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Sonographic Evaluation of Colon Carcinoma
Teresa Montano
DMS 495 Clinical Practicum II

Sonographic Evaluation of Colon Carcinoma

!!!!!!!!!!!!!!Although the use of CT is the preferred modality when evaluating the gastrointestinal
tract, sonography has proven to be a vital tool in the detection of colon carcinoma.1 Colon
carcinoma is rarely imaged sonographically due to the bowel gas present in the abdomen, which
makes visibility difficult, even impossible in some instances.2 In this particular case the patient
presented with right lower quadrant pain, which prompted an Abdomen Complete & Pelvic US
(ultrasound) that led to a CT that confirmed findings consistent with colon carcinoma. The focus
of this case study is to present the sonographic appearance of colon carcinoma, how it compares
to current literature, and typical treatment options.

Case History
A 77 year old Caucasian woman was admitted to the hospital with persistent, palpable right
lower quadrant pain (RLQ) for a few days (patient weight not available). Patient had a history of
controlled hypertension, and denied alcohol and tobacco use. Patient also stated that her last
colonoscopy was about a year ago, in which several benign polyps were removed. Previous
surgeries include: cholecystectomy and complete hysterectomy. In the course of a few days
patients creatinine levels rose form 2.1-2.3, which at first were attributed to patients antiinflammatory drugs. However, the patient stopped taking the above medications and her
creatinine continued to rise up to 2.7, and she also began complaining of sudden right lower
quadrant pain. This sudden elevation in her creatinine and symptoms concerned the patients
primary physician, and led her admission to the hospital. Other abnormal lab values during
patients hospital admission include an elevated BUN (24). The RLQ pain was described as
constant and dull and not associated with the ingestion of food, per patients chart. Patient also

denied blood in her stool, nausea, vomiting, chest pain, shortness of breath, or heart palpitations.
Patient interview revealed that the only clinical symptom that the patient was experiencing was
the RLQ abdominal pain, patient denied any other urinary or abdominal symptoms. An
abdominal US and Pelvic US was ordered based on patients elevated creatinine levels, and to
evaluate her RLQ pain. The Pelvic US reported the following findings: the uterus was not seen,
which was consistent with patients hysterectomy and no adnexal masses or free fluid was
visualized. The Abdominal US revealed right sided hydronephrosis with complex appearing right
lower quadrant mass. The abdominal sonogram was performed with patient supine and abdomen
exposed for visualization of abdominal organs with clean towel tucked under patients shirt. A
Logiq E9 machine with a C1-5 transducer with 4MHz frequency was used throughout the exam,
and when evaluating the area of pain a linear array transducer ML 6-15 with a frequency of
9MHz was used. After imaging all of the abdominal organs (pancreas, gallbladder, liver, aorta,
spleen, & kidneys), the sonographer imaged the area of pain as pointed out by the patient using
graded compression technique, multiple scan planes, gray-scale, cine clips, color Doppler,
spectral Doppler, and the use of a linear array transducer ML 6-15 with a frequency of 9MHz.
Next, a CT Abdomen and Pelvis without contrast was ordered that found a mass of terminal
ileum/ cecum and right sided hydronephrosis and hydroureter. A follow-up Renal US was
subsequently ordered after patients hemicolectomy, that showed dramatically improved
hydronephrosis or caliectasis.
Sonographic Findings
The sonographic findings on the Abdominal US, revealed a superficial, heterogeneous,
non-compressible mass with irregular borders and lack of peristalsis in the RLQ, superior to the
iliac crest. The mass measured 4.2 x 3 x 3.4 cm and displayed mixed echogenicity ranging from

anechoic, hypoechoic, to an echogenic center. Color Doppler demonstrated increased internal

vascularity with spectral Doppler demonstrating a low resistive waveform within the mass with a
velocity of 114.1 cm/s. No abnormal lymph nodes were visualized around the mass. Normally
the gastrointestinal tract has a distinct sonographic appearance known as the gut signature, that
consists of five layers of alternating echogenic and hypoechoic layers.2 The mass lacked the
classic appearance present in the gastrointestinal tract. Dilated renal pelvis and calyces (anechoic
and avascular) were also noted in the right kidney, and left kidney appeared within normal limits.
The findings in the Abdominal US exam, resulted in a CT Abdomen and Pelvis without
contrast for further evaluation of the mass found in the RLQ. The final CT report revealed an
exophytic mass arising from the terminal ileum/cecum measuring 4.4 x 3.0 with adjacent
adenopathy. The mass appeared to be compressing the right ureter causing the hydronephrosis
seen in US. These findings were consistent with cecal adenocarcinoma or carcinoid tumor.
Hemicolectomy was then scheduled to remove the carcinoma and resolve the obstruction to the
ureter. Operative report described the mass as a large fungating mass involving the cecum,
ileoceccal valve and the lymph nodes around the mass. Also the report stated that the patient had
massive hydroureter due to obstruction of the ureter by the tumor, and that the mass had grown
into the retroperitoneum, Gerotas fascia, that was trying to grow into the duodenum. Pathology
reported the mass to be undifferentiated carcinoma Grade 4 of 4 that had spread through the
layers of the gastrointestinal tract.
Colon cancer accounts for 80% of all malignant gastric neoplasms and it is the third
most common cancer in both women and men.2 Clinically patients are mostly asymptomatic, but
may present with blood in the stool, vague abdominal symptoms, palpable abdominal mass,

