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Colon, Adenocarcinoma: Imaging

Author: Isaac Hassan, MB, ChB, FRCR, DMRD, Former Senior Consultant Radiologist, Department of Radiology, St Bernard's Hospital, Gibraltar Contributor Information and Disclosures Updated: Mar 2, 2009

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Radiography

Polypoid carcinoma. A large, irregular lobulated mass is present in the rectosigmoid junction. [ CLOSE WINDOW ]

Polypoid carcinoma. A large, irregular lobulated mass is present in the rectosigmoid junction.

Annular carcinoma of the sigmoid colon. The lumen of the sigmoid is narrowed severely by the circumferential mass with mucosal destruction and the overhanging edges or shouldering at the tumor margins. [ CLOSE WINDOW ]

Annular carcinoma of the sigmoid colon. The lumen of the sigmoid is narrowed severely by the circumferential mass with mucosal destruction and the overhanging edges or shouldering at the tumor margins.

Flat carcinoma in the transverse colon. A broad-based contour defect with central ulceration. [ CLOSE WINDOW ]

Flat carcinoma in the transverse colon. A broad-based contour defect with central ulceration.

Double-contrast barium enema. 18-mm sessile polyp in the sigmoid colon showing crescent sign. [ CLOSE WINDOW ]

Double-contrast barium enema. 18-mm sessile polyp in the sigmoid colon showing crescent sign.

Double-contrast barium enema. Stalked 15-mm polyp in sigmoid colon. [ CLOSE WINDOW ]

Double-contrast barium enema. Stalked 15-mm polyp in sigmoid colon.

Cecal carcinoma. A large polypoid cecal mass involves the ileocecal valve and causes small bowel obstruction. [ CLOSE WINDOW ]

Cecal carcinoma. A large polypoid cecal mass involves the ileocecal valve and causes small bowel obstruction.

Colonic urticaria in ascending colon proximal to obstructing carcinoma in the hepatic flexure. [ CLOSE WINDOW ]

Colonic urticaria in ascending colon proximal to obstructing carcinoma in the hepatic flexure.

Local perforation and paracolic collection in an annular carcinoma of the descending colon. [ CLOSE WINDOW ]

Local perforation and paracolic collection in an annular carcinoma of the descending colon.

Synchronous annular carcinomas in the ascending colon and splenic flexure. [ CLOSE WINDOW ]

Synchronous annular carcinomas in the ascending colon and splenic flexure.

Annular carcinoma of the transverse colon is associated with a 2-cm polyp in the sigmoid colon. [ CLOSE WINDOW ]

Annular carcinoma of the transverse colon is associated with a 2-cm polyp in the sigmoid colon.

Findings
Advanced carcinoma Most colon cancers are relatively advanced, measuring 3-4 cm in diameter at diagnosis. The appearance of the tumors on double-contrast barium enema reflects the 3 morphologic types: polypoid, annular, or flat.

Polypoid lesions vary from small, smooth tumors to larger lobulated masses with an irregular surface and an associated contour deformity along 1 margin of the bowel wall (Image 1). The incidence of carcinoma in an adenomatous polyp is related to its size and surface features: larger, more irregular ulcerated lesions are more likely to contain carcinoma. Annular lesions result from irregular, circumferential masses that severely constrict the bowel lumen. The margins of the carcinoma show overhanging edges, the tumor shelf or shoulder (termed "apple-core" lesion). The mucosal folds in the narrowed segment are destroyed; ulceration may be present (Image 2). Flat lesions, which are rare, are visualized as a unilateral, broad-based, contour defect. Ulceration may be present (Image 3). Flat lesions may infiltrate the bowel wall and, if extensive, cause areas of nondistensibility.

Early carcinoma Small carcinomas usually present as a polypoid mass with a smooth outline; they may be indistinguishable from a benign polyp. Rarely, they may present as a small flat lesion (Image 3).

