Context-specific method for detection of soft-tissue lesions in non-cathartic low-dose dual-energy CT colonography

In computed tomographic colonography (CTC), orally administered fecal-tagging agents can be used to indicate residual feces and fluid that could otherwise hide or imitate lesions on CTC images of the colon. Although the use of fecal tagging improves the detection accuracy of CTC, it can introduce image artifacts that may cause lesions that are covered by fecal tagging to have a different visual appearance than those not covered by fecal tagging. This can distort the values of image-based computational features, thereby reducing the accuracy of computer-aided detection (CADe). We developed a context-specific method that performs the detection of lesions separately on lumen regions covered by air and on those covered by fecal tagging, thereby facilitating the optimization of detection parameters separately for these regions and their detected lesion candidates to improve the detection accuracy of CADe. For pilot evaluation, the method was integrated into a dual-energy CADe (DE-CADe) scheme and evaluated by use of leave-one-patient-out evaluation on 66 clinical non-cathartic low-dose dual-energy CTC (DE-CTC) cases that were acquired at a low effective radiation dose and reconstructed by use of iterative image reconstruction. There were 22 colonoscopy-confirmed lesions ≥6 mm in size in 21 patients. The DE-CADe scheme detected 96% of the lesions at a median of 6 FP detections per patient. These preliminary results indicate that the use of context-specific detection can yield high detection accuracy of CADe in non-cathartic low-dose DE-CTC examinations

Registration of prone and supine CT colonography images and its clinical application

Computed tomographic (CT) colonography is a technique for detecting bowel cancer and potentially precancerous polyps. CT imaging is performed on the cleansed and insufflated bowel in order to produce a virtual endoluminal representation similar to optical colonoscopy. Because fluids and stool can mimic pathology, images are acquired with the patient in both prone and supine positions. Radiologists then match endoluminal locations visually between the two acquisitions in order to determine whether pathology is real or not. This process is hindered by the fact that the colon can undergo considerable deformation between acquisitions. Robust and accurate automated registration between prone and supine data acquisitions is therefore pivotal for medical interpretation, but a challenging problem. The method proposed in this thesis reduces the complexity of the registration task of aligning the prone and supine CT colonography acquisitions. This is done by utilising cylindrical representations of the colonic surface which reflect the colon's specific anatomy. Automated alignment in the cylindrical domain is achieved by non-rigid image registration using surface curvatures, applicable even when cases exhibit local luminal collapses. It is furthermore shown that landmark matches for initialisation improve the registration's accuracy and robustness. Additional performance improvements are achieved by symmetric and inverse-consistent registration and iteratively deforming the surface in order to compensate for differences in distension and bowel preparation. Manually identified reference points in human data and fiducial markers in a porcine phantom are used to validate the registration accuracy. The potential clinical impact of the method has been evaluated using data that reflects clinical practise. Furthermore, correspondence between follow-up CT colonography acquisitions is established in order to facilitate the clinical need to investigate polyp growth over time. Accurate registration has the potential to both improve the diagnostic process and decrease the radiologist's interpretation time. Furthermore, its result could be integrated into algorithms for improved computer-aided detection of colonic polyps

Performance and Evaluation in Computed Tomographic Colonography Screening for Colorectal Cancer

