20CTC vs. Optical Colonoscopy: Sensitivities for All PolypsPolyp Size10mm8mm6mmCTC92.2%92.6%85.7%Colonoscopy88.2%89.5%90.0%Pickhard

14、t et al, NEJM 2003第二十頁，共二十七頁。CT虛擬結(jié)腸鏡21CTC: Additional Findings CTC identified 55 polyps not seen on initial colonoscopy 21 adenomas One 11 mm malignant polyp Extra-colonic findings 5 asymptomatic cancers Aortic aneurysms Renal and gall bladder calculiPickhardt et al, NEJM 2003第二十一頁，共二十七頁。CT虛擬結(jié)腸鏡22CT

15、C: Follow-up colonoscopyIndication for diagnostic/therapeutic colonoscopy varies markedly based on selected polyp size thresholdImportant implications for cost-effectiveness of CTCPolyp Size Threshold% Requiring colonoscopy10mm7.58mm13.56mm29.7Pickhardt et al, NEJM 2003第二十二頁，共二十七頁。CT虛擬結(jié)腸鏡23CT Colono

16、graphy: Additional Evidence A number of other studies have demonstrated a high level of sensitivity for cancer and large polyps Findings from the recently completed multi-center ACRIN trial reportedly are similar to those of Pickhardt et al Some results from this trial have been reported at medical

17、meetings, but have not yet been published Manuscript has been prepared and is currently under review第二十三頁，共二十七頁。CT虛擬結(jié)腸鏡24CT Colonography: Limitations Requires full bowel prep (which most patients find to be the most unpleasant aspect of colonoscopy)Colonoscopy is required if abnormalities detected,

18、sometimes necessitating a second bowel prepExtra-colonic findings can lead to additional testing (may have both positive and negative implications)Controversy regarding management of small polyps, sensitivity for “flat polyps”Radiation exposureSteep learning curve for radiologistsLimited availabilit

19、y to high quality exams in many parts of the countryMost insurers do not currently cover CTC as a screening modality 第二十四頁，共二十七頁。CT虛擬結(jié)腸鏡252008 CRC Guidelines continue to emphasize options because: Evidence does not yet support any single test as “best”Uncertainty exists about performance of differen

20、t screening methods with regard to benefits, harms, and costs (especially on programmatic basis) Uptake of screening remains disappointingly low Individuals differ in their preferences for one test or another Primary care physicians differ in their ability to offer, explain, or refer patients to all options equally Access is uneven geographically, and in terms of test charges and insurance coverage第二十五頁，共二十七頁。CT虛擬結(jié)腸鏡26If tests that can prevent CRC are preferred, why n