lesions particular for smaller polyp sizes 10 mm The report also found colonoscopy to be. more cost effective than CTC and flexible sigmoidoscopy for the screening of middle aged. people at high or average risk of colorectal cancer Similar results were found in a CADTH. systematic review comparing the clinical and cost effectiveness of CTC and colonoscopy for. colorectal cancer screening 6 Although there have been reports published on the comparative. effectiveness of these techniques for colorectal cancer screening there has been less. information on the use of these techniques for the diagnosis and treatment of colorectal cancer. with regards to clinical and cost effectiveness and patient appropriateness. The purpose of this review is to assess the clinical effectiveness and cost effectiveness of CTC. compared to colonoscopy and sigmoidoscopy for the diagnosis and treatment of colorectal. cancer as well as guidelines for the use of CTC,RESEARCH QUESTIONS. 1 What is the clinical effectiveness of CT colonography virtual colonoscopy compared to. colonoscopy and or sigmoidoscopy for the diagnosis and treatment of colorectal cancer. 2 What is the cost effectiveness of CT colonography virtual colonoscopy compared to. colonoscopy and or sigmoidoscopy for the diagnosis and treatment of colorectal cancer. 3 What are the guidelines regarding the use of CT colonography for the diagnosis and. treatment of colorectal cancer,KEY FINDINGS, In observational trials CT colonography was found to be as effective as colonoscopy for the. diagnosis of colorectal cancer CT colonography performed better than colonoscopy for the pre. operative evaluation of colorectal tumours due to incomplete colonoscopies in patients with. obstructive masses Clinical practice guidelines recommended that CT colonography may be. beneficial in specific sub groups of patients No evidence was identified regarding the cost. effectiveness of CT colonography or how it compares to sigmoidoscopy. Literature Search Strategy, A limited literature search was conducted on key resources including PubMed The Cochrane. Library 2012 Issue 10 University of York Centre for Reviews and Dissemination CRD. databases ECRI Health Devices Gold Canadian and major international health technology. agencies as well as a focused Internet search No filters were applied to limit the retrieval by. study type for research questions 1 and 2 A guideline filter was used for research question 3. The search was also limited to English language documents published between Jan 1 2007. and Nov 23 2012,Selection Criteria and Methods, One reviewer screened the titles and abstracts of the retrieved publications ad evaluated the. full text publications for the final article selection according to selection criteria resented in. Clinical and Cost Effectiveness of CT Colonography 2. Table 1 Selection Criteria, Population Adult patients who are diagnosed with colorectal cancer. Adult patients undergoing treatment for colorectal cancer. not a screening question, Intervention Computed tomographic colonography Virtual Colonoscopy. Comparators Colonoscopy Sigmoidoscopy flexible rigid. Outcomes Clinical Effectiveness diagnosis and treatment Safety and Harms. Cost Effectiveness Guidelines and Recommendations, Study Designs Health technology assessments systematic reviews meta analyses. randomized controlled trials RCTs non randomized studies. evidence based guidelines and economic evaluations. Exclusion Criteria, Studies were excluded if they did not meet the selection criteria were duplicate publications or. included in a selected systematic review or were published prior to 2007. Critical Appraisal of Individual Studies, The quality of included systematic reviews was assessed using the Assessment of Multiple. Systematic Reviews AMSTAR tool 7 Diagnostic accuracy studies were assessed using the. revised version of the Quality Assessment of Diagnostic Accuracy Studies QUADAS 2 8. Guidelines were assessed for quality using the Appraisal of Guidelines for Research and. Evaluation AGREE instrument 9 A numeric score was not calculated for each study Instead. strengths and limitations of each study were summarized and described. SUMMARY OF EVIDENCE,Quantity of Research Available. The literature search yielded 500 citations Upon screening titles and abstracts 469 citations. were excluded and 31 potentially relevant articles were retrieved for full text review An. additional six potentially relevant reports were identified through grey literature searching Of the. 37 potentially relevant reports 25 did not meet the inclusion criteria Twelve reports were. included in this review The study selection process is outlined in a PRISMA flowchart. Appendix 1 Two systematic reviews six non randomized studies and four evidence based. guidelines met the inclusion criteria