Pulmonary metastases from mucinous colorectal cancers and their appearance on CT: a case series

Abstract

Mucinous colorectal adenocarcinoma represents a small proportion of all colorectal cancers, characterised by mucinous tumour components. While its pattern of metastatic spread differs from that of conventional colorectal adenocarcinoma, pulmonary metastases are commonly seen in both mucinous and non-mucinous types. The assessment of pulmonary nodules in the context of malignancy is a commonly encountered problem for the radiologist given the high prevalence of benign pulmonary lesions. Low density of a pulmonary nodule on CT evaluation is one of the recognised and well-documented features of benignity that is used in the radiological assessment of such nodules. We present three cases of patients with histologically proven mucinous colorectal adenocarcinoma with evidence of pulmonary metastases. In all cases, the metastases were of low density on CT and in one case were initially suspected to represent benign hamartomatous lesions. There has been little documented about the density of mucinous pulmonary metastases on CT. We suspect the low density seen in the metastases in each case is accounted for by their high internal mucinous components. The cases presented here demonstrate the importance of recognising that mucinous colorectal metastases can be of low density and therefore mimic benign pathology. This review may help the radiologist to consider shorter interval follow-up of such lesions in the context of known mucinous neoplasms, or to investigate for an extrathoracic mucinous carcinoma in the presence of multiple low-density pulmonary nodules.

Figure 1.

Axial CT images on soft-tissue and lung window settings on post-contrast CT (A) and the CT component of a non-contrast PET-CT (B) performed 6 weeks later, which show an enlarging low-density pulmonary nodule within the lower lobe of the right lung. Note that image A suggests the presence of macroscopic fat anteriorly within the lesion. PET, positron emission tomography.

Figure 2.

Axial CT images on soft-tissue and lung window settings demonstrating one of multiple low-density pulmonary nodules within the right lung on initial arterial-phase contrast-enhanced CT (A), which increases in size on a subsequent CTPA (b) and then can be seen to have almost completely resolved following chemotherapy treatment on subsequent restaging contrast-enhanced CT (C). CTPA, CT pulmonary angiography.

Figure 3.

Axial CT images on soft-tissue and lung window settings demonstrating one of several small low-density pulmonary nodules within the right lower lobe on the CT component of a non-contrast PET-CT (arrowed) with a tiny focus of low density to its left side which may represent macroscopic fat (A). There is evidence of marked disease progression on subsequent CTPA performed 11 months later, with significant increase of the index nodule and several new lesions (B). CTPA, CT pulmonary angiography; PET, positron emission tomography.