Polyps should be reported with morphologic data in addition to size, as lesions with sessile or flat morphology are thought to confer a different risk of harboring carcinoma. Another important area of interest is the diagnostic performance of CTC for detecting flat lesions-polyps that primarily infiltrate along the colon mucosa and hence do not markedly impinge into the colon lumen (Fidler et al. 2002). A recent review of the National Polyp Study showed that flat lesions, as defined by pathologists, do not have an increased risk of dysplasia or carcinoma, independent of the lesion size (O'Brian et al. 2004). Fidler et al. (Fidler et al. 2002) have shown that flat lesions are less common than previously reported and that these lesions were also often hyperplastic. We propose that for reporting purposes, a flat lesion should be a one whose height is no more that 3 mm above the surrounding normal mucosa. (Avoid defining flat lesions as those whose height is 50% of the lesion diameter.) Accordingly, when a flat lesion is suspected, we recommend that authors report the additional dimension of lesion height. While lesion height may be easily measured from the CTC images, we recognize that lesion height from endoscopy may only be an estimate and is not normally reported unless prospectively requested. We propose that flat lesions should be further subdivided in those that are infiltrative with no perceptible raised component, and those that are raised and project into the lumen. The justification is that the latter may be more conspicuous to the CTC reader and may be more amenable to detection by shaped-based computer-aided diagnosis programs. Reporting the morphology of lesions more comprehensively will assist in fully evaluating the performance of CTC, since there may be differences in sensitivity related to morphology, particularly for flat lesions. In addition, to maximize our ability to retrospectively analyze the performance of CTC, we recommend that authors specify if flat or infiltrative lesions are visible only on one particular window/level setting. Analysis of this visualization data may permit future refinement of recommended reading protocols.
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