No economic evaluations were identified. Summary of Study Characteristics, Details on study characteristics can be found in Appendix 2. Study design and country of origin, Two systematic reviews and meta analyses 10 11 four prospective studies 12 15 two retrospective. studies 16 17 and four guidelines18 21 were included In the systematic reviews both RCTs and. non randomized studies were considered in the inclusion criteria 10 11. Clinical and Cost Effectiveness of CT Colonography 3. Non randomized studies were retrieved in one systematic review10 and the other did not specify. the type of studies retrieved 11, Two systematic reviews 10 11 one prospective study 12 and one retrospective study16 considered. the use of CTC for the diagnosis of colorectal cancer Three prospective studies13 15 and one. retrospective study17 considered the use of CTC to guide treatment for colorectal cancer. One systematic review10 and one guideline21 were from The Netherlands One systematic. review 11 and two guidelines18 20 were from the USA One prospective study14 and one. retrospective study16 were from Italy One prospective study each was from Bosnia and. Hercegovina 12 Poland 13 and Turkey 15 One retrospective study was from South Korea 17 One. guideline was from the UK 19,Patient characteristics. One systematic review10 included asymptomatic subjects at average risk for colorectal cancer. while the other systematic review11 included both asymptomatic and symptomatic subjects Both. systematic reviews examined the use of CTC for the diagnosis of colorectal cancer in. subjects 10 11, Of the non randomized studies that examined CTC for the diagnosis of colorectal cancer a. prospective study12 included patients with suspected symptoms of colorectal cancer while a. retrospective study16 included patients that had a 6 mm colorectal lesion as determined by. Of the studies that examined CTC for the guidance of surgical treatment of colorectal cancer. two prospective studies13 14 included patients with colorectal tumours identified at colonoscopy. while one prospective study15 and one retrospective study17 included patients who were. scheduled to undergo laparoscopy assisted colectomy for colorectal cancer. Intervention and comparators, All studies included a comparison between CTC and colonoscopy for diagnosis10 12 16 or. treatment13 15 17 of colorectal cancer In the studies that used CTC for the diagnosis of colorectal. cancer complete colonoscopy was used as a reference standard and conducted after CTC 10. In one systematic review11 and one prospective study 12 histology of samples taken during. colonoscopy was used to confirm cancer diagnosis In the studies that used CTC to guide. treatment of colorectal cancer CTC was performed after complete or incomplete. colonoscopy 13 15 17 Standard cathartic bowel preparations involving the ingestion of an. electrolyte solution were used in all but one retrospective study17 where the method of bowel. preparation was not described One retrospective study16 also used fecal tagging with an. iodinated contrast agent in the CTC protocol,Outcomes measured. CTC images were interpreted by two radiologists in two studies 14 16 by one radiologist in one. study 13 and was not specified in the remaining studies. One systematic review and meta analysis evaluated the ability of CTC to detect adenomas. advanced adenomas and colorectal cancer by calculating per patient and per polyp sensitivities. Clinical and Cost Effectiveness of CT Colonography 4. and specificities using colonoscopy as a reference standard 10 The other systematic review and. meta analysis reported the sensitivity of CTC and colonoscopy for detecting colorectal lesions. using histological analysis of biopsied samples as a reference standard 11. One prospective study reported the ability of CTC and colonoscopy to detect colorectal cancers. by calculating sensitivity specificity positive predictive value PPV and negative predictive. value NPV using biopsies taken during colonoscopy to confirm histology 12 One retrospective. study reported the PPV of CTC for the detection of colorectal neoplasia using colonoscopy as a. reference standard 16, All of the studies evaluating the use of CTC in guiding treatment for colorectal cancer reported. on the ability of CTC and colonoscopy to localize colorectal lesions for the pre operative. evaluation of patients with colorectal cancers 13 15 17 One prospective study also reported the. ability of CTC and colonoscopy to evaluate tumour size and volume 13. Summary of Critical Appraisal, Details on critical appraisal can be found in Appendix 3. Both systematic reviews were based on clearly pre defined criteria and included a detailed. summary of study characteristics of included studies with appropriate assessment of the. scientific quality 10 11 One systematic