DOI: 10.1148/rg.255045184
CT Colonography with Intravenous Contrast Material: Varied Appearances of Colorectal Carcinoma1
Alvin C. Silva, MD,
Amy K. Hara, MD,
Jonathan A. Leighton, MD and
Jacques P. Heppell, MD
1 From the Department of Diagnostic Radiology (A.C.S., A.K.H.), Division of Gastroenterology and Hepatology (J.A.L.), and Division of Colon and Rectal Surgery (J.P.H.), Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259. Recipient of a Cum Laude award for an education exhibit at the 2003 RSNA Annual Meeting. Received September 30, 2004; revision requested November 8 and received May 11, 2005; accepted May 12. A.K.H. receives royalties from GE Medical Systems, Waukesha, Wis, for a CT colonoscopy software license; all other authors have no financial relationships to disclose.
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Figure 1. Drawing illustrates the morphologic variations of colon carcinoma reviewed in this article. (Courtesy of the Mayo Foundation for Medical Education and Research, Rochester, Minn.)
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Figure 2. Stage B1 carcinoma (modified Astler-Coller-Dukes classification). Axial CT image shows a carcinoma of the sigmoid colon (long arrow). Note the well-defined periphery and clear adjacent fat (short arrows). At pathologic inspection, the tumor was found to be infiltrating the muscularis. CT colonography does not allow reliable differentiation of a carcinoma confined to the mucosa or submucosa (stage A) from one invading the muscularis (stage B1).
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Figure 3. Stage B2 carcinoma (modified Astler-Coller-Dukes classification). Axial CT image shows a polypoid carcinoma with a poorly defined, nodular peripheral margin that bulges into the pericolonic fat (arrows). At pathologic inspection, the tumor was found to extend into the mesenteric fat, but regional lymph nodes were negative.
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Figure 4a. Stage C carcinoma (modified Astler-Coller-Dukes classification). (a, b) Axial 2D images show a circumferential mass of the transverse colon (arrows) with an enlarged, necrotic pericolonic lymph node (arrowheads in b). (c, d) Intraluminal 3D image (c) and volume-rendered image (d) show only a small residual lumen (arrow). (The 3D image demonstrates the perspective indicated on the volume-rendered image [arrow in d].) Note the classic "apple core" appearance of the carcinoma on the volume-rendered image. Because annular masses may be indistinguishable from incompletely distended segments of the colon on 3D images, correlation with the axial 2D images is often required for differentiation.
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Figure 4b. Stage C carcinoma (modified Astler-Coller-Dukes classification). (a, b) Axial 2D images show a circumferential mass of the transverse colon (arrows) with an enlarged, necrotic pericolonic lymph node (arrowheads in b). (c, d) Intraluminal 3D image (c) and volume-rendered image (d) show only a small residual lumen (arrow). (The 3D image demonstrates the perspective indicated on the volume-rendered image [arrow in d].) Note the classic "apple core" appearance of the carcinoma on the volume-rendered image. Because annular masses may be indistinguishable from incompletely distended segments of the colon on 3D images, correlation with the axial 2D images is often required for differentiation.
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Figure 4c. Stage C carcinoma (modified Astler-Coller-Dukes classification). (a, b) Axial 2D images show a circumferential mass of the transverse colon (arrows) with an enlarged, necrotic pericolonic lymph node (arrowheads in b). (c, d) Intraluminal 3D image (c) and volume-rendered image (d) show only a small residual lumen (arrow). (The 3D image demonstrates the perspective indicated on the volume-rendered image [arrow in d].) Note the classic "apple core" appearance of the carcinoma on the volume-rendered image. Because annular masses may be indistinguishable from incompletely distended segments of the colon on 3D images, correlation with the axial 2D images is often required for differentiation.
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Figure 4d. Stage C carcinoma (modified Astler-Coller-Dukes classification). (a, b) Axial 2D images show a circumferential mass of the transverse colon (arrows) with an enlarged, necrotic pericolonic lymph node (arrowheads in b). (c, d) Intraluminal 3D image (c) and volume-rendered image (d) show only a small residual lumen (arrow). (The 3D image demonstrates the perspective indicated on the volume-rendered image [arrow in d].) Note the classic "apple core" appearance of the carcinoma on the volume-rendered image. Because annular masses may be indistinguishable from incompletely distended segments of the colon on 3D images, correlation with the axial 2D images is often required for differentiation.
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Figure 5a. Stage D carcinoma (modified Astler-Coller-Dukes classification). (a) Coronal contrast-enhanced 2D image shows a mass of the sigmoid colon (white arrows) and an associated liver metastasis (black arrow). (b–d) Intraluminal 3D image (b), colonoscopic image (c), and volume-rendered image (d) show a high-grade intraluminal obstruction with elevated, irregular margins (arrowheads in b and c) and a small residual lumen (arrow). (The 3D and colonoscopic images demonstrate the perspective indicated on the volume-rendered image [arrow in d].)
