CTC Workflow: Reviewing & Reporting Exams

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CTC Workflow: Reviewing & Reporting Exams. Abraham H. Dachman The University of Chicago. Aims. Explain the workflow involved in interpreting and reporting CTC Environment for Interpretation Quality assurance Common strategies of interpretation Generating a CTC report. - PowerPoint PPT Presentation

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  • CTC Workflow:Reviewing & Reporting ExamsAbraham H. DachmanThe University of Chicago

  • AimsExplain the workflow involved in interpreting and reporting CTCEnvironment for Interpretation Quality assuranceCommon strategies of interpretationGenerating a CTC report

  • Mike Macaris Office

  • Screen Shots . . .

  • Workflow of CTC InterpretationConfirm segmentation and map out colon 3D transparency view or coronalsQuality assuranceDistention, stool, fluid, taggingSearch for polyps using both 3D and 2DCharacterize and measure polyp candidatesSecondary CAD-assisted evaluationReport (follow C-RADS guidelines)Search for extracolonic findings

  • SUPINEPRONE

  • Supine-Prone Registration

  • Q.A. CHECKLIST

    Location of segments tortuosity mobility when comparing supine to prone Identify ileocecal valve Quality of distention

  • Q.A. CHECKLIST Retained stool size tagging Retained fluid quantity location tagging change supine prone Artifacts (e.g., metal, breathing)QA by technologist includes review of axial images for distention

  • Always Identify IC ValveNot always intuitive . . .Identify by:LocationFatShapePapillary (dome-shaped)LabialMixed

  • Poor PreparationExcessive untagged feces

  • Quality Assurance: The Bottom Line Are any segments suboptimal on both views?

    Could a 10 mm polyp be obscured?

  • Methods of Interpretation3D with 2D problem solving2D with 3D problem solvingSoft tissue windows for flat lesionsBone windows for dense oral contrast tagged fluid and stoolVirtual Pathology (open views)Computer-aided diagnosis (CAD)

  • Methods of Interpretation3D with 2D problem solving2D with 3D problem solvingSoft tissue windows for flat lesionsBone windows for dense oral contrast tagged fluid and stoolVirtual Pathology (open views)Computer-aided diagnosis (CAD)

  • 6 mm Polyp on a FoldCoated with tagging agentBasic Feature of Polyps

  • pronesupine

  • Non-tagged Stool Mobile, With Internal GasPRONESUPINE

  • Well Tagged Stool

  • Lipoma on the ICV

  • Courtesy of J.L. Fidler, MDDedicated Read for Flat LesionsWide Soft Tissue Window in 2DEndoscopic view

  • Polyps vs. StoolSolid, soft tissueCompare to muscleUse wide soft tissue window setting - interactivelyDoes not moveCompare supine to prone Decubs as neededUse many clues to confidently compareNearby folds, ticsCurvature of colonLesion morphology, sizeMottled patternUse wide soft tissue window interactivelyEntire target is mottledNot a polyp covered by stool: no footprint along wall that is solidMovesTo dependant surfaceAxial and sagittal views bestIf solid; beware of colonic mobility

  • Approach to Polyp Candidate AnalysisPolyp vs. fold > use > 3D or MPRsPolyp vs. stool > use > texture (W/L or color map)If solid . . .Compare supine / prone for mobilityIf mobile, check for long stalk, colonic rotation / flip

  • Primary 3D Read StrategiesForward and backwardSupine and proneSpecial software features (e.g., color map for polyp characterization, show blind areas)Problem solve in 2D as needed as you readBookmark & defer difficult problem solving (e.g., difficult supine/prone comparison)

  • Primary 2D ReadLearn to Track the ColonHighly magnified axialGo slowly ! Look at all surfacesEvaluate very short segments as you move along an imaginary centerlineUse a lung window (1500/-600) setting or colon (2000/0)Non-magnified or magnified MPRSimultaneous or deferred endoluminal comparison

  • 6090120Antegrade6090120?Retrograde

  • Polyp Transverse ColonDifficult 2D

  • Flat Lesions: Use Wide Soft Tissue WindowSupineProne

  • *Computer Aided Detection:Integrated Visualization Display12333

  • 3D Over-measuring Pitfallfalling off the cliffUse largest dimension on either 2D or 3D to triage managementPer C-RADS 6 mm threshold for reporting polyps9 mm18.5 mm

  • Filet View with Comparisons

  • Band View

  • Fit to WidthFit to Height

  • Cube View

  • Structured CTC Reporting HistoryPrepInformed of exam limitationsTechniqueColon findingsExtracolonic findingsC-RADS scores / RecommendationsFootnote qualifier / reference C-RADS

  • C-RADS ClassificationC0 Inadequate study (can not evaluate 10 mm lesions)C1 Normal, routine follow up (Q 5 yrs CTC)C2 Indeterminate; 1-3 yr f/uPolyp 6-9 mm, < 3 in numberFindings indeterminate; cannot exclude polyps 6 mm C3 10 mm or >3 6-9mm polyps ColonoscopyC4 Mass, likely malignant; surgical consult*Zalis et al for the Working Group on VC. Radiology 2005;236:3-9.

  • Summary Both 2D and 3D skills are needed use it in every case Use a systematic approach that involves QA of images, recognition of anatomic landmarks and supine-prone comparison Recognize pitfalls and use CAD secondary read Report using C-RADS guidelines and recommendations

  • THANK YOU !AcknowledgmentsContributors to The Atlas of Virtual Colonoscopy Eds1 & 2Mike Macari, Philippe Lefere.

    ****IVC: Avoid pitfall later w/ flat masses. Prove you have a complete exam to caput cecum.**18.4A, B

    ****6 mm polyp on a fold. 14.6A-C

    *Non tagged stool w/ air bubbles. 18.1A, B

    *Tagged stool18.3A, B

    *Lipoma of the icv20.4A, B

    *******3 omgekeerd17 polyps all adenomas. No known genetic syndrome. Martino (same as case3set1vid1). Starts at ICV. Fly and cant see polyp. Turn around and see pedunculated polyp attached to ICV. Vital Images Vitrea software (not cad) you can click on polyp and get auto measurement.*Case set 1. Cardiac patient. Pill which patient took a few hours prior. On supine view its near ICV. On prone it move axially too. *Axial_hill. (larger is better file). Corresponds to case2set1video2. Easily missed on 2D. Looks just like thick ventral fold.3D file is case2set1vid2.avi PROBLEM PLAYING IN PPT

    *Case4set1vid1. 28 year old female from India with abdominal pain, bleeding, bloating. Obstructing mass on OC. CTC to get competition.Shows mass on 3D and 2D. I think extent more apparent on 2D. (Mike ddx included TB b/c of age + country of origin, but was known cancer.)********Informed or consented.Footnote e.g., digital rectal exam for anal canal.. Ref CRADS**