review only searched one electronic source in detail 11. Although the review stated that this was due to a failure to detect additional references using. other electronic sources based on a preliminary search this may have resulted in missed. studies 11 In both systematic reviews it was unclear whether grey literature was included in the. search strategy 10 11, In the diagnostic accuracy studies included patients were generally appropriate for the. objectives of the studies though the studies may have been biased due to patient selection In a. retrospective study only patients that had a 6 mm lesion identified by CTC was referred for. colonoscopy 16 In the studies that used CTC for pre surgical evaluation of colorectal cancer. many of the patients underwent CTC after incomplete colonoscopy 13 15 17 CTC scans were read. and consensus reached by two radiologists in two studies which would decrease the risk of. error due to reader interpretation 14 16, Colonoscopy was used as a reference standard in one retrospective study 16 In the remaining. diagnostic accuracy studies histology or surgical verification was used as a reference. standard 12 15 17 In one retrospective study where colonoscopy was performed after CTC the. endoscopist was blinded to the CTC results 16 In a prospective study it was unclear whether the. endoscopist was blinded to the CTC results 12 In one prospective study evaluating the use of. CTC for pre surgical evaluation of colorectal cancer the radiologist who interpreted the CTC. images were blinded to the colonoscopy results 13 In the remaining studies that used CTC for. pre surgical evaluation of colorectal cancer it was unclear whether radiologists were blinded to. the results of the colonoscopy 14 15 17 The lack of blinding may introduce bias during the. assessment of CTC images or colonoscopy analysis, All of the included guidelines had a clear objective scope and target population and were. developed by appropriate professional groups 18 21 All recommendations were derived from. supporting evidence and this evidence was directly referenced in one guideline 19 The same. guideline provided a grade for the included recommendations 19 Potential barriers of applying. Clinical and Cost Effectiveness of CT Colonography 5. the recommendations were considered in one guideline 21 Cost implications of applying the. recommendations were not considered or reported in all guidelines. Summary of Findings, Details on findings can be found in Appendices 4 and 5. What is the clinical effectiveness of CT colonography virtual colonoscopy compared to. colonoscopy and or sigmoidoscopy for the diagnosis and treatment of colorectal cancer. Diagnosis of colorectal cancer, Two systematic reviews and meta analyses examined the use of CTC and colonoscopy for the. diagnosis of colorectal cancer 10 11 In one meta analysis CTC was found to have good. sensitivity for advanced adenomas 10 mm in size but lower sensitivity for advanced. adenomas 6 mm in size when using colonoscopy as a reference standard 10 In this study. sensitivity and specificity values were not calculated for the detection of advanced neoplasia. and colorectal cancer due to the small number of cancers detected in the included studies 10. However no colorectal cancers were missed in all included studies 10 In the other meta. analysis the pooled per patient sensitivity for the detection of colorectal cancer was found to be. equivalent with CTC and colonoscopy despite a wide range of CTC techniques used in the. included studies 11 In total 16 cancers were missed using CTC but no cancers were missed. when both cathartic bowel preparation and fecal tagging were used 11. One prospective study examined the ability of CTC to detect colorectal cancer compared with. colonoscopy 12 This study found that CTC and colonoscopy were equally sensitive in the. detection of colorectal tumours having identical sensitivity specificity and positive predictive. values 12 One retrospective study calculated the positive predictive value of CTC for detecting. colorectal neoplasia using colonoscopy as a reference standard in patients with a 6 mm lesion. detected by CTC 16 This study found that CTC was characterized by a very low rate of false. positive results for lesions 6 mm and that all cases of advanced neoplasia were found in. patients with a 10 mm lesion 16,Treatment of colorectal cancer. All studies that used CTC for pre operative staging of colorectal cancer found that CTC was. able to accurately localize colorectal tumours and was superior to colonoscopy due to the ability. to visualize the entire colon in patients who were unable to complete colonoscopy 13 15 17 In one. prospective study 51 1 of included patients were unable to complete colonoscopy due to. obstructive or occlusive masses compared to 10 2 who were