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Figure 5b. Stage D carcinoma (modified Astler-Coller-Dukes classification). (a) Coronal contrast-enhanced 2D image shows a mass of the sigmoid colon (white arrows) and an associated liver metastasis (black arrow). (b–d) Intraluminal 3D image (b), colonoscopic image (c), and volume-rendered image (d) show a high-grade intraluminal obstruction with elevated, irregular margins (arrowheads in b and c) and a small residual lumen (arrow). (The 3D and colonoscopic images demonstrate the perspective indicated on the volume-rendered image [arrow in d].)
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Figure 5c. Stage D carcinoma (modified Astler-Coller-Dukes classification). (a) Coronal contrast-enhanced 2D image shows a mass of the sigmoid colon (white arrows) and an associated liver metastasis (black arrow). (b–d) Intraluminal 3D image (b), colonoscopic image (c), and volume-rendered image (d) show a high-grade intraluminal obstruction with elevated, irregular margins (arrowheads in b and c) and a small residual lumen (arrow). (The 3D and colonoscopic images demonstrate the perspective indicated on the volume-rendered image [arrow in d].)
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Figure 5d. Stage D carcinoma (modified Astler-Coller-Dukes classification). (a) Coronal contrast-enhanced 2D image shows a mass of the sigmoid colon (white arrows) and an associated liver metastasis (black arrow). (b–d) Intraluminal 3D image (b), colonoscopic image (c), and volume-rendered image (d) show a high-grade intraluminal obstruction with elevated, irregular margins (arrowheads in b and c) and a small residual lumen (arrow). (The 3D and colonoscopic images demonstrate the perspective indicated on the volume-rendered image [arrow in d].)
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Figure 6a. Stage D invasive carcinoma (modified Astler-Coller-Dukes classification). (a) Axial 2D supine image shows loss of the normal fat planes (arrows) between a mass of the splenic flexure (M) and the stomach (S). Direct invasion was found at surgical resection. (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass (arrows) nearly occludes the colonic lumen.
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Figure 6b. Stage D invasive carcinoma (modified Astler-Coller-Dukes classification). (a) Axial 2D supine image shows loss of the normal fat planes (arrows) between a mass of the splenic flexure (M) and the stomach (S). Direct invasion was found at surgical resection. (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass (arrows) nearly occludes the colonic lumen.
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Figure 6c. Stage D invasive carcinoma (modified Astler-Coller-Dukes classification). (a) Axial 2D supine image shows loss of the normal fat planes (arrows) between a mass of the splenic flexure (M) and the stomach (S). Direct invasion was found at surgical resection. (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass (arrows) nearly occludes the colonic lumen.
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Figure 7a. Sessile adenocarcinoma. (a) Axial supine 2D image shows a sessile mass of the right colon (arrows). (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the mass (arrows).
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Figure 7b. Sessile adenocarcinoma. (a) Axial supine 2D image shows a sessile mass of the right colon (arrows). (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the mass (arrows).
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Figure 7c. Sessile adenocarcinoma. (a) Axial supine 2D image shows a sessile mass of the right colon (arrows). (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the mass (arrows).
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Figure 8a. Ulcerated adenocarcinoma. (a) Axial supine 2D image shows a polypoid rectal mass (arrow). (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass has a central ulceration (arrow).
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Figure 8b. Ulcerated adenocarcinoma. (a) Axial supine 2D image shows a polypoid rectal mass (arrow). (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass has a central ulceration (arrow).
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Figure 8c. Ulcerated adenocarcinoma. (a) Axial supine 2D image shows a polypoid rectal mass (arrow). (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass has a central ulceration (arrow).
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Figure 9a. Necrotic adenocarcinoma. (a) Axial contrast-enhanced 2D image shows a polypoid adenocarcinoma with avascular regions (arrows) in the right colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the adenocarcinoma. At pathologic inspection, the avascular regions corresponded to areas of necrosis.
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Figure 9b. Necrotic adenocarcinoma. (a) Axial contrast-enhanced 2D image shows a polypoid adenocarcinoma with avascular regions (arrows) in the right colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the adenocarcinoma. At pathologic inspection, the avascular regions corresponded to areas of necrosis.
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Figure 9c. Necrotic adenocarcinoma. (a) Axial contrast-enhanced 2D image shows a polypoid adenocarcinoma with avascular regions (arrows) in the right colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the adenocarcinoma. At pathologic inspection, the avascular regions corresponded to areas of necrosis.