Radiologic appearances Radiologically, a polypoid mass is visualized either as a filling defect in the barium column (single-contrast study) or, more commonly, as a barium-coated soft tissue mass protruding into the air-filled lumen (double-contrast study). A sessile polyp may be visualized as a crescent (or ring) shadow on the bowel wall (Image 4). Lobulation is common in polypoid lesions larger than 2 cm in diameter. Pedunculated polyps have stalks that may be identified easily on profile (Image 5). When the stalk is seen through the polyp itself, this results in a target (or Mexican hat) appearance. Malignant change may occur in the head of a stalked polyp. A long (2 cm or more) thin (5 mm or less) stalk may hinder the spread of carcinoma from the head of the polyp into the wall. Risk of malignancy The risk of malignancy in a polyp increases with its size. Risk is less than 1% in polyps with less than a 1 cm diameter. This risk of malignancy increases to 5% in adenomas of 1-2 cm in diameter. Patients with polyps larger than 2 cm have a risk of 11-50%. Thus, all polypoid lesions from 0.5-3 cm require endoscopic removal and histologic examination. Local complications Findings that result from complications of the primary tumor include the following:

Obstruction: Large bowel obstruction usually results in an annular carcinoma in the sigmoid or descending colon. Primary colonic adenocarcinoma accounts for 75% of large bowel obstruction in adults. Small bowel obstruction may be caused by a cecal lesion involving the ileocecal valve (Image 6). Colitis and colonic urticaria: Colitis is a rare complication and occurs proximal to an obstructing tumor. Colonic urticaria (a term describing confluent, polygonal raised areas) may be present from submucosal edema caused by the raised intraluminal pressure proximal to the obstruction (Image 7). Intussusception: This is rare in adults and usually occurs in polypoidal cecal tumors. Perforation: A localized perforation caused by tumor necrosis may result in a paracolic abscess simulating an inflammatory process (Image 8). Perforation also may occur proximal to an obstructing tumor, usually in the cecum. Fistulation: A tumor may extend through the bowel wall and invade adjacent organs. Fistulas also may form between the tumor and adjacent organs.

Synchronous lesions Approximately 5% of patients with colon cancer have more than 1 cancer at diagnosis (Image 9). Approximately 35% of patients with colon cancer have an adenomatous polyp (Image 10).

Second tumors are more likely to be overlooked. Plain abdominal radiography Plain abdominal radiographs are useful in patients presenting with large bowel obstruction or perforation. Free gas below the diaphragm is detected best by plain erect chest radiograph. Rarely, mucin-producing colon cancers show calcification in the primary tumor and in hepatic and peritoneal secondary deposits.

Degree of Confidence
Double-contrast barium enema detects approximately 90% of colonic tumors. The overall detection rate for single-contrast barium enema is approximately 80% but is much lower for small polypoid tumors. Colonoscopy and biopsy are recommended in patients whose findings are equivocal.

False Positives/Negatives
False-positive findings

Residual stool may adhere to the bowel wall and mimic a tumor. The ileocecal valve may mimic a cecal tumor. A submucosal mass, such as a lipoma, benign mucosal adenoma, or hyperplastic polyp, may be indistinguishable from a small polypoid cancer.

False-negative findings

Inadequate bowel preparation: Residual stool may obscure a carcinoma. A repeat examination or colonoscopy is required. Diverticulosis: When severe sigmoid diverticulosis is present, the incidence of missed cancers increases. Diverticulitis: Strictures and paracolic collections may mimic a neoplasm. Small lesions: Small lesions may be missed in a dense pool of barium. Errors of perception: These are responsible for more than 50% of cancers that are missed on barium enema; a second reading performed by a different observer may reduce such errors. Multiple cancers: Second lesions are more likely to be overlooked (satisfaction of search error). Strictures: Inflammatory bowel disease, ischemic colitis, radiation colitis, and tuberculous colitis may mimic malignant strictures. Extrinsic compression: Extrinsic compression of the colon by an adjacent tumor may mimic a primary colonic tumor.

Prominent peritoneal implants on the surface of the colon: Carcinomatosis from ovarian cancer or advanced endometriosis, for example, can mimic a primary colonic tumor.

Computed Tomography

Preoperative CT. Cecal wall thickening and infiltration of the pericolic fat. [ CLOSE WINDOW ]

Preoperative CT. Cecal wall thickening and infiltration of the pericolic fat.

Preoperative CT. Cecal carcinoma with circumferential involvement of the cecal wall.

[ CLOSE WINDOW ]

Preoperative CT. Cecal carcinoma with circumferential involvement of the cecal wall.

Preoperative CT. Irregular soft tissue mass involving the sigmoid colon. There is associated diverticular disease. [ CLOSE WINDOW ]

Preoperative CT. Irregular soft tissue mass involving the sigmoid colon. There is associated diverticular disease.

Enhancing 6 x 4 cm mass from recurrent carcinoma. Note enlarged left iliacus muscle from malignant involvement. [ CLOSE WINDOW ]

Enhancing 6 x 4 cm mass from recurrent carcinoma. Note enlarged left iliacus muscle from malignant involvement.