unable to complete CTC 13 One. prospective study found that CTC had better performance in the defining the segmental location. of the colon cancer than colonoscopy 14 Another prospective study found that the accuracy rate. of colorectal tumour localization was statistically significantly higher using CTC than with. colonoscopy 15 One retrospective study found that the sensitivity of CTC for detecting colorectal. tumours and the accuracy for tumour localization was high 17. What is the cost effectiveness of CT colonography virtual colonoscopy compared to. colonoscopy and or sigmoidoscopy for the diagnosis and treatment of colorectal cancer. Clinical and Cost Effectiveness of CT Colonography 6. No evidence on the cost effectiveness of CT colonography virtual colonoscopy compared to. colonoscopy and or sigmoidoscopy for the diagnosis and treatment of colorectal cancer was. identified, What are the guidelines regarding the use of CT colonography for the diagnosis and treatment. of colorectal cancer, Four evidence based guidelines provided recommendations on the use of CT colonography for. the diagnosis of colorectal cancer particularly with regards to when this technology is. appropriate and when it is contraindicated 18 21, Both the American Gastroenterological Association AGA 2011 and the American College of. Radiology ACR 2009 provided recommendations on the indications and contraindication of. patients undergoing CTC 18 20,According to both guidelines CTC is indicated for. Patients who failed to complete colonoscopy in whom evaluation of the colon is deemed. necessary including but not limited to those with abdominal pain diarrhea constipation. gastrointestinal bleeding anemia intestinal obstruction weight loss. Patients at increased risk for complications during optical colonoscopy advanced age. anticoagulant therapy sedation risk prior incomplete colonoscopy. The evaluation of the colon proximal to an obstructing lesion. Patients with colorectal lesions indeterminate on optical colonoscopy18 20. According to both guidelines CTC is contraindicated for. Patients with symptomatic acute colitis acute diarrhea recent acute diverticulitis recent. colorectal surgery symptomatic colon containing abdominal wall hernia recent deep. endoscopic biopsy or polypectomy mucosectomy known or suspected colonic. perforation symptomatic or high grade small bowel obstruction. Routine follow up of inflammatory bowel disease hereditary polyposis or nonpolyposis. cancer syndromes evaluation of anal canal disease the pregnant or potentially. pregnant patient18 20, The Scottish Intercollegiate Guidelines Network SIGN 2011 recommends that CTC can be. used as a sensitive and safe alternative to colonoscopy 19 For frail elderly patients CT. colonography with minimal bowel preparation can be used 19. The National Working Group on Gastrointestinal Cancers 2008 states that CTC can be. indicated as a diagnostic or adjuvant diagnostic test for patients with incomplete colonoscopy. without diagnosis when colonoscopy is not possible or when precise tumour localization is. needed and not sufficiently determined by colonoscopy 21 CTC can be used as a second line. diagnostic test to detect or rule out colorectal carcinoma and is preferred over barium enema 21. Limitations, Different models of CTC scanners were used in all of the studies which may limit the. comparability of results between studies Earlier studies that were included may have used CT. scanners that perform differently than current models limiting the generalizability of results to. Clinical and Cost Effectiveness of CT Colonography 7. current settings Included prospective and retrospective studies were observational and enrolled. a specific subset of patients which may not be representative of the general population and. which may have biased the results For example one retrospective study only performed. colonoscopy analysis on patients that had a 6 mm lesions determined by CTC 16 Also the. studies that used CTC as pre surgical evaluation of colorectal tumours performed CTC after. incomplete colonoscopy which may have biased the results in favour of CTC. Colonoscopy was used as a reference standard in the systematic reviews10 11 and one. retrospective study 16 which is not ideal as colonoscopy is not 100 accurate The length of. time between when CTC colonoscopy and reference tests were performed was not reported in. four studies 12 14 15 17 In the studies where the length of time between techniques was reported it. ranged from same day analysis13 to within 3 months 10 Longer time intervals between CTC and. colonoscopy may have affected the results due to changing pathology of the disease condition. None of the included guidelines were published by a Canadian society which may limit. generalizability to the Canadian setting In