Morphometric Methods for Virtual Endoscopy

Ronald M. Summers, in Handbook of Medical Imaging, 2000

1 Overview of Virtual Endoscopy

Virtual endoscopy (VE) is a novel display method for three-dimensional

medical imaging data. It produces endoscope-like displays of the interior of
hollow anatomic structures such as airways, the gastrointestinal tract, and
blood vessels [1–5]. For example, Fig. 1 shows a virtual bronchoscopy
reconstruction of the air passages of a human lung with depiction of
bronchi as small as fifth and sixth order. Studies have shown virtual
endoscopy to be useful for the visualization of morphologic abnormalities
such as aneurysms, tumors, and stenoses [6–8].

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FIGURE 1. Images derived from CT scans of autopsy human lung specimen. (A) Coronal

multiplanar reformatted image shows excellent resolution required to depict small airways. Airways

are the black branching structures (arrow). The three lobes of the right lung (left side of image) and

two lobes of the left lung are shown. (B) Anteroposterior view of three-dimensional surface

reconstruction of airways showing exquisite depiction of branching to fifth and sixth order. (C) Virtual

bronchoscopy view of bifurcation of a fifth order bronchus only 2 or 3 mm in diameter, at or near

furthest point reachable by a conventional bronchoscope.

VE displays are usually produced from planar 2D computed
tomography (CT) or magnetic resonance (MR) images using surface or
volume rendering [9, 10]. Surface rendering is generally done by taking
an isosurface through the imaging volume at a specified threshold value;
this generates contours in three dimensions that are analogous to the two-
dimensional isocontours of temperature or pressure (isotherms, isobars) on
weather maps. In the case of VE, the contours represent the wall of a
hollow anatomic structure, such as airways or blood vessels. One
commonly used isosurface algorithm called “marching cubes” generates a
triangular tessellation of the isosurface suitable for interactive display on
computers equipped with graphics accelerators [11]. Disadvantages of
surface rendering are that a complex segmentation must be done as a
preprocessing step and only a fraction of the data is retained in the final
image.
In contrast to surface rendering, volume rendering is done by considering
the imaging volume to be a translucent gelatin whose optical density and
opacity are mapped to each voxel intensity through user-adjustable transfer
functions. Volume rendering overcomes a disadvantage of surface
rendering in that segmentation is not required. However, volume rendering
is typically not interactive unless very expensive computers are used. In
addition, the transfer functions can span a wide range of values; this
freedom offers considerable flexibility, but it can be difficult to identify the
correct choices to produce an accurate image. Some progress has been
made toward defining an appropriate transfer function for virtual
colonoscopy [12].
Since VE is used to visualize small structures such as airways, blood
vessels, and colonic polyps whose size may be 1 cm or less, image data
with small voxel dimensions, desirably 1 mm 3 or less, is required to
generate a VE. The smallest pathologic structure visualized on a VE will be
on the order of the voxel resolution, which is as large as or larger than the
voxel dimension. The voxel resolution depends on a host of adjustable
parameters (e.g., for CT: helical pitch, reconstruction algorithm, section
index) [13].
Presently, VE is viewed as either static images or as a movie-like “fly-
through” that simulates conventional endoscopy. The lack of physical
feedback necessitates new tools to orient the observer. Examples of such
tools include navigation aids to integrate cross-sectional images with the
VE image, centerline computation for automated flight planning, unraveling
of the colon to ease polyp identification, and cockpit displays to provide
greater visual coverage of the wall of the lumen and reduce blind spots
[14–18].
Clinical uses for VE presently include detection of many of the same
abnormalities for which conventional endoscopy is indicated, for example
virtual colonoscopy to detect colonic polyps, virtual bronchoscopy to detect
bronchial stenoses and to guide biopsies, and virtual angioscopy to detect
vascular pathology [19–22]. Relative to conventional endoscopy, VE's main
benefits are its noninvasiveness and ability to integrate information about
both the lumen and extraluminal structures into a single image. Although
VE seeks to emulate conventional endoscopy, which has proven to be a
powerful diagnostic and therapeutic tool, VE may surpass conventional
endoscopy by solving some of the problems of conventional endoscopy
(underutilization due to expense and invasiveness). In this context, VE may
play a role in screening a general patient population for the presence of
disease and serial evaluation to detect disease recurrence in already
affected individuals. Screening would greatly expand the number of VE
studies performed.

