Magnetic resonance colonography without bowel cleansing: a prospective cross sectional study in a screening population

Christiane Kuehle

Jost Langhorst

Susanne Ladd

Thomas Zoepf

Jost Langhorst, Thomas Zoepf, Guido Gerken, Department of Gastroenterology and Hepatology, University Hospital Essen, Germany

Florian Grabellus, Department of Pathology, Hospital Essen, Germany

Correspondence to: Christiane A Kühle
Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, D‐45122 Essen, Germany; christiane.kuehle@ uni‐due.de

Christiane A Kuehle, Susanne C Ladd, Michael Nuefer, Joerg Barkhausen, Thomas C Lauenstein, Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, GermanyJost Langhorst, Thomas Zoepf, Guido Gerken, Department of Gastroenterology and Hepatology, University Hospital Essen, GermanyFlorian Grabellus, Department of Pathology, Hospital Essen, GermanyCorrespondence to: Christiane A Kühle
Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, D‐45122 Essen, Germany; christiane.kuehle@ uni‐due.de

Revised 2007 Feb 7; Accepted 2007 Feb 23.

Abstract

Background and aim

To evaluate the diagnostic accuracy of magnetic resonance colonography (MRC) without bowel cleansing in a screening population and compare the results to colonoscopy as a standard of reference.

Methods

315 screening patients, older than 50 years with a normal risk profile for colorectal cancer, were included in this study. For MRC, a tagging agent (5.0% Gastrografin, 1.0% barium sulphate, 0.2% locust bean gum) was ingested with each main meal within 2 days prior to MRC. No bowel cleansing was applied. For the magnetic resonance examination, a rectal water enema was administered. Data collection was based on contrast enhanced T1 weighted images and TrueFISP images. Magnetic resonance data were analysed for image quality and the presence of colorectal lesions. Conventional colonoscopy and histopathological samples served as reference.

Results

In 4% of all colonic segments, magnetic resonance image quality was insufficient because of untagged faecal material. Adenomatous polyps >5 mm were detected by means of MRC, with a sensitivity of 83.0%. Overall specificity was 90.2% (false positive findings in 19 patients). However, only 16 of 153 lesions <5 mm and 9 of 127 hyperplastic polyps could be visualised on magnetic resonance images.

Conclusions

Faecal tagging MRC is applicable for screening purposes. It provides good accuracy for the detection of relevant (ie, adenomatous) colorectal lesions >5 mm in a screening population. However, refinements to optimise image quality of faecal tagging are needed.

Abstract

Colorectal cancer (CRC) is the second leading cause of cancer death in Western countries.¹ The vast majority of CRC develop from benign colonic adenomas/polyps over a time scale of several years.² Screening programmes targeting precancerous polyps and subsequent endoscopic polypectomy have been shown to considerably reduce CRC mortality. Although colonoscopy has been established as an accurate method for the assessment of the colon, a large discrepancy between the screening potential and clinical reality remains apparent. Even in countries with free access to this diagnostic procedure, participation in cancer screening programmes based on colonoscopy is suboptimal.³

Upcoming non‐invasive alternative methods are mainly based on cross sectional imaging, such as CT and MRI.⁴⁵ By means of post‐processing software, acquired CT or MRI data can be reconstructed into a virtual endoscopic view or fly through. Because of the higher clinical availability of scanners and lower costs, most approaches to date have focused on CT colonoscopy (CTC). Despite promising diagnostic results, the long term impact of CTC as a screening method remains uncertain, with the associated ionising radiation burden raising the possibility of a public health concern.⁶⁷ A compelling rationalisation for pursuing magnetic resonance colonography (MRC) is safety and avoidance of risks associated with exposure to ionising radiation of an otherwise mostly healthy screening population. While the diagnostic effectiveness of CTC has already been assessed in a screening cohort,⁵ MRC approaches have been evaluated only in high risk populations with a limited number of subjects.⁸⁹¹⁰ In addition, most MRC protocols in the past required bowel purgation similar to the preparation for colonoscopy. However, this part of the procedure is considered very unpleasant by the vast majority of patients¹¹¹² and negatively impacts on acceptance levels. The requirement for bowel cleansing can be reduced by adding contrast agents to regular meals prior to the magnetic resonance examination, thereby modulating the signal characteristics of faecal material (faecal tagging).