addition only one guideline assigned grades of. recommendations based on the evidence supporting it 19 No economic evaluations on CTC. compared to colonoscopy and or sigmoidoscopy for the diagnosis and treatment of colorectal. cancer were identified No studies were identified that compared CTC to flexible or rigid. sigmoidoscopy, CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING. According to the included studies CTC was generally found to perform equally as well or almost. as well as colonoscopy for the diagnosis of colorectal tumours For the pre operative evaluation. of colorectal tumours CTC was found to have better performance than colonoscopy mainly due. to incomplete colonoscopies in patients with obstructive masses In pre operative staging CTC. was found to accurately detect and localize colorectal tumours which is important for planning. resection of the appropriate colon segment Colonoscopy is still considered the gold standard. for diagnosis and tumour staging due to its high sensitivity and specificity but it fails to show the. entire colon in cases where the patient cannot tolerate the procedure or there are obstructive. masses within the colon, The CADTH report published in 2008 found that CTC did not perform as well as colonoscopy in. the detection of smaller colorectal lesions in the context of colorectal cancer screening 5 This. current report aimed to determine the performance of CTC compared with colonoscopy in the. context of diagnosis and treatment of colorectal cancer From the included studies it appears. that CTC performs well in the detection of colorectal cancer and advanced adenomas which. are characterized by larger lesions It should be noted however that detection of late stage. cancers does not necessarily improve survival rate emphasizing the importance of early. screening for non cancerous colon polyps and adenomas 1 3. Guidelines suggest that CTC can be used as an alternative to colonoscopy in patients that are. contraindicated for colonoscopy who are at risk for complications during colonoscopy who. failed to complete colonoscopy or when precise tumour localization is needed and not. sufficiently determined by colonoscopy In addition CTC should not be performed in patients. with severe colon issues or who have recently undergone a deep endoscopic biopsy. Clinical and Cost Effectiveness of CT Colonography 8. No evidence was identified regarding the cost effectiveness of CTC compared to colonoscopy. for the diagnosis and treatment of colorectal cancer No studies were identified that compared. CTC to flexible or rigid sigmoidoscopy,PREPARED BY. Canadian Agency for Drugs and Technologies in Health. Tel 1 866 898 8439,www cadth ca, Clinical and Cost Effectiveness of CT Colonography 9. REFERENCES, 1 Neri E Faggioni L Cini L Bartolozzi C Colonic polyps inheritance susceptibility risk. evaluation and diagnostic management Cancer Manag Res Internet 2010 cited 2012. Dec 4 3 17 24 Available from, http www ncbi nlm nih gov pmc articles PMC3048090 pdf cmr 3 017 pdf. 2 Colorectal Cancer Association of Canada Internet Toronto The Association 2012. Colorectal cancer statistics 2012 cited 2012 Dec 10 Available from. http www colorectal cancer ca en just the facts colorectal. 3 CT colonograply virtual colonoscopy for colon cancer screening Technol Eval Cent. Assess Program Exec Summ 2009 Aug 24 1 1 2, 4 ASGE Technology Committee Farraye FA Adler DG Chand B Conway JD Diehl DL et. al Update on CT colonography Gastrointest Endosc 2009 Mar 69 3 Pt 1 393 8. 5 Canadian Agency for Drugs and Technologies in Health Colonoscopy versus. sigmoidoscopy and CT colonography a clinical and cost effectiveness review Internet. Ottawa CADTH 2008 Mar 7 Health Technology Inquiry Service cited 2012 Dec 6. Available from, http www cadth ca media pdf htis Colonoscopy 20vs 20Sigmoidoscopy 20and 20C. T 20Colonography 20Clinical 20and 20Cost Effectiveness pdf. 6 Canadian Agency for Drugs and Technologies in Health Computer tomographic. colonography for colorectal cancer screening in an average risk population systematic. review and economic evaluation Internet Ottawa CADTH 2008 Dec Technology. Report HTA Issue 114 cited 2012 Oct 25 Available from. http www cadth ca media pdf H0474 tr CTC for colorectal cancer screening tr e pdf. 7 Shea BJ Grimshaw JM Wells GA Boers M Andersson N Hamel C et al Development. of AMSTAR a measurement tool to assess the methodological quality of systematic. reviews BMC Med Res Methodol Internet 2007 cited 2012 Oct 17 7 10 Available from. http www ncbi nlm nih gov pmc articles PMC1810543 pdf 1471 2288 7 10 pdf. 8 Whiting P Rutjes AW Reitsma JB Bossuyt PM Kleijnen J The development of. QUADAS a tool for the quality assessment of studies of diagnostic accuracy included in. systematic reviews BMC Med Res Methodol Internet 2003 Nov 10 cited 2012 Sep. 25 3 25 Available from http www ncbi nlm nih gov pmc articles PMC305345. 