CT scan pada

keganasan colonrectum
Patricia M.Widjaja,SpR
Bag.Radiologi RS HUSADA

CT scan abdomen : keganasan usus

besar

CT

scan abdomen
biasa
CT Colonography,
virtual conoloscopy

CT scan colonography

CT colonography merupakan
pemeriksaan CT scan khusus usus besar
yang non-invasif, peranannya dapat
disamakan dengan konventional
colonoskopi dalam screening Ca colon .
Dibandingkan dengan CT scan abdomen
biasa, CT colonography membutuhkan
persiapan yang lebih repot, hampir
sama dengan persiapan untuk
colonoskopi.
Dibutuhkan indikasi dan tujuan yang
jelas mengarah pada Ca colon-rectum.

Gambaran Ca colorectal

Macam macam :
Sessile
Annular
Ulcerated
Necrotic
Mucinous
Invasive
Non invasive

Imaging pitfalls :
Retained fecal
material
Incomplete distention
Advanced
diverticulosis
Focal mukosa
thickening due to
inflammation process.

In T staging, overall accuracy was 73%

when transverse images were evaluated
alone and 83% when they were evaluated
in combination with MPRs. This difference
was not significant. N staging was
associated with an overall accuracy of 59%
with transverse images alone and 80% with
combined transverse and MPR images (P < .
01). Antonella Filippone et al. ,Radiology 2004,231:83-90.

The prognosis of patients with colorectal carcinoma is dependent

on the stage of disease at the time of diagnosis. The depth of
wall invasion and the presence of lymph node and distant
metastases are the major factors that influence prognosis.
Detection of colorectal carcinoma before the malignancy has
invaded into or extended through the muscularis propria and
before lymph node metastases have occurred offers the best
prognosis for the patient and the option of more limited surgery.

The use of intravenously administered contrast material to

enhance the bowel wall during CT is a relatively recent
development in gastrointestinal imaging. To our knowledge, Amin
et al (10,11) were the first to describe the use of intravenously
administered contrast material during dynamic helical CT of an
air-insufflated colon in the detection and staging of colorectal
cancer.

The overall accuracy of the assessment of lymph node

involvement on contrast-enhanced multidetector row CT
colonographic images was 59% (24 of 41 patients). Over- and
understaging occurred in 12 of 41 (29%) patients and five of 41
(12%) patients, respectively.
The overall accuracy of the assessment of lymph nodes on
transverse images in combination with MPRs was 80% (33 of 41
patients). Over- and understaging occurred in five of 41 (12%)
patients (Fig 5) and three of 41 (7%) patients, respectively. The
difference between transverse images plus MPRs and transverse
images alone was statistically significant ( P < .01). Nodal
metastases were detected in 16 of 20 (80%) patients by using
transverse images alone and in 18 of 20 (90%) patients by
using transverse images combined with MPRs.

C S Ng et al British Journal of Radiology 75 (2002),31-37

Abnormal pericolic fat on CT appears as linear "stands", "wisps" or

nodular opacities, or simply as a "mistiness" ("haziness" or
"muckiness") in the surrounding fat. Although a wide range of
causes were identified when originally described [1, 2], it has
become generally inferred that in the context of colorectal cancer
staging its presence is suspicious for extension of tumour beyond
the muscle coat (muscularis propria) and suggestive of at least
Dukes' stage B, or TNM stage pT3 or pT4 disease [310]. Our
results lend only limited support to this notion. Although the
sensitivity of abnormal pericolic fat on CT as an indicator of
histopathologically confirmed extramuscular tumour infiltration
was 79% and the PPV was 91%, the specificity and NPV were only
33% and 15%, respectively (Tables1 and 2 ). The presence of
abnormal pericolic fat on CT therefore does not necessarily
indicate the presence of extramuscular extension of tumour. In
these circumstances, some authors have identified "reactive"
tissue in the surrounding connective tissue on histopathology

Abnormal pericolic fat (stranding, nodularity, "mucky" or

"misty" fat [1, 2]) may be observed on CT in association
with colorectal cancers. It is generally taken to be
suspicious of tumour extension beyond the muscle coat and
a number of studies have used it as a criterion for tumour
staging [310]. Abnormal pericolic fat was shown to be
strongly associated with the presence of tumour in a
previous study from our own institution examining the
efficacy of CT in identifying colorectal carcinoma in elderly
patients. The pathological correlate of this radiological sign
has not been previously evaluated.

Abnormal pericolic fat on CT appears as linear "stands", "wisps" or

nodular opacities, or simply as a "mistiness" ("haziness" or
"muckiness") in the surrounding fat. Although a wide range of causes
were identified when originally described [ 1, 2], it has become
generally inferred that in the context of colorectal cancer staging its
presence is suspicious for extension of tumour beyond the muscle
coat (muscularis propria) and suggestive of at least Dukes' stage B, or
TNM stage pT3 or pT4 disease [310]. Our results lend only limited
support to this notion. Although the sensitivity of abnormal pericolic
fat on CT as an indicator of histopathologically confirmed
extramuscular tumour infiltration was 79% and the PPV was 91%, the
specificity and NPV were only 33% and 15%, respectively (Tables1
and 2 ).