Source: https://www.sciencedirect.com/topics/medicine-and-dentistry/virtual-endoscopy
Endoscopy: Traditional, Virtual, or Capsule?
February 15, 2018 by Cynthia Hayward

Endoscopy typically refers to looking inside the body for medical reasons using an
endoscope — an instrument used to examine the interior of a hollow organ or cavity of
the body. Unlike most other medical imaging devices, endoscopes are inserted directly
into the organ. There are several types of traditional endoscopy. Those using natural
body openings include upper endoscopy, gastroscopy, enteroscopy, colonoscopy, and
sigmoidoscopy. Endoscopies are usually performed under sedation to assure patient
comfort. In recent years, newer forms of endoscopy have been developed where tubes
are not inserted directly into the body.

Virtual endoscopy is really an imaging test, not an endoscopy procedure. It uses a

special CT scan to look at the inside surfaces of organs such as the lungs (virtual
bronchoscopy) or colon (virtual colonoscopy or CT colonography). The patient must still
prepare for the test by using medications and laxatives to clean out the colon to get
good pictures during a virtual colonoscopy. Virtual endoscopy has some advantages
over standard endoscopy — nothing is put into the body and no drugs are needed for
the test. However, the doctor cannot take biopsy samples or remove growths during the
procedure. If something abnormal is found, the patient may still need a standard
endoscopy
Capsule endoscopy. Doctors can see a lot of the digestive tract using upper endoscopy
or colonoscopy. But it is more difficult to see the 20 feet or so of small intestine in this
way. Capsule endoscopy provides a new option — a person swallows a capsule that
contains a light source and a tiny camera (about the size of a large vitamin pill). Like any
other pill, the capsule goes through the stomach and into the small intestine. It travels
through the small intestine, which usually takes about eight hours, and takes thousands
of pictures. These pictures are sent to a device worn around the person’s waist, while he
or she goes on with normal daily activities. The pictures can then be downloaded onto a
computer, where the doctor can look at them as a video. Like food, the capsule passes
out of the body and is flushed away. This technique helps find the source of bleeding,
pain, or other symptoms involving the small intestine but it is not as useful for looking
closely at the colon or other parts of the body.

Source: https://blog.spacemed.com/endoscopy-traditional-virtual-or-capsule/
How Endoscopy Detects Stomach CancerPrint this Page
Gastroenterology Stomach (Gastric) Cancer Diagnosis and Screening for Gastric Conditions

Reviewed By:

Saowanee Ngamruengphong, M.D.

In the early stages of stomach cancer, many patients experience few or no symptoms.
Because the lack of symptoms makes stomach cancer difficult to detect, doctors often
diagnose the disease at more advanced stages. By that point, it is more challenging to
treat.

Johns Hopkins gastroenterologist Saowanee Ngamruengphong, M.D., explains how

doctors look at the stomach lining without performing surgery. The endoscopic procedure
helps screen high-risk patients and diagnose this disease earlier.

Screening for Stomach Cancer

Unfortunately, there’s no recommended screening test for spotting early gastric cancer in
the general population. However, Ngamruengphong says doctors use upper endoscopy to
screen for — and detect — stomach cancer in people at high risk for developing the
disease.

“There’s no standard guideline on who to screen for stomach cancer, so we base

screening recommendations on patients’ risk for developing this cancer. Based on what
we find, we determine how often patients should undergo follow-up screenings,” she says.

Factors that Ngamruengphong considers when identifying at-risk patients include:

 Ethnicity : First- and second-generation immigrants from East Asia, Russia and South
America are considered higher risk. Those areas see more cases of stomach cancer than the
United States.
 Family history : Having a family member with stomach cancer increases risk.
 Race : Non-Caucasians are at higher risk.
 Smoking history : Smoking increases the risk of stomach cancer.
 Physical health and genetics : Certain types of gastric infection and hereditary
syndromes, such as Lynch syndrome and Peutz-Jeghers syndrome, also increase stomach
cancer risk.
Diagnosing Stomach Cancer

Ngamruengphong says upper endoscopy is the gold standard test for diagnosing

stomach cancer today.

During an upper endoscopy procedure:

1. Patients receive general sedation so they are asleep for the procedure and feel no pain.
2. A doctor routes a tube (with a camera attached to the end) down the mouth, through the
esophagus and to the stomach.
3. As the scope moves, a doctor looks closely at the lining of the esophagus and stomach,
carefully inspecting any suspicious areas that may be cancer.

What Makes Endoscopy So Effective

Even with an endoscope, it can be difficult to distinguish cancerous lesions from healthy or
scarred stomach tissue.

Ngamruengphong explains why: “When we perform a screening endoscopy, we don’t see

a large mass when cancer is present. Instead, we often see very small, very subtle lesions.”