Each year over 20,000 people die from colorectal cancer (CRC). However, despite causing the second highest number of cancer deaths, CRC is not only curable if detected early but can be prevented by population screening. The detection and removal of pre-malignant polyps in the colon prevents cancer from ever developing. As such, screening of the at-risk population (those over 45-50 years) confers protection against CRC incidence and mortality. Although the principles and benefit of screening are well established, the adequate provision of screening is a complex process requiring robust healthcare infrastructure, evidence-based quality assurance and resources. The success of any screening programme is dependent on the accuracy of the screening investigations deployed and sufficiently high uptake by the target population. In England, the Bowel Cancer Screening Programme (BCSP) delivers screening via initial stool testing to triage patients for the endoscopic procedure, colonoscopy, or the radiological investigation CT colonography (CTC) in some patients. There has been considerable investment in colonoscopy accreditation processes which contribute to high quality services, suitable access for patients and a competent endoscopy workforce. The performance of colonoscopists in the BCSP is tightly monitored and regulated; however, the same is not true for CTC. Comparatively, there has been little investment in CTC services, and in fact there is no mandatory accreditation or centralised training. Instead, CTC reporting radiologists must learn ad hoc on the job, or at self-funded commercial workshops. This inevitably leads to variability in quality and expertise, inequity in service provision, and could negatively impact patient outcomes. To address this disparity and develop evidence-based training, one must determine what factors affect the performance of CTC reporting radiologists, what CTC training is necessary, and what training works. This thesis investigates these topics and is structured as follows: Section A reviews the background literature, describing the public health burden of CRC and the role of screening. Aspects of CTC screening and its role in the BCSP are explored. The importance of performance monitoring and value of accreditation are examined and the disparity between CTC, colonoscopy and other imaging-based screening programmes is discussed. Section B expands on radiologist performance by determining the post-imaging CRC (or interval cancer) rate through systematic review and meta-analysis. Factors contributing to the interval cancer rate are evaluated, and an observational study assessing factors affecting CTC accuracy is presented. The impact of CTC training is assessed via a structured review and best principles for training delivery are discussed. Section C presents a multicentre, cluster-randomised control trial developed from the data and understanding described in Sections A and B. Section D summarises the thesis and discusses future recommendations and research

Colonoscopy and Colorectal Cancer Screening

Colorectal cancer (CRC) represents a major public health problem worldwide. Fortunately most CRCs originate from a precursor lesion, the adenoma, which is accessible and removable. This is the rationale for CRC screening programs, which are aimed to diagnose CRC at an early stage or even better to detect and resect the advanced adenoma before CRC has developed. In this background colonoscopy emerges as the main tool to achieve these goals with recent evidence supporting its role in CRC prevention. This book deals with several topics to be faced when implementing a CRC screening program. The interested reader will learn about the rationale and challenges of implementing such a program, the management of the detected lesions, the prevention of complications of colonoscopy, and finally the use of other screening modalities that are emerging as valuable alternatives. The relevance of the topics covered in it and the updated evidence included by the authors turn this book into a very useful tool to introduce the reader in this amazing and evolving field

Feature extraction to aid disease detection and assessment of disease progression in CT and MR colonography

Computed tomographic colonography (CTC) is a technique employed to examine the whole colon for cancers and premalignant adenomas (polyps). Oral preparation is taken to fully cleanse the colon, and gas insufflation maximises the attenuation contrast between the enoluminal colon surface and the lumen. The procedure is performed routinely with the patient both prone and supine to redistribute gas and residue. This helps to differentiate fixed colonic pathology from mobile faecal residue and also helps discover pathology occluded by retained fluid or luminal collapse. Matching corresponding endoluminal surface locations with the patient in the prone and supine positions is therefore an essential aspect of interpretation by radiologists; however, interpretation can be difficult and time consuming due to the considerable colonic deformations that occur during repositioning. Hence, a method for automated registration has the potential to improve efficiency and diagnostic accuracy. I propose a novel method to establish correspondence between prone and supine CT colonography acquisitions automatically. The problem is first simplified by detecting haustral folds which are elongated ridgelike endoluminal structures and can be identified by curvature based measurements. These are subsequently matched using appearance based features, and their relative geometric relationships. It is shown that these matches can be used to find correspondence along the full length of the colon, but may also be used in conjunction with other registration methods to achieve a more robust and accurate result, explicitly addressing the problem of colonic collapse. The potential clinical value of this method has been assessed in an external clinical validation, and the application to follow-up CTC surveillance has been investigated. MRI has recently been applied as a tool to quantitatively evaluate the therapeutic response to therapy in patients with Crohn's disease, and is the preferred choice for repeated imaging. A primary biomarker for this evaluation is the measurement of variations of bowel wall thickness on changing from the active phase of the disease to remission; however, a poor level of interobserver agreement of measured thickness is reported and therefore a system for accurate, robust and reproducible measurements is desirable. I propose a novel method which will automatically track sections of colon, by estimating the positions of elliptical cross sections. Subsequently, estimation of the positions of the inner and outer bowel walls are made based on image gradient information and therefore a thickness measurement value can be extracted

