Direct Invasion from Contiguous Primary Tumors

Intrinsic involvement of the alimentary tract by an immediately contiguous neoplasm indicates that a locally aggressive tumor has usually broken through fascial planes.84,85 The most common primaries arise in the ovary, uterus, prostate, and kidney.

With pelvic tumors, the cardinal roentgen signs include an identifiable mass and invasion of the wall of adjacent bowel, often over a considerable length, usually without overhanging margins (Fig. 4-86). Tethering of mucosal folds is often a conspicuous feature. In a female, the most common primary that directly invades the large intestine is carcinoma of the ovary. On the left, the inferior border of the sigmoid colon is characteristically involved first. Stages of involvement range from fixation with nodular irregularities (Figs. 4-87 through 4-89) or gross desmoplastic angulation of mucosal folds (Fig. 4-90) to annular involvement (Fig. 4-91).

Advanced prostatic carcinoma can spread across Denon-villier's fascia to invade the rectum anteriorly or circum-ferentially86-88 (Figs. 4-92 through 4-94). Winter89 reported that 26 of 225 (11.6%) patients with carcinoma

Fig. 4—87. Direct invasion of the sigmoid colon by carcinoma of the left ovary.

A large nodular infiltration involves the inferior border. Pseudosacculations result on the pliable superior border. (Reproduced from Meyers.5)

Fig. 4—87. Direct invasion of the sigmoid colon by carcinoma of the left ovary.

A large nodular infiltration involves the inferior border. Pseudosacculations result on the pliable superior border. (Reproduced from Meyers.5)

Antimesenteric Border Sigmoid Colon

Fig. 4—88. Direct invasion of the sigmoid colon by carcinoma of the left ovary.

Nodular infiltrations involve the inferior border.

Fig. 4—88. Direct invasion of the sigmoid colon by carcinoma of the left ovary.

Nodular infiltrations involve the inferior border.

Fig. 4-89. Direct invasion of the sigmoid colon by carcinoma of the left ovary.

(a) Barium enema shows gross nodular invasion extending from inferior border of sigmoid colon.

(b) CT demonstrates the presence of bilateral ovarian carcinomatous masses (M), with those on the left straightening and displacing the markedly narrowed sigmoid colon (arrows). B = urinary bladder.

(Courtesy of Michiel Feldberg, M.D., Ph.D, University of Utrecht, The Netherlands.)

Fixated Sigmoid Colon

Fig. 4-90. Direct invasion of the sigmoid colon by carcinoma of the left ovary.

Mass displacement and fixation of the inferior border are accompanied by striking mucosal tethering.

Fig. 4-91. Direct invasion of the sigmoid colon by carcinoma of the left ovary.

Extension has progressed to annular involvement.

of the prostate had rectal involvement. Young90 found 12 instances of rectal mucosal involvement at autopsy in 800 patients with prostatic carcinoma, an incidence of 1.5%. Annular type constriction of the rectum may cause partial to complete obstruction.

Renal neoplasms may invade adjacent segments of bowel directly, possibly as recurrences many years after resection of the primary tumor. The late manifestations of renal metastasis may occur as long as 30 years after diagnosis. The delay in extension from the nephrectomy site may be due to the poor blood supply of the scar.91 With growth, they tend to produce bulky intraluminal masses without significant obstruction, since they generally do not elicit a desmoplastic response.1,92,93 Occasionally, they may produce luminal narrowing with mu-cosal destruction, simulating a primary carcinoma of the bowel (Fig. 4-95). Recognition of the usual sites of involvement and identification of any extraluminal soft-

Annular Narrowing Jejunum

Fig. 4—92. Annular rectal invasion by prostatic carcinoma.

tissue mass lead to the correct diagnosis. On the right, the descending duodenum (Figs. 4-95 through 4-97) and, on the left, the distal transverse colon or proximal descending colon (Figs. 4-98 and 4-99) are most often involved. At times, jejunal loops may be affected (Figs. 4-100 and 4-101).