Doctors with extensive experience using this screening tool can more easily spot the
subtleties of very early stomach cancer. With the help of recent endoscopic technology
advances such as high-quality images and dyes, doctors can detect cancer at even earlier
stages.

The combination of experienced doctors and sophisticated technology advancements

means people can get diagnosed — and treated — earlier. And the earlier cancer is
treated, the higher the chance of a successful result.

Source: https://www.hopkinsmedicine.org/health/conditions-and-diseases/stomach-gastric-cancer/
how-endoscopy-detects-stomach-cancer
Virtual Endoscopy: A Promising New
Technology
BRADFORD J. WOOD, M.D., AND POUNEH RAZAVI, M.D.

Virtual Colonoscopy
The most promising clinical use of endoluminal imaging is in examination of the colon (Figure
1). Colon cancer is the number 2 cause of cancer deaths in the United States, with a projected
incidence of approximately 135,400 new cases and 56,700 deaths in 2001. 2

FIGURE 1.

zoom_out_mapEnlargeprintPrint

Virtual colonoscopic view of polyp (arrow) in left colon.

Early detection of colon cancer is the key to a good prognosis. The five-year survival rate for
colon cancer is nearly 90 percent for localized disease versus about 6 percent for distant
metastases.3 It can take from 10 to 15 years for an adenomatous polyp to become an invasive
cancer.4 Thus, there is a considerable time for detection and clinical intervention if the proper
screening methods are used. Studies of fecal occult blood testing and flexible sigmoidoscopy
have shown that screening for colorectal cancer in high-risk countries can decrease mortality by
50 percent.5 Yet, it is reported that fewer than 20 percent of American adults have undergone
colorectal cancer screening.6

CONVENTIONAL SCREENING

Conventional screening examinations for colorectal cancer are eligible for Medicare
reimbursement. The American Cancer Society guidelines for screening are outlined in Table
1.7 A similar set of guidelines was established by the Agency for Health Care Policy and
Research (now called the Agency for Healthcare Research and Quality). 8 The choice of
procedure should depend on medical status and community-specific quality of available
examination methods. Screening is a more complex issue in moderate- to high-risk patients
(those with a history of colorectal cancer, adenomatous polyps, inflammatory bowel disease,
familial adenomatous polyposis, or family history of colorectal cancer).

Information from American Cancer Society. Cancer facts & figures—2001. Atlanta, Ga.: American
Cancer Society, 2001. Retrieved September 2001 from:www.cancer.org.
Each of the conventional screening procedures has specific disadvantages. The fecal occult
blood test is not useful in detecting a precancerous stage because large adenomatous polyps
rarely cause bleeding and remain undetected. 9 In fact, the test's reported sensitivity varies from
38 percent to 92 percent and is extremely laboratory-dependent. 8 Flexible sigmoidoscopy has a
restricted range and cannot go beyond the splenic flexure.

A recent study to determine the prevalence and location of advanced colonic neoplasms found
that 52 percent of 128 patients with proximal neoplasms had no distal adenomas. 10 These
neoplasms would not have been detected with examination of the distal colon or flexible
sigmoidoscopy. Therefore, an adequate screening method should visualize the entire colon. In
fact, in one quarter of patients with precancerous polyps or invasive cancer, sigmoidoscopy and
the fecal occult blood test will miss the lesions when performed once, in combination. 11

Colonoscopy can, in most cases, visualize the entire colon and is the “gold standard” of
examination methods. However, the procedure does not permit passage through obstructions
or twisted portions of bowel. Furthermore, the United States Congress Office of Technology
Assessment reported that colonoscopy is associated with the risk of bowel perforation (1:1,000
procedures) and mortality (1:5,000 procedures). 12 Finally, colonoscopy is invasive and time-
consuming, and these disadvantages can result in decreased patient compliance.

Double-contrast barium enema also allows for visualization of the complete colon. However,
sensitivity and specificity may be impaired by retained feces, pooling of barium, and overlapping
segments of bowel.13 In addition, the procedure causes pain and distress to patients. 14

