Multidetector CT Colonography: Spectrum of Diseases Fig.

3:Tandemcarcinoma (a
Colon Cancer
Adenocarcinomas are the most common colonic primary malignancies,
50% of which are found in the rectum and 25% in the sigmoid colon. In
up to 5% of cases, a synchronous carcinoma is present. CT colonography
gives information about local tumor invasion, the prestenotic colon,
lymph nodes, and liver metastasis.
rrow) in therans
t versecolon.
Colonic Polyps
Colon polyps are the most common benign tumors of the colon.
Most malignancies of the colon arise from adenomatous polyps. The
risk of malignant transformation increases with the size of the polyp
(< 1% with a polyp ≤ 10 mm in size, 30-50% at > 20 mm in size). Most
polyps are sessile, although some have a stalk.
Intestinal Lipoma
Lipomas are the most common submucosal lesions near the colon (very
common at the ileocecal valve). CT colonography allows confident diagnosis
of lipomas based on their characteristic fatty attenuation. Lipomas in
general are 1 to 3 cm in size and rarely exceed 4 cm. Only large lipomas
require endoscopic resection because they can lead to intussusception.

CT Features CT Features CT Features

 Focal, asymmetric or circular wall thickening  VE: Round, oval, or lobulated intraluminal filling defect  VE: Polypoid filling defect
 Annular stricture  VE: Incomplete ring shadowing  2D: Submucosal lesion with fatty attenuation (diagnostic!)
 Wall irregularity  2D: Soft tissue attenuation, CM enhancement  Occasionally pedunculated
 CM enhancement  VE, 3D: No mobility in prone or supine positions  Smooth surface
 Pericolic invasion (pericolic soft tissue stranding) (caveat: mobile colon segments, pedunculated lesions!)  Shape may change in prone vs. supine position (soft lesions) (Fig. 7b, c)
 Local lymphadenopathy
 Metastases

T Staging
T1 Invasion of the mucosa/submucosa
T2 Infiltration of the muscularis propria


T3 Infiltration of pericolic fat
T4 Invasion of adjacent organs b prone, unenhanced b supine


Reliable differentiation between mucosal/submucosal invasion (T1) and
infiltration of the muscularis propria (T2) with CT is still not possible. 


c supine, IV contrast a supine c prone

Fig. 7: Large intestinal lipoma: Virtual colonoscopy shows a polypoid


pedunculated lesion with a smooth surface (a). Submucosal lesion with
fatty attenuation (b, c).
 a


Fig. 4: 8 mm round polyp in the sigmoid colon (arrow): Soft tissue

attenuation (b), homogenous CM enhancement (c). No mobility in prone


or supine positions (b, c).

Diverticular Disease
a b

Fig. 1: Semicircular cancer on the right flexure (arrow). Diverticula may simulate polyps when seen en face on VE images.
Diverticula impacted with fecal material may appear as a raised lesion
▲

and mimic polyps.


b c  CT Features

▲
Diverticula


 2D: Gas-filled outpouching of colon wall

 VE: Complete dark ring


 Caveat: polypoid pseudolesion in VE “en face“

a b


Impacted Diverticula – DD: Polyp

a IV contrast
Fig. 5: Lobulated polyp (arrow) on the cecum, near the appendiceal
orifice (arrowhead): Soft tissue attenuation and CM enhancement (b).  VE: Polypoid pseudolesion
 VE: Incomplete ring shadowing
 2D: Stool-filled diverticula; hyperdense diverticular wall
unenhanced

Fig. 2: Apple core configuration (a) of a stenotic cancer in the ascending


colon (arrow).

 ▲


▲


▲
▲





a b prone a b

Fig. 6: Stalked polyp (arrow) in the descending colon; stalk outlined Fig. 8: Normal (arrow) and a stool-impacted diverticulum (arrowhead).
by an arrowhead. VE shows complete dark ring (arrow) and incomplete ring shadowing
a b (arrowhead) as a sign of a raised lesion.

Fig. 3: Tandem carcinoma (arrow) in the transverse colon.

Pseudolesions Inflammatory Bowel Disease

Polypoid Stool Ileocecal Valve Ulcerative colitis typically begins in the rectum and continuously extends
proximally to involve parts or all of the colon. CT colonography helps
CT Features CT Features to assess the colon proximal to a stenosis, which cannot be passed with
 Most common pseudolesion  Papillary or labial form endoscopy. Differentiation between an inflammatory stenosis in ulcerative
 2D: Trapped gas (diagnostic!)  May be lipomatous (2D images!) colitis and cancer is the domain of endoscopy with biopsy. Crohn’s disease
 2D: Inhomogeneous attenuation  Located at the medial wall of the cecum most commonly discontinuously affects the terminal ileum and the
 2D: No CM enhancement proximal colon, although this disease can involve the whole GI tract.
 Mobility between prone and supine scan (caveat: wall-adherent)
 VE: Geometric morphology (fibers, etc.) CT Features
 Discrete irregular wall thickening (continuous vs. discontinuous)
 Flattening or disappearance of haustra
 Increased CM enhancement of wall
 Stenosis
 Pseudopolyps


 Cobblestone pattern
 Fibrofatty proliferation around colon
 Lymph nodes


 Abscess, fistula, pseudotumor



a b


Fig. 13: Lipomatous ileocecal valve: Large filling defect (arrow) in VE (a).
Diagnostic clue: 2D reveals prominent fat-containing ileocecal valve.

a b

Haustral Folds
Fig. 11: Polypoid stool in the descending colon simulates a polypoid filling
defect on virtual colonoscopy (a). Gas bubble inside the pseudolesion (b).
CT Features
 2D: Folds may appear as polypoid lesion especially if they are
bulbous or irregular
 VE: Helpful for differentiating fold versus polyp a b

Fig. 9: Crohn’s disease: Cobblestone pattern (a), wall thickening

(b, arrow).

Retained Barium



CT Features 

 VE: Retained barium in fecal matter may simulate polyps


 2D is diagnostic: High attenuation may be used for fecal tagging


a b


Fig. 14: Haustral folds may appear as round or pedunculated filling

 defects (arrow) on 2D images (a). VE shows a haustral fold (arrow) (b). a b

Fig. 10: Crohn‘s disease: skip lesions (arrow) in the terminal ileum (a)
and in the transverse colon (a, b).
Extrinsic Defects

CT Features
a b prone  VE: Compression caused by adjacent organs or structures may
simulate stenosis or endoluminal mass
Fig. 12: Retained Barium: Polypoid mass (arrow) adjacent to haustral fold  2D reveals extraintestinal mass and is helpful to avoid misinterpretation
(a) with hyperattenuation on 2D (b).


Impressum: Dr. Thomas Mang

Prof. Dr. Andrea Maier
Prof. Dr. Wolfgang Schima

Department of Radiology
Medical University of Vienna a b
Email: thomas.mang@meduniwien.ac.a
Fig. 15: Uterine fibroid (b) causes colon impression (arrow) simulating
submucosal mass in virtual endoscopy (a).