Barium enema. Typical annular carcinoma in the proximal sigmoid colon with adjacent diverticular disease (same patient as in Image 13 in Multimedia). [ CLOSE WINDOW ]

Barium enema. Typical annular carcinoma in the proximal sigmoid colon with adjacent diverticular disease (same patient as in Image 13 in Multimedia).

Retroperitoneal lymphadenopathy from cecal carcinoma. [ CLOSE WINDOW ]

Retroperitoneal lymphadenopathy from cecal carcinoma.

Enlarged portal nodes (observed between inferior vena cava and portal vein); hepatic metastases. [ CLOSE WINDOW ]

Enlarged portal nodes (observed between inferior vena cava and portal vein); hepatic metastases.

Contrast-enhanced CT showing liver metastases. Several low-density metastases from the colonic primary tumor involve both lobes of the liver.

[ CLOSE WINDOW ]

Contrast-enhanced CT showing liver metastases. Several low-density metastases from the colonic primary tumor involve both lobes of the liver.

CT scan following a partial hepatectomy for a metastasis in the right lobe. [ CLOSE WINDOW ]

CT scan following a partial hepatectomy for a metastasis in the right lobe.

Chest radiograph. Pulmonary metastases from colon cancer. [ CLOSE WINDOW ]

Chest radiograph. Pulmonary metastases from colon cancer.

CT scan of cerebral metastasis from colon cancer. This is a rare site for metastases from colonic cancer. [ CLOSE WINDOW ]

CT scan of cerebral metastasis from colon cancer. This is a rare site for metastases from colonic cancer.

Enhancing mass in rectus sheath from metastasis from colon cancer (same patient as in Image 14 in Multimedia). [ CLOSE WINDOW ]

Enhancing mass in rectus sheath from metastasis from colon cancer (same patient as in Image 14 in Multimedia).

Postradiotherapy inflammatory mass in the left iliac fossa. Note stranding into the pericolic fat and presacral soft tissue swelling. [ CLOSE WINDOW ]

Postradiotherapy inflammatory mass in the left iliac fossa. Note stranding into the pericolic fat and presacral soft tissue swelling.

Dilated left ureter from inflammatory mass shown in Image 23 in Multimedia. [ CLOSE WINDOW ]

Dilated left ureter from inflammatory mass shown in Image 23 in Multimedia.

Findings Indications for CT scan

CT scan is used for staging colon cancer before surgery, for assessing and staging recurrent disease, and for detecting the presence of distant metastases.6,7,8,9,10 Preoperative CT scan is indicated if there is clinical suggestion of distant metastases or local invasion of the adjacent organs or abdominal wall. In older patients who may be unable to undergo colonoscopy or barium enema, modified CT scan may be performed for primary detection of colorectal tumors. Colonic tumors may be diagnosed on CT scan as an incidental finding. Tumor staging: CT scan findings of primary colon cancer CT scan staging (Table 2, below)or TNM staging (Table 3, below) systems may be used to assess colonic neoplasms. Table 2. CT Scan Staging System for Colonic Cancer*11 Open table in new window [ CLOSE WINDOW ]
Table

Stage Description T1 Intraluminal polypoid mass; no thickening of bowel wall T2 Thickened colonic wall > 6 mm; no periodic extension T3a Thickened colonic wall plus invasion of adjacent muscle or organs T3b Thickened colonic wall plus invasion of pelvic side wall or abdominal wall T4 Distant metastases, usually liver, lung, or adrenal glands Stage Description T1 Intraluminal polypoid mass; no thickening of bowel wall T2 Thickened colonic wall > 6 mm; no periodic extension T3a Thickened colonic wall plus invasion of adjacent muscle or organs T3b Thickened colonic wall plus invasion of pelvic side wall or abdominal wall T4 Distant metastases, usually liver, lung, or adrenal glands * Modified from Thoeni.11 Table 3. TNM/Modified Dukes Classification System*12 Open table in new window [ CLOSE WINDOW ]