The presence of abnormal pericolic fat on CT therefore does

not necessarily indicate the presence of extramuscular
extension of tumour. In these circumstances, some authors
have identified "reactive" tissue in the surrounding connective
tissue on histopathology

Colorectal cancer is a common malignancy that results in

significant morbidity and mortality. Abdominal computed
tomography (CT) is valuable in planning surgery for colon cancer
because it can demonstrate regional extension of tumor as well as
adenopathy and distant metastases. At CT, colorectal cancer
typically appears as a discrete soft-tissue mass that narrows the
colonic lumen. Colorectal cancer can also manifest as focal colonic
wall thickening and luminal narrowing. Complications of primary
colonic malignancies such as obstruction, perforation, and fistula
can be readily visualized with CT. At CT, local extension of tumor
appears as an extracolic mass or simply as thickening and
infiltration of pericolic fat. Extracolic spread is also suggested by
loss of fat planes between the colon and adjacent organs. The
liver is the predominant organ to be involved with metastases
from colorectal cancer. At CT, hepatic metastases usually appear
as hypoattenuating masses, which are best visualized during the
portal venous phase of liver enhancement. Other common sites of
metastases from colon cancer include the lungs, adrenal glands,
and bones. Use of CT is critical for identifying recurrences,
evaluating anatomic relationships, documenting "normal"
postoperative anatomy, and confirming the absence of new
lesions during and after therapy.

Colorectal cancer is the second most common cause of cancer death in developed
countries. In 1998, there were 131,000 new cases of colorectal cancer and 56,000
deaths in the United States (1). The initial diagnosis is usually made with
colonoscopy or air-barium enema examination; however, with the increased use of
computed tomography (CT) as the initial imaging modality in patients with a variety
of gastrointestinal symptoms, the radiologist may be the first to suggest the
diagnosis of colon cancer on the basis of CT findings. Nevertheless, at this time, CT
is not routinely performed for detection of colon cancer, although continued
advancements in scanner and computer technology may allow CT to play a future
role in detection of polyps and early-stage colon cancer.
The current role of CT in patients with known colon cancer is controversial. Accuracy
rates for preoperative staging of colon cancer with CT have been disappointing,
ranging between 48% and 77% (26). Limitations of CT staging include an inability
to definitively identify nodes that contain tumor or to determine the exact depth of
tumor invasion through the wall. Despite these limitations, CT is valuable in the
management of colon cancer. Preoperative CT is useful for planning surgery or
radiation therapy, particularly when local extension of tumor into adjacent organs
or distant metastases are detected. In addition, preoperative CT provides baseline
findings for comparison during the postoperative period and is the modality of
choice for detection of local recurrence after surgical resection.
Given the prevalence of colon cancer in the United States and the role of CT in
preoperative staging, treatment planning, and postoperative follow-up, the
radiologist should be familiar with the CT appearance of colon cancer. This article
discusses the technique of colon CT, staging of colon cancer, primary tumors, local
spread, metastases, tumor recurrence, and therapeutic considerations.

Primary tumor (T)TX = primary tumor cannot be

assessedT0 = no evidence of primary tumorTis =
carcinoma in situT1 = tumor invades the
submucosaT2 = tumor invades the muscularis
propriaT3 = tumor invades through the muscularis
propria into the subserosa or into nonperitonealized
pericolic or perirectal tissuesT4 = tumor directly
invades other organs or structures or perforates the
visceral peritoneumRegional lymph nodes (N)NX =
regional lymph nodes cannot be assessedN0 = no
regional lymph node metastasisN1 = metastasis in 13
pericolic or perirectal lymph nodesN2 = metastasis in
4 pericolic or perirectal lymph nodesDistant metastasis
(M)MX = distant metastasis cannot be assessedM0 =
no distant metastasisM1 = distant metastasis

Colon cancer in a 74-year-old man. Contrast material-enhanced spiral

CT scan shows luminal narrowing and marked wall thickening
involving the right side of the transverse colon (arrow). There is
adjacent stranding of the serosa and mesenteric fat, a finding
compatible with local tumor extension.

Adenocarcinoma in a 64-year-old woman with right lower

quadrant pain. Contrast-enhanced CT scan shows marked
circumferential thickening of the cecum (curved arrows).
The wall has a low-attenuation component (straight arrow),
which is due to necrosis. There is also stranding of the
pericolic fat, a finding suggestive of tumor invasion through

the wall. Adenocarcinoma was confirmed at endoscopy

Adenocarcinoma in an 89-year-old woman with severe

abdominal pain. Spiral CT scan obtained with oral contrast

material shows segmental circumferential thickening of the
hepatic flexure (arrows) with ascites. Adenocarcinoma was
confirmed at colonoscopy and biopsy.

Rectal cancer in a 65-year-old man with rectal bleeding. Spiral CT

scan obtained with rectal contrast material shows an eccentric
rectal cancer (black arrow) as well as adjacent nodes (white

arrows).

Diverticulitis in a 42-year-old man with pain and heme-positive

stools. CT scan obtained with oral contrast material shows focal,
masslike thickening of the sigmoid colon (straight arrows) with
adjacent stranding of the pericolic fat. On the basis of the CT
appearance and clinical history, colon cancer was suspected. At
endoscopy, diverticulitis was diagnosed. In retrospect, the
presence of minimal adjacent mesenteric fluid (curved arrow)
favored diverticulitis.