9 The AGREE Collaboration Appraisal of guidelines for research and evaluation AGREE. instrument Internet London The AGREE Research Trust 2001 Sep cited 2012 Aug 8. Available from http www agreetrust org o 1085, 10 de Haan MC van Gelder RE Graser A Bipat S Stoker J Diagnostic value of CT. colonography as compared to colonoscopy in an asymptomatic screening population a. meta analysis Eur Radiol 2011 Aug 21 8 1747 63, 11 Pickhardt PJ Hassan C Halligan S Marmo R Colorectal cancer CT colonography and. colonoscopy for detection systematic review and meta analysis Radiology Internet. Clinical and Cost Effectiveness of CT Colonography 10. 2011 May cited 2012 Sep 25 259 2 393 405 Available from. http www ncbi nlm nih gov pmc articles PMC3079122, 12 Sofic A Beslic S Kocijancic I Sehovic N CT colonography in detection of colorectal. carcinoma Radiol Oncol Internet 2010 Mar cited 2012 Dec 4 44 1 19 23 Available. from http www ncbi nlm nih gov pmc articles PMC3423676 pdf rado 44 01 19 pdf. 13 Leksowski K Rudzinska M Rudzinski J Computed tomographic colonography in. preoperative evaluation of colorectal tumors a prospective study Surg Endosc 2011. Jul 25 7 2344 9, 14 Neri E Turini F Cerri F Faggioni L Vagli P Naldini G et al Comparison of CT. colonography vs conventional colonoscopy in mapping the segmental location of colon. cancer before surgery Abdom Imaging 2010 Oct 35 5 589 95. 15 Baca B Selcuk D Kilic IE Erdamar S Salihoglu Z Hamzaoglu I et al The contributions. of virtual colonoscopy to laparoscopic colorectal surgery Hepatogastroenterology 2007. Oct 54 79 1976 82, 16 Iafrate F Hassan C Ciolina M Lamazza A Baldassari P Pichi A et al High positive. predictive value of CT colonography in a referral centre Eur J Radiol 2011. Dec 80 3 e289 e292, 17 Cho YB Lee WY Yun HR Lee WS Yun SH Chun HK Tumor localization for. laparoscopic colorectal surgery World J Surg 2007 Jul 31 7 1491 5. 18 Cash BD Rockey DC Brill JV AGA standards for gastroenterologists for performing and. interpreting diagnostic computed tomography colonography 2011 update. Gastroenterology 2011 Dec 141 6 2240 66, 19 Scottish Intercollegiate Guidelines Network SIGN Diagnosis and management of. colorectal cancer A national clinical guideline Internet Edinburgh SIGN 2011 Dec. SIGN publication no 126 cited 2012 Dec 10 Available from. http www sign ac uk pdf sign126 pdf, 20 ACR practice guideline for the performance of computed tomography CT colonography. in adults Reston VA American College of Radiology ACR 2009. 21 National Guideline Clearinghouse Internet Rockville MD Agency for Healthcare. Research and Quality Colon cancer 2008 cited 2012 Dec 6 Available from. http www guideline gov content aspx id 13556 search colonography. Clinical and Cost Effectiveness of CT Colonography 11. APPENDIX 1 Selection of Included Studies,500 citations identified from. electronic literature search and,468 citations excluded. 31 potentially relevant articles,retrieved for scrutiny full text if. 6 potentially relevant,reports retrieved from,other sources grey. literature hand,37 potentially relevant reports,25 reports excluded. irrelevant comparator 3,no comparator 1,irrelevant outcomes 6. irrelevant guidance 3,already included in at least one of. the selected systematic reviews 7,published in language other than. other review articles editorials 4,12 reports included in review. Clinical and Cost Effectiveness of CT Colonography 12. APPENDIX 2 Summary of Study Characteristics, First Author Study Patient Intervention Comparator Clinical. Publication Design and Characteristics Outcomes,Year Country Length Measured. de Haan 2011 Systematic 5 studies non CTC Colonoscopy Ability to detect. review and RCTs including performed advanced, The Netherlands meta analysis 4086 asymptomatic within 3 months adenomas and. subjects aged 50 after CTC CRC,75 years at sensitivity. average risk for specificity, Pickhardt 2011 Systematic 49 studies including CTC Optical Sensitivity for. review and 11151 subjects after standard colonoscopy detecting CRC. USA meta analysis 4883 bowel after cathartic,asymptomatic preparation in preparation. subjects 6668 44 studies,symptomatic cancers were,subjects histologically. Sofic 2010 Prospective 231 patients with CTC 4 slice Colonoscopy Ability to detect. study suspected multi detector biopsies taken CRC, Bosnia and symptoms of CRC CT scanner to confirm CRC sensitivity. Hercegovina mean age Volume zoom using histology specificity PPV. 57 9 11 3 years Siemens performed after NPV,53 female standard bowel CTC. preparation,Ducolax and, Iafrate 2011 Retrospective 516 patients with a CTC 64 Colonoscopy PPV for. study 6 mm lesion channel multi performed detecting. Italy determined by CTC detector CT within 8 weeks neoplasia. May 2009 May that