Table

TNM Stage Modified Dukes Stage Description T1 N0 M0 A Limited to submucosa T2 N0 M0 B1 Limited to muscularis propria T3 N0 M0 B2 Transmural extension T2 N1 M0 C1 T2, enlarged mesenteric nodes T3 N1 M0 C2 T3, enlarged mesenteric nodes T4 C2 Invasion of adjacent organs Any T M1 D Distant metastases TNM Stage Modified Dukes Stage Description T1 N0 M0 A Limited to submucosa T2 N0 M0 B1 Limited to muscularis propria T3 N0 M0 B2 Transmural extension T2 N1 M0 C1 T2, enlarged mesenteric nodes T3 N1 M0 C2 T3, enlarged mesenteric nodes T4 C2 Invasion of adjacent organs Any T M1 D Distant metastases *American Joint Committee on Cancer.12 Findings A localized tumor may be seen on CT scan as an intraluminal or intramural mass of soft tissue density adjacent to the gas-filled or contrast-filled bowel lumen; this is the appearance of a stage A tumor (Tables 2 and 3). There is no mural thickening or pericolic fat invasion in stage A tumors. To opacify the entire bowel, oral water-soluble contrast (1% Gastrografin) is administered at 12 hours and at 2 hours before examination. More advanced tumors are associated with thickening of the bowel wall (>6 mm) and infiltration of the pericolic fat. Thin strands of tissue may extend from the tumor into the pericolic fat (Image 11). Annular carcinomas are detected by a thickening of the bowel wall and narrowing of the lumen. This thickening is concentric if the scanning plane is at right angles to the long axis of the bowel (Image 12). Extracolonic tumor spread is indicated by a loss of tissue fat planes between the colon and surrounding structures (Image 13). Invaded muscle may be enlarged (Image 14). The comparative barium enema findings are shown in Image 15. Colonic tumors may invade the anterior abdominal wall, liver, pancreas, spleen, or stomach. Complications of the primary tumor Obstruction, perforation, and fistula formation can be demonstrated by CT scan.

An intussuscepting colonic tumor may have a typical targetlike appearance with alternating rings of soft tissue and fat on CT scan, if mesenteric fat is present between the intussusceptum and the intussuscipiens. A local perforation of a carcinoma may be associated with an extraluminal fluid collection. N staging Nodes greater than 10 mm in diameter are considered abnormal. CT scan is unable to distinguish between enlarged benign nodes and enlarged malignant nodes. Furthermore, malignant foci may be present in nodes less than 1 cm in diameter. Overall, 60% of affected nodes are detected by CT scan. Enlarged nodes may be detected in the mesentery and retroperitoneum (Image 16). Occasionally, enlarged nodes are observed around the porta hepatis (Image 17). Rectosigmoid tumors may metastasize to external iliac nodes. M Staging Hepatic metastases are the most common site of distant spread. Following injection of intravenous contrast medium (Image 18), CT scan detects hepatic metastases as well-defined areas of low density (compared with normal liver parenchyma) in the portal venous phase. In the earlier arterial phase, hepatic metastases may show rim enhancement or become hyperdense or isodense (in relation to normal liver). Hepatic metastases may be suitable for surgical resection if they are small (usually <3 cm), number fewer than 3, and are suitably located (Image 19), but others are suitable only for intraarterial chemotherapy or radiofrequency (RF) ablation (see Intervention). Other common sites include the lungs, adrenal glands, peritoneum, and omentum. Although pulmonary metastases may be detected by chest radiograph (Image 20), CT scan has a higher sensitivity for small pulmonary metastases (<10 mm). Adrenal metastases may occur in as many as 14% of patients with colon cancer. They manifest with enlargement (>2 cm), asymmetry, and heterogeneity. Bony and cerebral metastases are uncommon (Image 21). Early cancers and polyps Tumors less than 2 cm in diameter cannot be detected reliably by the standard CT scan technique.