Endoscopic ultrasonography has been shown to be useful for evaluating the depth of colonic mural invasion71 (Figs. 4-102 through 4-104).

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Fig. 4—92. Annular rectal invasion by prostatic carcinoma.

Fig. 4-93. Direct invasion of rectosigmoid colon by prostatic carcinoma.

Lateral (a) and mild left posterior oblique (b) views of rectum show mass effect and markedly spiculated contour along anterior rectosigmoid junction and sigmoid colon and widening of superior presacral space. (Reproduced from Rubesin et al. )

Fig. 4-93. Direct invasion of rectosigmoid colon by prostatic carcinoma.

Lateral (a) and mild left posterior oblique (b) views of rectum show mass effect and markedly spiculated contour along anterior rectosigmoid junction and sigmoid colon and widening of superior presacral space. (Reproduced from Rubesin et al. )

Circumferential Colon Tumor

Fig. 4-94. Circumferential invasion of the rectum by carcinoma of the prostate.

(a) Lateral view. Note the widened retrorectal and rectovesical spaces as well as the mucosal alterations in the rectum. Urinary bladder (B) opacified by simultaneous intravenous urography.

(Reproduced from Meyers and McSweeney. )

(b) Frontal view. The superior border of the annular involvement of the rectum corresponds to the base of the urinary bladder (arrows), which is elevated by the enlarged prostate gland.

Fig. 4-94. Circumferential invasion of the rectum by carcinoma of the prostate.

(a) Lateral view. Note the widened retrorectal and rectovesical spaces as well as the mucosal alterations in the rectum. Urinary bladder (B) opacified by simultaneous intravenous urography.

(Reproduced from Meyers and McSweeney. )

(b) Frontal view. The superior border of the annular involvement of the rectum corresponds to the base of the urinary bladder (arrows), which is elevated by the enlarged prostate gland.

Reposision Cuerpos Vertebrales

Fig. 4-95. Direct invasion of the descending duodenum by right renal cell carcinoma.

(a) Mucosal destruction simulates a primary neoplasm of the duodenum. (Reproduced from Meyers and McSweeney. )

(b) Intravenous urogram shows large mass with a few faint calcifications within the lower pole of the right kidney, displacing the collecting system.

Fig. 4-95. Direct invasion of the descending duodenum by right renal cell carcinoma.

(a) Mucosal destruction simulates a primary neoplasm of the duodenum. (Reproduced from Meyers and McSweeney. )

(b) Intravenous urogram shows large mass with a few faint calcifications within the lower pole of the right kidney, displacing the collecting system.

Fig. 4—96. Direct invasion of the descending duodenum by right renal cell carcinoma.

This results in multiple polypoid intramural masses of varying sizes, without angulation.

Fig. 4-97. Direct invasion of the descending duodenum by right renal cell carcinoma.

(a) Upper GI series, lateral view, shows a large mass effect upon the posterior wall of the descending duodenum. The curved arrows indicate faint tumoral calcification. D1 = duodenal bulb.

(b) CT demonstrates a large heterogeneous mass (asterisks) of the right kidney invading the second portion of the duodenum (arrow).

(Reproduced from K. Cho: In Gourtsoyiannis and Nolan.80)

Radiology Duodenal Bulb

Fig. 4-98. Direct invasion of the colon by left renal carcinoma.

(a) Extrinsic and intramural masses of the distal transverse and proximal descending colon with bulky polypoid intraluminal extensions. There is no obstruction or acute angulation. (Reproduced from Meyers and McSweeney.1)

(b) Abdominal aortogram shows neovascularity from the renal artery. In addition, a hugely dilated inferior mesenteric artery (arrows) contributes blood supply to the tumor invasion of the colon.

Fig. 4-98. Direct invasion of the colon by left renal carcinoma.

