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Deal Jurnal DR Oktin PDF
Deal Jurnal DR Oktin PDF
Diagnostic Radiology of
Colon and Rectal Cancer
MARK L. MONTGOMERY, MD
PETER R. MUELLER, MD
Evaluating colorectal neoplasms by means of radiographic imaging continues to play a major role in
detecting and staging cancer of the lower gastrointestinal tract. A variety of imaging modalities can be
used in staging, detection, and follow-up of patients
with colorectal carcinoma. The diagnosis of colon
cancer has traditionally been made on the basis of
barium enema and/or colonoscopy. Computed
tomography (CT) scanning is typically used in the
evaluation of patients with known colonic neoplasms or in the detection of colorectal tumors in
patients with nonspecific abdominal complaints.
Virtual colonoscopy is a relatively new method of
imaging colonic mucosa that uses virtual-reality
software and CT. Magnetic resonance imaging
(MRI) is extremely helpful in detection and characterization of suspected hepatic metastases, particularly in the setting of a negative CT scan. MRI is
also effective in the staging of tumor for local extension. Transrectal ultrasonography has become popular in staging tumors for local extension because of
its ability to demonstrate the various layers of the
colon wall. Positron emission tomography (PET) is
helpful in following patients with colorectal neoplasms and gauging therapeutic treatment responses.
BARIUM ENEMA
Barium enema continues to be a safe, accurate, and
effective means of diagnosing colonic polyps and cancer. Polyps measuring 1 cm in diameter have a 10 percent chance of harboring malignancy.1,2 The sensitivity of a colonic examination is therefore judged on its
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2 cm are not usually associated with malignant invasion into the adjacent wall.10 Polyps measuring
between 0.6 and 1 cm should proceed to biopsy.11
Colorectal neoplasm has a variety of morphologic appearances. Lesions typically appear as annular regions of poor distensibility and have been
likened to the appearance of an apple core (Figure
72). These lesions have a sharp transition point to a
more normal-appearing colon. Sharp shouldering
usually demarcates the lesion. Lesions can also have
a semiannular or saddle appearance. Scirrhous neoplasms may produce marked bowel wall thickening.
Extravasation of contrast producing the double-tract
sign has also been reported with colonic neoplasm.12
Barium enema and colonoscopy should be considered complementary examinations. Barium enema
and colonoscopy have a similar sensitivity rate for
detecting lesions within the colon.13,14 Colonoscopy
carries a greater risk of perforation, with rates
reported between 1:200 and 1:5,000.15 Colonoscopy
is approximately 3 to 5 times more expensive than
barium enema. Although experienced colonoscopists
reach the cecum in 95 percent of patients, rates of less
experienced operators can be highly variable. Barium
studies are rarely unsuccessful in reaching the cecum.
Colonoscopy, however, has the added advantage of a
lower false-positive error rate since this technique
easily differentiates polyps from stool. Biopsy and
polypectomy are tremendous advantages of
colonoscopy. By optimizing the combination of
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VIRTUAL COLONOSCOPY
Simulated endoscopic visualization of the colon is a
new imaging technique used to evaluate the hollow
organ viscous. Virtual colonoscopy makes use of
specific computer algorithms of helical CT data sets
to acquire images that can be viewed two-dimensionally or three-dimensionally. The radiologist can
view the colon as if perceiving motion similar to
conventional endoscopy (Figures 76 to 79).
The technique of virtual colonoscopy requires
adequate bowel cleansing and the insufflation of air
through a rectal enema tube. Intravenous glucagon is
usually administered to relieve spasm and reduce
motion artifact. Images of the abdomen and pelvis
are usually obtained in a single breathhold, with a
scan slice thickness of 5 mm that can be reconstructed at 2-mm intervals. The CT data can then be
B
Figure 73. A, CT scan through the pelvis shows a large soft tissue attenuation lesion involving the distal sigmoid colon. B, Barium
enema of the same apple core appearing lesion involving the distal
sigmoid colon.
B
Figure 74. A, CT scan of the pelvis showing a rectal carcinoma
with an associated pericolonic lymph node before radiation and
chemotherapy. B, CT scan shows interval reduction in size of the
rectal tumor and lymph node following radiation and chemotherapy.
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Figure 75. CT scan of the abdomen performed after the intravenous adminstration of contrast shows a large metastatic lesion
involving the right lobe of the liver with a central area of low density
representing necrosis.
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Figure 78. Virtual and conventional colonoscopy images of a 6-mm transverse colon polyp. Images courtesy of Dr. Helen Fenlon.
Figure 79.