Framework for the detection and classification of colorectal polyps

In this thesis we propose a framework for the detection and classification of colorectal polyps to assist endoscopists in bowel cancer screening. Such a system will help reduce not only the miss rate of possibly malignant polyps during screening but also reduce the number of unnecessary polypectomies where the histopathologic analysis could be spared. Our polyp detection scheme is based on a cascade filter to pre-process the incoming video frames, select a group of candidate polyp regions and then proceed to algorithmically isolate the most probable polyps based on their geometry. We also tested this system on a number of endoscopic and capsule endoscopy videos collected with the help of our clinical collaborators. Furthermore, we developed and tested a classification system for distinguishing cancerous colorectal polyps from non-cancerous ones. By analyzing the surface vasculature of high magnification polyp images from two endoscopic platforms we extracted a number of features based primarily on the vessel contrast, orientation and colour. The feature space was then filtered as to leave only the most relevant subset and this was subsequently used to train our classifier. In addition, we examined the scenario of splitting up the polyp surface into patches and including only the most feature rich areas into our classifier instead of the surface as a whole. The stability of our feature space relative to patch size was also examined to ensure reliable and robust classification. In addition, we devised a scale selection strategy to minimize the effect of inconsistencies in magnification and geometric polyp size between samples. Lastly, several techniques were also employed to ensure that our results will generalise well in real world practise. We believe this to be a solid step in forming a toolbox designed to aid endoscopists not only in the detection but also in the optical biopsy of colorectal polyps during in vivo colonoscopy.Open Acces

Bidirectional Propulsion of Devices Along the Gastrointestinal Tract Using Electrostimulation

This thesis describes a method for propelling devices such as video capsule endoscopes in either direction along the small intestines using electrostimulation-induced muscular contractions. When swallowed, passive diagnostic ‘one-shot’ devices rely on sporadic peristaltic movement, possibly missing vital ‘areas of interest’. This bidirectional propulsion method provides active control for that all-important ‘second look’. Design considerations, within the dimensional constraints, required a device shape that would achieve maximum propulsion from safely induced useful contractions produced by the electrodes and encapsulated miniature electrostimulator. Construction materials would have to produce minimal friction against the mucosal surface while having the physical properties to facilitate construction and electrode attachment. Design investigations included coefficient of friction measurements of different construction materials and the evaluation of different capsule and electrode dimensions over a range of stimulation parameters, to obtain optimal propulsion. A swallowable 11 mm diameter device was propelled at 121 mm/min with stimulation parameters of 12.5 Hz, 20 ms, at 20 V in an anaesthetised pig. A modified passive video capsule endoscope was propelled at 120 mm/min with stimulation parameters of 12.5 Hz, 20 ms, at 10 V in an unanaesthetised human volunteer. A radio-controlled capsule incorporating an electrostimulator, voltage converter and 3 V power supply was propelled at 60 mm/min with stimulation parameters of 12.5 Hz, 20 ms, and 30 V in an anaesthetised pig. 4 Other possible uses of electrostimulation were investigated including propulsion of anally administered large intestine devices and introduction of the intestinal mucosal surface into a biopsy chamber. Results are presented. The ultimate aim of the project was to provide bidirectional propulsion for wireless remote controlled devices along the gastrointestinal tract utilising contractile force produced by electrostimulation of the intestinal wall. The controllability of this system could provide clinicians with a real time view of the entire small intestines without surgical enteroscopy