In 1996, Vining introduced CT scan colonography (virtual colonoscopy) as a screening tool for the detection of colorectal polyps and small cancers.13 This technique involves a 3-dimensional computer reconstruction from a volumetric data set that uses a workstation as well as distention of a clean colon with air. Images are read as soft copy from the workstation using a combination of paging through the 2-D axial images, aided by multiplanar and 3-D endoluminal images. Multisectional helical scanners have reduced the time required to obtain the images (usually 30 seconds for each series; scans involve the patient in the prone and supine positions, using a reduced tube current to minimize the radiation dose). The length of time required for image analysis (currently ranging from 5-30 min) also has decreased with the introduction of sophisticated software programs that enable a mathematically straightened colon to be viewed. Advances in computer-aided diagnosis and novel methods of display are expected to improve the performance of this test and reduce the reading time. The sensitivity of virtual colonoscopy using multisectional helical scanners is greater than that of the double-contrast barium enema. For polyps larger than 10 mm, it has a sensitivity of 91% but a specificity of 76%. Sensitivity falls to 81% for 5- to 10-mm polyps. The examination has the advantage of displaying incidental extracolonic findings as well. Data from several ongoing retrospective and prospective multicenter trials are expected in the near future. Colorectal cancer screening CT colonography (virtual colonoscopy) has become an acceptable noninvasive option for colorectal cancer screening that can reliably depict clinically important colorectal lesions. However, substantial controversy remains regarding its exact role. Recent studies have shown that the sensitivity of CT colonography may not be as high when performed and interpreted by radiologists who do not have the required expertise and training. Significant lesions may be missed, and mucosal folds and residual fecal matter may be misinterpreted as polyps, leading to unnecessary colonoscopy. CT scan findings in recurrent colorectal cancer A baseline CT scan study is obtained 3 months following resection of a colonic tumor and reanastomosis. Recurrent tumor is staged by similar criteria as described above for primary cancers. There is a local recurrence rate of 20-40% and a distant metastasis rate of approximately 35% after curative resection. Most of these distant metastases occur within 2 years after surgery. Although colonoscopy and barium enema reveal better mucosal detail of a local anastomotic recurrence, CT scan is able to detect recurrence away from the anastomosis as well as lymphadenopathy and distant metastases. A recurrent tumor mass is typically large and often extrinsic to the bowel wall (see Images 14 and 22). CT scan criteria of a recurrent tumor include invasion of adjacent structures, enlargement, and associated lymphadenopathy. An inflammatory mass following surgery or radiation therapy may mimic a recurrent tumor and may require biopsy for differentiation. Postoperative soft tissue masses are usually from

granulation tissue but may be the result of a hematoma or abscess. Of these, 60% decrease but 40% may remain unchanged for up to 2 years. Both recurrent tumor and inflammatory masses can cause hydronephrosis by ureteric obstruction (see Images 23 and 24).

Degree of Confidence
Degree of Confidence: Colonic lesions smaller than 2 cm usually are not detected. The accuracy and quality of CT scan studies can be increased using air contrast (rectal air insufflation), smooth muscle relaxants, and laxatives. CT scan:

More accurately assesses stage T4 cancers. The spatial resolution of CT scan is too low to distinguish T2 from T3 lesions. Has a 50% sensitivity for local invasion; it does not distinguish between direct tumor infiltration and an inflammatory reaction induced by radiation therapy or surgery (Image 23). Detects as many as 60% of pericolic nodes. Small nodes (<1 cm in diameter) may contain tumor and are not detected. Nodes may be enlarged because of other reasons, such as infection. Detects 90% of liver metastases as well-defined rounded areas of low density following intravenous contrast medium (Image 18).

For polyps larger than 10 mm, CT scan colonography (virtual colonoscopy) has a sensitivity of 91% but a specificity of 76%. Sensitivity falls to 81% for 5- to 10-mm polyps.

False Positives/Negatives
Colon cancer may be indistinguishable from a large benign tumor as well as from metastasis to the colon (usually from an ovarian primary). CT scan signs for colon cancer are not specific and may be caused by any disease associated with focal thickening of the colonic wall. These diseases include diverticulitis, Crohn disease, ischemic colitis, and tuberculous colitis. In cachectic patients, the absence of fat planes is a result of nutritional status and not tumor invasion. A paracolic collection may be seen in diverticulitis, as well as in local perforation of a carcinoma. Chronic radiation changes in the pelvis may mimic recurrent colonic tumors and require biopsy for differentiation.

Tumors in the transverse colon and colonic flexures may be visualized incompletely. A primary gastric carcinoma with extension into the colon may be indistinguishable from a colonic tumor involving the stomach. Enlarged lymph nodes may result from inflammation rather than tumor. Lymph nodes of normal size may contain tumor. Hypodense hepatic lesions may be caused by simple cysts rather than metastases (Image 18). Hemangiomas also may cause confusion.

Magnetic Resonance Imaging


Findings
MRI provides greater contrast between soft tissues than CT scan. Colonic tumors have low signal intensity (similar to adjacent skeletal muscle) on T1-weighted sequences, which facilitates their differentiation from high-signal perirectal fat. T2-weighted images are used to detect pelvic sidewall invasion.14 Tumor enhancement can be achieved by paramagnetic agents such as gadolinium. Gadoliniumbased contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to endstage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape. The new technique of MRI colonography can detect colonic polyps greater than 1 cm in diameter and will compete with CT scan colonography in screening programs.