The aim of the present study was to assess the diagnostic accuracy of a faecal tagging based MRC protocol in a screening population compared with colonoscopy serving as the gold standard.

Abbreviations

CRC - colorectal cancer

CTC - computed tomography colonoscopy

FOV - field of view

MRC - magnetic resonance colonography

TE - echo time

TR - repetition time

Abbreviations

Footnotes

This study was supported by grant 70‐3006 from the German Cancer Aid (Deutsche Krebshilfe).

Competing interests: None.

Footnotes

References

1. Jemal A, Tiwari R C, Murray T. et al Cancer statistics, 2004. CA Cancer J Clin 2004548–29. [[PubMed]
2. Grady W MEpigenetic events in the colorectum and in colon cancer. Biochem Soc Trans 200533684–688. [[PubMed][Google Scholar]
3. Increased use of colorectal cancer tests—United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep 200655308–311. [[PubMed]
4. Geenen R W, Hussain S M, Cademartiri F. et al CT and MR colonography: scanning techniques, postprocessing, and emphasis on polyp detection. Radiographics 200424e18 [[PubMed]
5. Pickhardt P J, Choi J R, Hwang I. et al Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 20033492191–2200. [[PubMed]
6. Brenner D J, Elliston C DEstimated radiation risks potentially associated with full‐body CT screening. Radiology 2004232735–738. [[PubMed][Google Scholar]
7. Debatin J F, Luboldt W, Bauerfeind PVirtual colonoscopy in 1999: computed tomography or magnetic resonance imaging? Endoscopy 199931174–179. [[PubMed][Google Scholar]
8. Ajaj W, Pelster G, Treichel U. et al Dark lumen magnetic resonance colonography: comparison with conventional colonoscopy for the detection of colorectal pathology. Gut 2003521738–1743.
9. Hartmann D, Bassler B, Schilling D. et al Colorectal polyps: detection with dark‐lumen MR colonography versus conventional colonoscopy. Radiology 2006238143–149. [[PubMed]
10. Pappalardo G, Polettini E, Frattaroli F M. et al Magnetic resonance colonography versus conventional colonoscopy for the detection of colonic endoluminal lesions. Gastroenterology 2000119300–304. [[PubMed]
11. Tangka F K, Molinari N A, Chattopadhyay S K. et al Market for colorectal cancer screening by endoscopy in the United States. Am J Prev Med 20052954–60. [[PubMed]
12. Thomeer M, Bielen D, Vanbeckevoort D. et al Patient acceptance for CT colonography: what is the real issue? Eur Radiol 2002121410–1415. [[PubMed]
13. Dafnis G, Granath F, Pahlman L. et al Patient factors influencing the completion rate in colonoscopy. Dig Liver Dis 200537113–118. [[PubMed]
14. Nelson D B, McQuaid K R, Bond J H. et al Procedural success and complications of large‐scale screening colonoscopy. Gastrointest Endosc 200255307–314. [[PubMed]
15. Rex D K, Cutler C S, Lemmel G T. et al Colonoscopic miss rates of adenomas determined by back‐to‐back colonoscopies. Gastroenterology 199711224–28. [[PubMed]
16. Ajaj W, Lauenstein T C, Pelster G. et al MR colonography in patients with incomplete conventional colonoscopy. Radiology 2005234452–459. [[PubMed]
17. Hartmann D, Bassler B, Schilling D. et al Incomplete conventional colonoscopy: magnetic resonance colonography in the evaluation of the proximal colon. Endoscopy 200537816–820. [[PubMed]
18. Cotton P B, Durkalski V L, Pineau B C. et al Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 20042911713–1719. [[PubMed]
19. Rockey D C, Paulson E, Niedzwiecki D. et al Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005365305–311. [[PubMed]
20. Rogalla P, Meiri N, Hoksch B. et al Low‐dose spiral computed tomography for measuring abdominal fat volume and distribution in a clinical setting. Eur J Clin Nutr 199852597–602. [[PubMed]