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Figure 10a. Mucinous carcinoma. (a) Intraluminal 3D image shows an oval filling defect involving the distal transverse colon (arrowheads). (b) Oblique axial 2D image shows that the mass (arrowheads) has heterogeneous hypovascularity (arrow), which corresponded to mucinous material at pathologic inspection.
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Figure 10b. Mucinous carcinoma. (a) Intraluminal 3D image shows an oval filling defect involving the distal transverse colon (arrowheads). (b) Oblique axial 2D image shows that the mass (arrowheads) has heterogeneous hypovascularity (arrow), which corresponded to mucinous material at pathologic inspection.
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Figure 11a. Flat adenocarcinoma. (a) Axial supine 2D image shows a tumor that is wider than it is tall (arrows). (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass conforms to the nondependent colonic wall (arrows).
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Figure 11b. Flat adenocarcinoma. (a) Axial supine 2D image shows a tumor that is wider than it is tall (arrows). (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass conforms to the nondependent colonic wall (arrows).
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Figure 11c. Flat adenocarcinoma. (a) Axial supine 2D image shows a tumor that is wider than it is tall (arrows). (b, c) Intraluminal 3D (b) and colonoscopic (c) images show that the mass conforms to the nondependent colonic wall (arrows).
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Figure 12a. Ulcerated flat adenocarcinoma growing off a haustral fold. (a) Axial 2D image shows an ulcerated mass (arrow) emanating from a haustral fold in the distal ascending colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the mass (arrows).
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Figure 12b. Ulcerated flat adenocarcinoma growing off a haustral fold. (a) Axial 2D image shows an ulcerated mass (arrow) emanating from a haustral fold in the distal ascending colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the mass (arrows).
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Figure 12c. Ulcerated flat adenocarcinoma growing off a haustral fold. (a) Axial 2D image shows an ulcerated mass (arrow) emanating from a haustral fold in the distal ascending colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images also show the mass (arrows).
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Figure 13a. Flat adenocarcinoma mimicking a thickened fold. (a) Axial 2D image shows an adenocarcinoma (arrowheads) confined to a haustral fold in the transverse colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images show only partial involvement (arrows) of the haustral fold (arrowhead in b).
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Figure 13b. Flat adenocarcinoma mimicking a thickened fold. (a) Axial 2D image shows an adenocarcinoma (arrowheads) confined to a haustral fold in the transverse colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images show only partial involvement (arrows) of the haustral fold (arrowhead in b).
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Figure 13c. Flat adenocarcinoma mimicking a thickened fold. (a) Axial 2D image shows an adenocarcinoma (arrowheads) confined to a haustral fold in the transverse colon. (b, c) Intraluminal 3D (b) and colonoscopic (c) images show only partial involvement (arrows) of the haustral fold (arrowhead in b).
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Figure 14a. Direct invasion by an endometrial carcinoma. (a) Axial 2D image shows a large mass (M) that markedly displaces and attenuates the rectosigmoid colon with polypoid invasion through the bowel wall (arrows). (b) Intraluminal 3D image also shows the polypoid invasion through the bowel wall (arrows).
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Figure 14b. Direct invasion by an endometrial carcinoma. (a) Axial 2D image shows a large mass (M) that markedly displaces and attenuates the rectosigmoid colon with polypoid invasion through the bowel wall (arrows). (b) Intraluminal 3D image also shows the polypoid invasion through the bowel wall (arrows).
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Figure 15a. Metastatic lymph node with secondary colonic extension. (a) Axial 2D image shows a large mass involving the sigmoid colon (arrows). The epicenter of the mass is extraluminal. (b) Intraluminal 3D image shows the irregular mucosal surface of the mass (arrows), which is pressing on the lumen. CT colonography performed 10 months earlier showed an adenocarcinoma of the right colon (not shown). (c) Axial 2D image obtained 10 months earlier shows a small peri–sigmoid colon lymph node (arrow). In retrospect, the location of this lymph node corresponded to the location of the subsequent mass.
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Figure 15b. Metastatic lymph node with secondary colonic extension. (a) Axial 2D image shows a large mass involving the sigmoid colon (arrows). The epicenter of the mass is extraluminal. (b) Intraluminal 3D image shows the irregular mucosal surface of the mass (arrows), which is pressing on the lumen. CT colonography performed 10 months earlier showed an adenocarcinoma of the right colon (not shown). (c) Axial 2D image obtained 10 months earlier shows a small peri–sigmoid colon lymph node (arrow). In retrospect, the location of this lymph node corresponded to the location of the subsequent mass.