unexplained weight loss, and weakness or fatigue. 3 Colon carcinoma is cancer involving the
large intestine, most of them originating with benign adenomatous polys, which eventually
become colon cancers.3 Colon cancer can lead to direct invasion, regional lymph node
enlargement, and liver metastases.2 Some risk factors for developing colon cancer include:
increased age (older than 50), a personal history of colorectal cancer or polyps, obesity, smoking,
alcohol use, family history of colon cancer and colon polyps, and radiation therapy for
cancer.3Sonographically the mass may appear as hypoechoic, with a hyperechoic center (target
sign or pseudokidney), irregular wall thickening, lack of peristalsis, and the absence of normal
layered appearance of the colon wall.4 The thickened wall may be either a concentric
symmetrical or an asymmetrical pattern. 2 Another sonographic appearance of colon carcinoma is
a localized hypoechoic mass up to 10 cm or more with an irregular shape lobulated contour.5
When compared to the literature review of colon carcinoma this case was found to present
with most of the classic clinical and sonographic features associated with the pathology.
Clinically the patient presented with one of the usual symptoms associated with colon carcinoma,
which was the abdominal pain. However, typically patients with colon carcinoma have the
abdomen pain, but may additionally present with blood in their stool, weakness, fatigue weight
loss, etc.3 The patient also presented with some the associated risk factors of colon carcinoma,
which included her advanced age and her history of colon polyps. Sonographically the patients
mass coincided with the typical appearance of colon carcinoma. The mass exhibited a target-like
appearance with an echogenic center, irregular shape, non-compressible, there was no
visualization of the gut signature and it was hypervascular.

It is important for sonographers to explore the patients source of abdominal pain if all other
organs imaged lacked any pathology that could be causing the pain. For example, if the
Abdominal US was ordered for abdomen pain it is vital for the sonographer to ask the patient the
exact location of this pain in order to rule out any pathology in the gastrointestinal tract. Since
the area of interest may have overlying bowel gas, it is also equally important for the
sonographer to use various techniques when accessing a suspicious mass in the gastrointestinal
tract before dismissing as bowel loops or gas. One technique is graded compression, which
involves using transducer pressure over the questionable mass. If the mass compresses then it is
bowel content, but if it does not it could be a malignant mass that would need further evaluation.
Additionally once a mass is identified, the sonographer should use color and spectral Doppler to
determine the presence of blood flow within the mass and the type of waveform. In the case of
malignancy hypervascularity will be see along with a low-resistance waveform.
According to the literature the appropriate treatment for color carcinoma depends on the
extent of the pathology. For instance if the colon carcinoma has grown into or through the colon,
a partial colectomy may be recommended to remove the affected section of the colon and the

healthy portions of the colon will be anastomosed In addition to the partial colectomy, nearby
lymph nodes will be removed and tested for cancer.3 After surgery usually chemotherapy is used
to destroy cancer cells that have spread to the lymph nodes, therefore reducing the risk of cancer
recurrence.3 If the cancer is advanced, surgery is recommended to relieve the blockage of the
colon to improve the associated symptoms, but it will not cure the cancer.3 Other treatment
options include targeted drug therapy, which involves the used of drugs that target specific
defects that allow cancer cells to grow. 3 This kind of treatment is commonly used in patients

with advance colon cancer. 3 In this specific case the hemicolectomy was the appropriate
treatment because the mass was extending beyond the colon and obstructing the ureter.

1. Maturen KE, Wasnik AP, Kamaya A, Dillman JR, Kaza RK, Pandya A, Maheshwary RK.
Ultrasound Imaging of Bowel Pathology: Technique and Keys to Diagnosis of the Acute
Abdomen. American Journal of Roentgenology 2011;197:6: W1067-W1075
2. Rumack C, Wilson S, Charboneau JW, Levine D. (2011) Diagnostic Ultrasound. Vol. 1. 4th
ed. St. Louis, MO: Mosby Inc; 2011.
3. Mayo Clinic Staff. Colon Cancer. Mayo Clinic web site. Updated Aug 22, 2013. Accessed
March 7, 2014
4. MD, Taylor CR. Imaging in Adenocarcinoma of the Colon. Medscape web site. Updated May 16, 2013. Accessed
March 7, 2014.
5. Ledermann HP, Brner N, Strunk H, Bongartz G, Zollikofer C, Struckmann G. Bowel Wall
Thickening on Transabdominal Sonography. American Journal of Roentgenology 2000;