(a) Extrinsic and intramural masses of the distal transverse and proximal descending colon with bulky polypoid intraluminal extensions. There is no obstruction or acute angulation. (Reproduced from Meyers and McSweeney.1)

(b) Abdominal aortogram shows neovascularity from the renal artery. In addition, a hugely dilated inferior mesenteric artery (arrows) contributes blood supply to the tumor invasion of the colon.

Fig. 4-99. Direct invasion of the colon by left renal cell carcinoma.

(a) Extrinsic masses deform and narrow the descending colon and grow into its lumen.

(b) Selective inferior mesenteric arteriogram demonstrates a plethora of neovascularity within the invaded colon.

Fig. 4-99. Direct invasion of the colon by left renal cell carcinoma.

(a) Extrinsic masses deform and narrow the descending colon and grow into its lumen.

(b) Selective inferior mesenteric arteriogram demonstrates a plethora of neovascularity within the invaded colon.

What Adenoma Mass The Jejunum

Fig. 4—100. Direct invasion of the jejunum by left renal cell carconoma.

Following a nephrectomy, recurrent tumor invades overlyingjejunal loops as bulky intramural and intraluminal growths.

Fig. 4—100. Direct invasion of the jejunum by left renal cell carconoma.

Following a nephrectomy, recurrent tumor invades overlyingjejunal loops as bulky intramural and intraluminal growths.

Fig. 4—101. Direct invasion of the jejunum by left renal cell carcinoma.

(a) Compression spot film demonstrates infiltration of the mesentery and jejunal loops.

(b) Percutaneous puncture of neoplastic mass arising from lower pole of left kidney shows its polypoid components.

Distal Sigmoid Colon MassGallstone Ileus

Fig. 4—102. Depth of direct invasion of the sigmoid colon by ovarian carcinoma shown by endoscopic ultrasonography.

(a) Double-contrast barium enema demonstrates narrowing of the distal sigmoid colon with tethering of mucosal folds (arrow).

(b) Endoscopic ultrasonography reveals that the pelvic tumor (T) has invaded into the hypoechoic layer representing the muscularis propria (pm) but the hyperechoic submucosa (sm) is intact.

(c) Microscopic findings document that the ovarian carcinoma has directly invaded into the muscularis propria (pm).

(Reproduced from Hirata et al. )

Depth Invasion MriDepth Invasion

Fig. 4-103. Depth of direct invasion of rectum by carcinoma of the ovary shown by endoscopic ultrasonography.

(a) Double-contrast barium enema shows nodular mural irregularities involving the rectosigmoid junction.

(b) Endoscopic ultrasonography reveals the pelvic tumor (T) invading through the wall, extending to the hyperechoic layer of the submucosa (sm), which is thin without interruption.

(c) Histologic findings confirm that the depth of invasion by the ovarian carcinoma is to the submucosa. (Reproduced from Hirata et al.71)

Fig. 4-103. Depth of direct invasion of rectum by carcinoma of the ovary shown by endoscopic ultrasonography.

(a) Double-contrast barium enema shows nodular mural irregularities involving the rectosigmoid junction.

(b) Endoscopic ultrasonography reveals the pelvic tumor (T) invading through the wall, extending to the hyperechoic layer of the submucosa (sm), which is thin without interruption.

(c) Histologic findings confirm that the depth of invasion by the ovarian carcinoma is to the submucosa. (Reproduced from Hirata et al.71)

Invasion Into Muscularis Propria

Fig. 4—104. Depth of direct invasion of the sigmoid colon by a Krukenberg tumor of the ovary shown by endoscopic ultrasonography.

(a) Barium enema reveals extrinsic compression with tethering (arrow).

(b) On endoscopic ultrasonography, a Krukenberg tumor (K) invades into the muscularis propria (pm).

Fig. 4—104. Depth of direct invasion of the sigmoid colon by a Krukenberg tumor of the ovary shown by endoscopic ultrasonography.

(a) Barium enema reveals extrinsic compression with tethering (arrow).

(b) On endoscopic ultrasonography, a Krukenberg tumor (K) invades into the muscularis propria (pm).

Essentials of Human Physiology

Essentials of Human Physiology

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