Virtual and conventional colonoscopy images of a 15-mm dysplatic cecal polyp. Images courtesy of Dr. Helen Fenlon.
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Figure 711. Axial images through the pelvis show a large irregular mass involving the rectum, with disruption of the perirectal fat
planes.
MRI and CT should be considered complementary in the work-up of colorectal neoplasms. MRI is
usually not used as a first-step imaging modality. As
previously mentioned, MRI is particularly helpful
when there is a high clinical suspicion of hepatic
metastases despite a high-quality negative CT scan.
MRI and CT are helpful in determining whether a
patient will benefit from preoperative radiation or if
a sphincter-saving procedure can be performed in
rectal carcinoma.20 CT and MRI are also helpful in
designing radiation ports of patients. As accessibility and imaging techniques continue to improve,
MRI will undoubtedly play a greater role in the
future evaluation of colorectal neoplasm.
ULTRASONOGRAPHY
Transrectal ultrasonography (TRUS) has recently
become popular in staging colonic malignancy. TRUS
allows visualization of the layers of the colonic wall;
therefore, the depth of tumor extension can be ascertained. Pericolonic nodes and extension beyond the
serosa can often be diagnosed with TRUS.
Sensitivities ranging from 67 to 96 percent for
detection of tumor spread beyond the rectal wall
have been reported.19,36,37 Detection of local
adenopathy has been reported at 50 to 75 percent.19,36,37 Although perirectal infiltration of tumor
is usually detected with sensitivities as high as
97 percent, the specificity of examining the perirectal region is low, with numbers reported at 24 percent.38 Advanced neoplasms are often difficult to
evaluate with TRUS and are generally better
assessed with CT or MRI.
Images produced from TRUS appear as rings
radiating from a transducer that is placed within the
colonic lumen. The transducer is covered with a balloon filled with water that appears hypoechoic
(black).20 The various layers of the colonic wall produce different levels of echogenicity. The innermost
ring appears as a hyperechoic band (white) and represents the interface of the balloon with mucosa.20
The second layer seen appears relatively hypoechoic
and represents the muscularis mucosa.20 The third
layer is hyperechoic and represents the submucosa.20
The fourth ring seen is hypoechoic and represents
the muscularis propria.20 The fifth layer is hyper-
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echoic and represents the interface between pericolonic fat and the serosa of the colon.20
Colorectal neoplasms often appear as hypoechoic nodules within the wall of the colon. Extent
of tumor within the colon is depicted by disruption
of the various ultrasonographic layers as previously
described (Figures 713 and 714). Although it is
often difficult to distinguish malignant and benign
nodes by TRUS, malignant nodes may appear
hypoechoic surrounded by the more echogenic fat.
TRUS combined with endoscopy provides a
unique method of assessing colonic neoplasm.
Lesions can be detected, staged for local extension
invasion, and biopsied in one setting. The presence
or absence of pericolonic nodes is often possible. CT
or MRI is, however, required for assessment of distant metastases.
Recently a new ultrasonographic technique,
hydrocolonic sonography, has been described; it
uses water instillation into the colon. The abdomen
is then scanned with a traditional transabdominal
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Figure 713. Colonoscopy and endorectal ultrasound showing a T2 N0 adenocarcinoma of the rectum. Images
courtesy of Drs. Richard Erickson and Andrejs Avots-Avotins, Scott and White Clinic, Temple, TX.
Figure 714. Colonoscopy and endorectal ultrasonography showing a T4 rectal carcinoma with prostate invasion. Images courtesy of Drs. Richard Erickson and Andrejs Avots-Avotins, Scott and White Clinic, Temple, TX.
cose undergo phosphorylation by the enzyme hexokinase, which is used to trap charged species within
the cell. Increased hexokinase activity correlates
with a variety of neoplastic lesions in body tumor
imaging. Tumor conspicuity is therefore increased
with PET imaging after the administration of FDG.
PET images are obtained after injecting 5 to
10 mCi of FDG. Obtaining contiguous 9.7-cm segments is generally considered sufficient in the
detection to liver neoplasm. Imaging is acquired in
10-minute sequential intervals over a period of 60
to 80 minutes. Hepatic metastases show maximum
conspicuity after approximately 60 minutes.39
PET imaging is highly effective in identifying
liver metastases in patients with colorectal neoplasms.40 Studies have shown lesion conspicuity to
exceed CT in detecting liver metastases.41 Morphologic features of metastases have been well characterized, including the characteristic ring configuration of hepatic metastases (Figures 715 and 716).
PET imaging has been advocated as a means of evaluating presacral abnormalities in patients with col-
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