Degree of Confidence
MRI has lower sensitivity and higher specificity than CT scanning in T staging. The techniques have a similar overall accuracy in T staging, as well as a similar overall accuracy (approximately 60%) in the detection of enlarged lymph nodes (N staging) and liver metastasis (M staging). In detecting local recurrence, MRI has a higher sensitivity (91%) than CT scan (82%) and a higher specificity (100%) than CT scan (69%).

Nevertheless, most centers tend to use CT scanning rather than MRI for staging and follow-up imaging of colonic neoplasms because of their greater experience with and the wider availability of CT scans. In addition, spiral CT scan (and the newer multislice CT scan) can assess the whole abdomen and pelvis in a much shorter time than MRI.

False Positives/Negatives
Limitations of MRI are similar to those of CT scanning. Colon cancer may be indistinguishable from a large benign tumor and from metastasis to the colon (usually from an ovarian primary). MRI signs for colon cancer are not specific and may be caused by any disease associated with focal thickening of the colonic wall. These diseases include diverticulitis, Crohn disease, ischemic colitis, and tuberculous colitis. A paracolic collection may be seen in diverticulitis, as well as in local perforation of a carcinoma. Chronic radiation changes in the pelvis may mimic recurrent colonic tumors and require biopsy for differentiation. Enlarged lymph nodes may result from inflammation rather than tumor. Lymph nodes of normal size may contain tumor.

Ultrasonography

Ultrasound scan through the right lobe of the liver showing large hyperechoic metastasis from colon cancer. [ CLOSE WINDOW ]

Ultrasound scan through the right lobe of the liver showing large hyperechoic metastasis from colon cancer.

Ultrasound scan of a large cecal carcinoma showing concentric thickening of the hypoechoic bowel wall by the tumor. [ CLOSE WINDOW ]

Ultrasound scan of a large cecal carcinoma showing concentric thickening of the hypoechoic bowel wall by the tumor.

Ultrasound scan demonstrating intussuscepting cecal carcinoma. [ CLOSE WINDOW ]

Ultrasound scan demonstrating intussuscepting cecal carcinoma.

Findings
The primary role of ultrasound (US) in patients with colon cancer is the detection of hepatic metastases. US has a detection rate of 70-90% for hepatic metastases, which reflects the operator dependence of this modality, the range of equipment available, and the size of the individual metastasis. Hepatic metastases from a colonic primary tumor are usually hyperechoic (increased echogenicity in relation to normal liver; Image 25) but also may be hypoechoic (decreased echogenicity).

On US, a colonic tumor typically appears as an echo-poor mass with a hyperechoic center, which is known as the target sign (Image 26). Other findings include localized irregular colonic wall thickening, an irregular contour, lack of normal peristalsis, and an absence of the normal layered appearance of the colonic wall. US may detect a colonic tumor as a chance finding or may be used specifically in instances when a palpable abdominal mass is observed that is consistent with a colonic tumor (Image 26). Intussuscepting colonic tumors have a characteristic targetlike appearance from concentric rings of soft tissue and mesenteric-fat density (Image 27).

Degree of Confidence
US usually cannot detect colonic tumors smaller than 2 cm. US is difficult to use in rectosigmoid lesions.

False Positives/Negatives
US has a high false-negative rate for the detection of colonic tumors, with a sensitivity of 3180%, depending on tumor size, and cannot be used as a screening tool. Conversely, US has a low false-positive rate, with a specificity greater than 90%. US may reduce the need for more intrusive procedures in older patients and in those with advanced disease. Its primary role in colon cancer management is to detect hepatic metastases, where it has a detection rate of 70-90%.

Nuclear Imaging
Findings
Nuclear medicine has a small peripheral role in colon cancer. Consider using radioimmunoscintigraphy with monoclonal antibody that recognizes CEA or tumor-associated glycoprotein-72 to detect disease recurrence in the pelvis or extrahepatic abdomen. Consider using positron emission tomography (PET) with fluorodeoxyglucose (FDG) to detect recurrent disease.

Degree of Confidence

A recent study by Meta et al evaluated the impact of FDG-PET on the management of patients with colorectal carcinoma.15 They noted a change in the clinical stage and major management decisions in approximately 40% of patients. Of the changes in clinical stages in 25 patients, the disease was upstaged in 20 patients (80%) and downstaged in 5 patients (20%). As a result of PET findings, physicians avoided major surgery in 41% of patients for whom surgery was the intended treatment.

False Positives/Negatives
False-positive results may occur with FDG from nonspecific inflammatory reactions following radiotherapy or in patients with abscesses.