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Figure 15c. Metastatic lymph node with secondary colonic extension. (a) Axial 2D image shows a large mass involving the sigmoid colon (arrows). The epicenter of the mass is extraluminal. (b) Intraluminal 3D image shows the irregular mucosal surface of the mass (arrows), which is pressing on the lumen. CT colonography performed 10 months earlier showed an adenocarcinoma of the right colon (not shown). (c) Axial 2D image obtained 10 months earlier shows a small peri–sigmoid colon lymph node (arrow). In retrospect, the location of this lymph node corresponded to the location of the subsequent mass.
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Figure 16a. Incomplete distention. (a) Supine axial 2D image obtained with intravenous contrast material shows an eccentric carcinoma of the sigmoid colon (arrows). (b) On a prone axial 2D image, the carcinoma is obscured by underdistention.
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Figure 16b. Incomplete distention. (a) Supine axial 2D image obtained with intravenous contrast material shows an eccentric carcinoma of the sigmoid colon (arrows). (b) On a prone axial 2D image, the carcinoma is obscured by underdistention.
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Figure 17a. Adherent stool. (a) Intraluminal 3D image shows a polypoid mass (arrows). (b, c) Prone (b) and supine (c) axial 2D images show that the mass (arrow) is adherent to the posterolateral colonic wall. The heterogeneous high attenuation of the lesion is due to barium tagging and thus indicates stool rather than a polyp or malignancy.
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Figure 17b. Adherent stool. (a) Intraluminal 3D image shows a polypoid mass (arrows). (b, c) Prone (b) and supine (c) axial 2D images show that the mass (arrow) is adherent to the posterolateral colonic wall. The heterogeneous high attenuation of the lesion is due to barium tagging and thus indicates stool rather than a polyp or malignancy.
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Figure 17c. Adherent stool. (a) Intraluminal 3D image shows a polypoid mass (arrows). (b, c) Prone (b) and supine (c) axial 2D images show that the mass (arrow) is adherent to the posterolateral colonic wall. The heterogeneous high attenuation of the lesion is due to barium tagging and thus indicates stool rather than a polyp or malignancy.
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Figure 18a. Residual fluid. (a, b) Prone axial 2D (a) and intraluminal 3D (b) images show a polypoid cecal adenocarcinoma (arrow). Note the layering, dependent mixture of residual fluid and stool (FS in a). (c, d) On supine axial 2D (c) and intraluminal 3D (d) images, the adenocarcinoma is obscured by the fluid. However, the addition of intravenous contrast material increases the conspicuity of the submerged, enhancing lesion (arrow in c) relative to that of the nonenhancing fluid and stool.
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Figure 18b. Residual fluid. (a, b) Prone axial 2D (a) and intraluminal 3D (b) images show a polypoid cecal adenocarcinoma (arrow). Note the layering, dependent mixture of residual fluid and stool (FS in a). (c, d) On supine axial 2D (c) and intraluminal 3D (d) images, the adenocarcinoma is obscured by the fluid. However, the addition of intravenous contrast material increases the conspicuity of the submerged, enhancing lesion (arrow in c) relative to that of the nonenhancing fluid and stool.
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Figure 18c. Residual fluid. (a, b) Prone axial 2D (a) and intraluminal 3D (b) images show a polypoid cecal adenocarcinoma (arrow). Note the layering, dependent mixture of residual fluid and stool (FS in a). (c, d) On supine axial 2D (c) and intraluminal 3D (d) images, the adenocarcinoma is obscured by the fluid. However, the addition of intravenous contrast material increases the conspicuity of the submerged, enhancing lesion (arrow in c) relative to that of the nonenhancing fluid and stool.
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Figure 18d. Residual fluid. (a, b) Prone axial 2D (a) and intraluminal 3D (b) images show a polypoid cecal adenocarcinoma (arrow). Note the layering, dependent mixture of residual fluid and stool (FS in a). (c, d) On supine axial 2D (c) and intraluminal 3D (d) images, the adenocarcinoma is obscured by the fluid. However, the addition of intravenous contrast material increases the conspicuity of the submerged, enhancing lesion (arrow in c) relative to that of the nonenhancing fluid and stool.
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Figure 19a. Chronic stricture caused by diverticular disease. (a) Prone axial 2D image shows a masslike lesion of the sigmoid colon (arrows). (b) Supine axial 2D image obtained with intravenous contrast material shows the elongated, enhancing lesion (arrows) as well as diverticula (arrowheads). Repeat biopsies revealed chronic inflammatory cells but no malignancy.
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Figure 19b. Chronic stricture caused by diverticular disease. (a) Prone axial 2D image shows a masslike lesion of the sigmoid colon (arrows). (b) Supine axial 2D image obtained with intravenous contrast material shows the elongated, enhancing lesion (arrows) as well as diverticula (arrowheads). Repeat biopsies revealed chronic inflammatory cells but no malignancy.
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Copyright © 2005 by the Radiological Society of North America.