21. Bond J HClinical relevance of the small colorectal polyp. Endoscopy 200133454–457. [[PubMed][Google Scholar]
22. Ferrucci J TColon cancer screening with virtual colonoscopy: promise, polyps, politics. AJR Am J Roentgenol 2001177975–988. [[PubMed][Google Scholar]
23. Ferrucci J TColonoscopy: virtual and optical—another look, another view. Radiology 200523513–16. [[PubMed][Google Scholar]
24. Fletcher J G, Johnson C D, Krueger W R. et al Contrast‐enhanced CT colonography in recurrent colorectal carcinoma: feasibility of simultaneous evaluation for metastatic disease, local recurrence, and metachronous neoplasia in colorectal carcinoma. AJR Am J Roentgenol 2002178283–290. [[PubMed]
25. Laghi A, Iannaccone R, Bria E. et al Contrast‐enhanced computed tomographic colonography in the follow‐up of colorectal cancer patients: a feasibility study. Eur Radiol 200313883–889. [[PubMed]
26. Kirchin M A, Runge V MContrast agents for magnetic resonance imaging: safety update. Top Magn Reson Imaging 200314426–435. [[PubMed][Google Scholar]
27. Shellock F G, Kanal ESafety of magnetic resonance imaging contrast agents. J Magn Reson Imaging 199910477–484. [[PubMed][Google Scholar]
28. Luboldt W, Bauerfeind P, Steiner P. et al Preliminary assessment of three‐dimensional magnetic resonance imaging for various colonic disorders. Lancet 19973491288–1291. [[PubMed]
29. Lauenstein T C, Herborn C U, Vogt F M. et al Dark lumen MR‐colonography: initial experience. Rofo 2001173785–789. [[PubMed]
30. Lauenstein T C, Ajaj W, Kuehle C A. et al Magnetic resonance colonography: comparison of contrast‐enhanced three‐dimensional vibe with two‐dimensional FISP sequences: preliminary experience. Invest Radiol 20054089–96. [[PubMed]
31. Bruzzi J F, Moss A C, Brennan D D. et al Colonic surveillance by CT colonography using axial images only. Eur Radiol 200414763–767. [[PubMed]
32. Bond J HClinical evidence for the adenoma–carcinoma sequence, and the management of patients with colorectal adenomas. Semin Gastrointest Dis 200011176–184. [[PubMed][Google Scholar]
33. Winawer S J, Zauber A GThe advanced adenoma as the primary target of screening. Gastrointest Endosc Clin N Am 2002121–9v. [[PubMed][Google Scholar]
34. Mysliwiec P A, Brown M L, Klabunde C N. et al Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2004141264–271. [[PubMed]
35. Lieberman D A, Weiss D G, Bond J H. et al Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med 2000343162–168. [[PubMed]
36. Wardle J, Sutton S, Williamson S. et al Psychosocial influences on older adults' interest in participating in bowel cancer screening. Prev Med 200031323–334. [[PubMed]
37. Centers for Disease Control and Prevention Trends in screening for colorectal cancer—United States, 1997 and 1999. JAMA 20012851570–1571. [[PubMed]
38. Mant D, Fuller A, Northover J. et al Patient compliance with colorectal cancer screening in general practice. Br J Gen Pract 19924218–20.
39. Akerkar G A, Yee J, Hung R. et al Patient experience and preferences toward colon cancer screening: a comparison of virtual colonoscopy and conventional colonoscopy. Gastrointest Endosc 200154310–315. [[PubMed]
40. van Gelder R E, Birnie E, Florie J. et al CT colonography and colonoscopy: assessment of patient preference in a 5‐week follow‐up study. Radiology 2004233328–337. [[PubMed]
41. Ristvedt S L, McFarland E G, Weinstock L B. et al Patient preferences for CT colonography, conventional colonoscopy, and bowel preparation. Am J Gastroenterol 200398578–585. [[PubMed]