Virtual colonoscopy provides several advantages as a screening tool. It allows the examiner to
visualize the entire colon and adjacent anatomic structures. The procedure also allows
visualization of areas distal to an obstructed or twisted bowel, providing information on
occlusive carcinomas. In addition, virtual colonoscopy can be a valuable tool in preoperative
evaluation of the colon.15 It defines the exact anatomic location of abnormalities and the
proximity of adjacent structures, whereas conventional colonoscopy only estimates the location
of lesions.
Virtual colonoscopy rivals conventional colonoscopy and exceeds double-contrast barium
enema in sensitivity for colorectal polyps.13,16,17 Virtual colonoscopy's sensitivity is related to
polyp size.10,18,19 Sensitivity and specificity have been reported as 75 percent and 90 percent,
respectively, for polyps greater than 10 mm in diameter. 18 Sensitivity drops for smaller polyps
(less than 10 mm); however, these are also much less likely to develop into cancer. At present,
the size designating a clinically significant polyp is a matter of controversy. The sensitivity of
virtual colonoscopy is actually higher for adenomatous polyps, the main precursor to colorectal
cancer, than for hyperplastic polyps.18 False-negative results can occur with flat lesions and
inadequate insufflation, while false-positive results are often due to residual feces. 1

Certain aspects of virtual colonoscopy can lead to increased patient compliance. Virtual
colonoscopy is faster than colonoscopy. It is minimally invasive and does not involve sedation
or significant loss of work time. Patient preparation requires only breath holding, a colon
cleansing preparation and air insufflation, with or without intravenous smooth muscle relaxant.
Of 100 patients who underwent virtual colonoscopy, none requested the examiner to stop
because of discomfort or pain.18

Actual costs for the routine use of virtual colonoscopy as a screening tool are not available. To
become cost-effective and enter widespread use, virtual colonoscopy would have to be
inexpensive and demonstrate high patient compliance compared with conventional
colonoscopy.20 At present, there is no specific reimbursement code for virtual colonoscopy. To
achieve cost-effectiveness as a screening test, the procedure will require a specific
reimbursement code that will differentiate it from abdominal and pelvic CT scanning. Virtual
colonoscopy is not now eligible for Medicare reimbursement; however, it is being offered in
many communities and academic centers.
Finally, the cost of virtual colonoscopy will undoubtedly be reduced with further development
and deployment of faster, yet lower-cost processing systems. 21 Computer-aided diagnosis,
autonavigation, and stool-tagging may further ease and facilitate clinical deployment of this
technique.22

The radiation exposure incurred during a virtual colonoscopy examination is currently equivalent
to that of two plain abdominal films and will probably decrease with continued software and
hardware developments.19 Reports have shown that by using low-current radiation, the total
dose of radiation from virtual colonoscopy is less than that incurred in a double-contrast barium
enema.1 Because retained fecal matter can be misinterpreted as polyps, one alternative is to
use specific contrast material to label fecal matter. Virtual colonoscopy is somewhat limited in
visualizing mucosal detail and polyps smaller than 1 cm, 23 and it does not allow for biopsy
specimens to be taken.

A consensus will need to be reached on the size of polyps that should be biopsied. If a
screening examination using virtual colonoscopy shows a polyp or polyps that meet the
designated criterion, the next step would likely be conventional colonoscopy with polypectomy.
Despite its obvious limitations, virtual colonoscopy could lead to increased patient compliance
and cancer detection, resulting in less colon cancer.

Virtual Bronchoscopy
The work-up for chest tumors and metastatic disease routinely includes a helical CT scan and
bronchoscopy to evaluate patients preoperatively and postoperatively. Bronchoscopy allows the
physician to determine the extent of the disease. Unfortunately, this procedure has some
disadvantages. It is invasive, requires sedation and cannot be tolerated by some patients,
especially children. In addition, the bronchoscope cannot pass areas of stenosis or occlusion,
prohibiting evaluation of distal areas. 24

Virtual bronchoscopy simulates an actual bronchoscopic examination by computing data

acquired from helical CT scans (Figure 2). Virtual bronchoscopy can visualize beyond the
segmental bronchus, allowing the physician to detect stenosis, occlusion, and external
impression on the bronchial lumen. 24 In addition, CT images obtained during virtual
bronchoscopy provide bronchoscopic views not only of the airways but also of lung
parenchyma.

FIGURE 2.
Virtual bronchoscopic view from above carina, looking down at right main-stem endobronchial
mass (arrow).

Studies comparing virtual to fiberoptic bronchoscopy have shown that although there are “no
significant differences in grading [the degree] of stenosis,” 24 virtual bronchoscopy has certain
advantages (Table 3). Virtual bronchoscopy is a noninvasive procedure that requires only breath
holding as patient preparation.1 Virtual bronchoscopy can pass high-grade stenoses and allows
examination of distal (peripheral) airways. 24 An added benefit is that virtual bronchoscopy can
also anatomically localize lesions. 1 Airway stenoses may be reliably evaluated with virtual
bronchoscopy to the level of the segmented bronchus. 25 Automated navigational aids and
detection software are being developed and refined. 26 In addition, the position of extrabronchial
processes, such as external impressions, can be correlated with cross-sectional images, aiding
in localization.24 Furthermore, virtual bronchoscopy can be an excellent teaching tool, in that the
clinician can simulate the procedure before the actual bronchoscopy.

