JAMA. 2004;291:1713-1719.
Computed Tomographic Colonography (Virtual Colonoscopy)
A Multicenter Comparison With Standard Colonoscopy
for Detection of Colorectal Neoplasia
Peter B. Cotton, MD, FRCP, FRCS; Valerie L.
Durkalski, PhD; Benoit C. Pineau, MD, MSc (Epid);
Yuko Y. Palesch, PhD; Patrick D. Mauldin, PhD;
Brenda Hoffman, MD; David J. Vining, MD; William
C. Small, MD; John Affronti, MD, MS; Douglas
Rex, MD; Kenyon K. Kopecky, MD; Susan Ackerman,
MD; J. Steven Burdick, MD; Cecelia Brewington,
MD; Mary A. Turner, MD; Alvin Zfass, MD; Andrew
R. Wright, MBBS; Revathy B. Iyer, MD; Patrick
Lynch, MD; Michael V. Sivak, MD; Harold Butler,
MD
Context Conventional colonoscopy is the
best available method for detection of colorectal
cancer; however, it is invasive and not without
risk. Computed tomographic colonography (CTC),
also known as virtual colonoscopy, has been
reported to be reasonably accurate in the diagnosis
of colorectal neoplasia in studies performed
at expert centers.
Objective To assess the accuracy of CTC
in a large number of participants across multiple
centers.
Design, Setting, and Participants A nonrandomized,
evaluator-blinded, noninferiority study design
of 615 participants aged 50 years or older who
were referred for routine, clinically indicated
colonoscopy in 9 major hospital centers between
April 17, 2000, and October 3, 2001. The CTC
was performed by using multislice scanners immediately
before standard colonoscopy; findings at colonoscopy
were reported before and after segmental unblinding
to the CTC results.
Main Outcome Measures The sensitivity
and specificity of CTC and conventional colonoscopy
in detecting participants with lesions sized
at least 6 mm. Secondary outcomes included detection
of all lesions, detection of advanced lesions,
possible technical confounders, participant
preferences, and evidence for increasing accuracy
with experience.
Results A total of 827 lesions were detected
in 308 of 600 participants who underwent both
procedures; 104 participants had lesions sized
at least 6 mm. The sensitivity of CTC for detecting
participants with 1 or more lesions sized at
least 6 mm was 39.0% (95% confidence interval
[CI], 29.6%-48.4%) and for lesions sized at
least 10 mm, it was 55.0% (95% CI, 39.9%-70.0%).
These results were significantly lower than
those for conventional colonoscopy, with sensitivities
of 99.0% (95% CI, 97.1%->99.9%) and 100%,
respectively. A total of 496 participants were
without any lesion sized at least 6 mm. The
specificity of CTC and conventional colonoscopy
for detecting participants without any lesion
sized at least 6 mm was 90.5% (95% CI, 87.9%-93.1%)
and 100%, respectively, and without lesions
sized at least 10 mm, 96.0% (95% CI, 94.3%-97.6%)
and 100%, respectively. Computed tomographic
colonography missed 2 of 8 cancers. The accuracy
of CTC varied considerably between centers and
did not improve as the study progressed. Participants
expressed no clear preference for either technique.
Conclusions Computed tomographic colonography
by these methods is not yet ready for widespread
clinical application. Techniques and training
need to be improved.
Author Affiliations: Department of Gastroenterology
(Drs Cotton and Hoffman) and Radiology (Dr Ackerman),
The Digestive Disease Center, and Department
of Pharmacy and Clinical Sciences (Dr Mauldin),
and The Clinical Innovation Group (Drs Durkalski
and Palesch), Medical University of South Carolina,
Charleston; Departments of Gastroenterology
(Dr Pineau) and Radiology (Dr Vining), Wake
Forest University School of Medicine, Winston-Salem,
NC; Departments of Radiology (Dr Small) and
Gastroenterology (Dr Affronti), Emory University
Hospital, Atlanta, Ga; Departments of Gastroenterology
(Dr Rex) and Radiology (Dr Kopecky), Indiana
University Hospital, Indianapolis; Departments
of Gastroenterology (Dr Burdick) and Radiology
(Dr Brewington), University of Texas Southwestern,
Dallas; Departments of Radiology (Dr Turner)
and Gastroenterology (Dr Zfass), Virginia Commonwealth
University Medical Center, Medical College of
Virginia, Richmond; Department of Radiology,
St Mary's Hospital, London, England (Dr Wright);
Departments of Radiology (Dr Iyer) and Gastroenterology
(Dr Lynch), M. D. Anderson Cancer Center, Houston,
Tex; Departments of Gastroenterology (Dr Sivak)
and Radiology (Dr Butler), University Hospitals
of Cleveland, Cleveland, Ohio.
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