were scanner GE after CTC used,2010 subsequently Healthcare as reference. referred for fecal tagging standard,colonoscopy n 76 with iodinated. contrast agent, Leksowski 2011 Prospective 49 consecutive CTC 64 slice Colonoscopy Tumour. study patients with row CT scanner presence,Poland colorectal tumours Siemens location size. identified with Sensation morphologic,colonoscopy Cardiac 64 features. median age 70 standard bowel,years range 24 88 preparation. years 63 male polyethylene,glycol electrolyte,performed after. colonoscopy on,the same day, Neri 2009 Prospective 65 symptomatic CTC multi row Colonoscopy Segmental. study patients with CRC CT scanner localization of. Italy diagnosed at LightSpeed colorectal,colonoscopy mean Plus GE masses. age 64 years 70 Medical,female Systems,standard bowel. Clinical and Cost Effectiveness of CT Colonography 13. First Author Study Patient Intervention Comparator Clinical. Publication Design and Characteristics Outcomes,Year Country Length Measured. preparation, Baca 2007 Prospective 40 consecutive CTC Optical Localization of. study patients who were multiphase colonoscopy colonic lesions. Turkey scheduled to contrast,January 2005 undergo enhanced. June 2006 laparoscopic multidetector CT,resection for scanner. colorectal standard bowel,neoplasm median preparation Na. age 63 7 years phospho soda,range 32 9 60, Cho 2007 Retrospective 310 patients who CTC n 94 Colonoscopy Accuracy of. study underwent n 310 localizing,South Korea laparoscopy colorectal. April 2000 assisted colectomy lesions,March 2006, CRC colorectal cancer CTC computed tomographic colonography NPV negative predictive value PPV positive. predictive value, Clinical and Cost Effectiveness of CT Colonography 14. APPENDIX 3 Summary of Critical Appraisal,First Author Strengths Limitations. Publication Year,Study Design, de Haan 2011 Comprehensive literature search based Unclear whether grey literature was. on pre defined criteria included in search strategy. Systematic review and Summary of study characteristics and list Pooled data of studies was highly. meta analysis of included studies provided heterogeneous. Scientific quality of included studies Data was too limited to calculate. assessed sensitivities per patient for the detection of. Risk of publication bias assessed CRC, Pickhardt 2011 Literature search based on pre defined Only one electronic source Pubmed was. criteria searched in detail, Systematic review and Summary of study characteristics and list Unclear whether grey literature was. meta analysis of included studies provided included in search strategy. Scientific quality of included studies Risk of publication bias not assessed. Sofic 2010 A reference standard histology was Unclear how study sample was selected. used Time period between index CTC and,Prospective study reference test histology from. colonoscopy biopsy not specified,Unclear whether readers were blinded to. the results of other tests, Iafrate 2011 The index test was described in sufficient Colonoscopy was used as a reference. detail to permit replication standard, Retrospective study CTC scans were read by two radiologists Endoscopist was not blinded to the CTC. Study was reflective of clinical practice in results. a dedicated centre Only a subset of patients 6 mm lesions. on CTC underwent colonoscopy not a,randomized sample. Leksowski 2011 A consecutive sample of patients was CTC images were interpreted by only one. enrolled radiologist, Prospective study A reference standard histology was Standard deviations of values were not. used reported,Both CTC and colonoscopy where,histological samples were taken were. performed on the same day,Radiologist who interpreted CTC images. were blinded to colonoscopy results, Neri 2009 A reference standard surgery was used Specificity PPV and NPV values were. Two radiologists interpreted CTC images not reported for colonoscopy. Prospective study Standard deviations of values were not. Time period between CTC and,colonoscopy not specified. Unclear whether radiologists were blinded,to colonoscopy results. Baca 2007 A reference standard histology was Time period between CTC and. used colonoscopy not specified, Prospective study Unclear whether radiologists were blinded. to colonoscopy results,Machine used to perform CTC not. Standard deviations of values were not, Clinical and Cost Effectiveness of CT Colonography 15.
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Mechanics of Rigid Body 1.B Kinetics, Dynamics 1.- Introduction 2.- Kinematics. Types of Rigid Body Motion: Translation, Rotation General Plane Motion 3.- Kinetics. Forces and Accelerations. Energy and Momentum Methods. Angular Momentum and Moment of Inertia Fundamental Equations of Dynamics 4.- Statics. Equilibrium. Mechanics of Rigid Body 1.B Kinetics, Dynamics 3.- Kinetics. Forces and ...