Virtual bronchoscopy's disadvantages are its inability to obtain biopsy material and show color,
friability and detail of the mucosal surface. 24 Distal portions of the bronchial tree can become
difficult to assess if they are filled with viscous secretions, such as blood. 24 However, the
combination of virtual bronchoscopy and crosssectional imaging could improve preoperative,
intraoperative and postoperative evaluations. Precise localization of anatomic structures and
abnormalities with virtual bronchoscopy could be helpful in the selection of a biopsy site and an
operative approach, and in follow-up. Sensitivity and specificity of virtual bronchoscopy have not
been determined.

Other Applications

The same models and software discussed in this article have been used in other areas of
medicine. For example, vascular applications can be valuable in the assessment of abdominal
or cerebral aneurysms, carotid or renal stenoses, and atherosclerotic plaques. Three-
dimensional CT angiography may assist in the evaluation of cerebral aneurysms and could
potentially obviate conventional invasive angiography in some cases. Virtual angioscopy can aid
in the characterization of broad-based aneurysms, which can help to determine whether
surgical treatment is preferable to coil embolization. 27

Virtual endoscopy has also been used to evaluate the bladder, kidneys, small intestine, stomach,
larynx, nasolacrimal ducts and paranasal sinuses. Therefore, this method could potentially
provide a means for the screening and surveillance of bladder tumors, which tend to
recur (Figure 3).FIGURE 3.

Virtual cytoscopic view of transitional cell carcinoma of the bladder. The tumor is seen at the
posterior wall (thin arrow) and left ureterovesicular junction (thick arrow).
Virtual endoscopy can also be used to simulate endoscopic surgery before the actual
performance, thus helping the surgeon plan the operative approach. In summary, virtual
endoscopy is a nascent technique with multiple potential applications that could have a
significant impact on common clinical issues, especially colorectal cancer screening. Improved
screening could detect certain cancers at an early, curable stage and could prevent the
development of cancer.

Source: https://www.aafp.org/pubs/afp/issues/2002/0701/p107.html
Endoscopy is a medical procedure that allows a doctor to observe the inside of the body without
performing major surgery. An endoscope (fibrescope) is a long flexible tube with a lens at one
end and a video camera at the other.

The end with the lens is inserted into the patient. Light passes down the tube (via bundles of
optical fibres) to illuminate the relevant area, and the video camera magnifies the area and
projects it onto a television screen so the doctor can see what is there. Usually, an endoscope is
inserted through one of the body’s natural openings, such as the mouth, urethra, or anus.

Specially designed endoscopes are used to perform simple surgical procedures, such as:

 Locating, sampling or removing tumours from the lungs and digestive tract.
 Locating and removing foreign objects from the lungs and digestive tract.
 Taking small samples of tissue for diagnostic purposes (biopsy).
 Removing stones from the bile duct.
 Placing tubes (stents) through blockages in the bile duct, oesophagus, duodenum, or
colon.

A range of endoscopes
Endoscopes have been developed for many parts of the body. Each has its own name,
depending on the part of the body it is intended to investigate, such as:

 Bronchoscope – inserted down the trachea (windpipe) to examine the lung.

 Colonoscope – inserted through the anus to examine the colon (bowel).
 Gastroscope – inserted down the oesophagus to examine the stomach.
 Duodenoscope – inserted through the stomach into the duodenum to inspect and
perform procedures on the bile duct and /or pancreatic duct, called ERCP (Endoscopic
Retrograde Cholangio-Pancreatogram).
 Hysteroscope – inserted through the cervix to examine the uterus.
 Cystoscope and ureteroscope - inserted via the urethra to inspect the urinary bladder
and ureters.

Medical issues to consider

Depending on the condition under investigation, some endoscopies can be carried out in the
doctor’s surgery. Others need a trip to hospital or day surgery facility, and may require a general
anaesthetic.

Endoscopies are generally painless, although they may still cause some discomfort. Compared
with the stress experienced by the body in a full surgical procedure, an endoscopy is simple, low
risk, and cost effective. Other advantages include:

 No scar – as a natural body opening is used.

 Quick recovery time.
 Less time in hospital. Often, no time in hospital is required as the procedure is performed
in the doctor’s rooms.

Source:https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/endoscopy#taking-care-of-
yourself-at-home