Case Study: Diagnostic Imaging in Colorectal Cancer Management

This case study analyzes the medical imaging techniques employed in the diagnosis and management of a 58-year-old female patient (Patient X) presenting with symptoms indicative of colorectal cancer and its complications. The study details the patient's history, including familial adenomatous polyposis and various symptoms such as headaches, facial spasms, abdominal pain, and changes in bowel habits. The diagnostic process involved an elbow X-ray to assess bone metastasis, a head CT scan to investigate headaches and facial spasms, and a cervical spine MRI due to lung metastasis. Further imaging included a chest, abdomen, and pelvis CT scan with contrast to evaluate the extent of the disease, and a chest X-ray to assess pneumonia and lung metastasis. The case study highlights the importance of each imaging modality, including their accuracy, sensitivity, and specificity, in determining the patient's condition and guiding treatment decisions. The results of the imaging revealed bone metastasis, neurological complications, vertebral lesions, lung metastasis, and metastatic colorectal carcinoma, emphasizing the need for a comprehensive and multidisciplinary approach to healthcare interventions. The study also discusses the ethical considerations, such as palliative care, and the impact of imaging on patient outcomes.

Medical Imaging: Colorectal Cancer Case Analysis 1
MEDICAL IMAGING: COLORECTAL CANCER CASE ANALYSIS
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Medical Imaging: Colorectal Cancer Case Analysis 2
Medical Imaging: Colorectal Cancer Case Analysis
During a diagnostic process, the practitioner could recommend the creation of visual
representations that show the interior of the patient’s body for accurate conclusions regarding the
magnitude and nature of their condition. The process, which is called medical imaging, ensures
that there is enough evidence for clinical analysis for quality diagnostic and treatment decisions.
Medical Imaging could also include the representation of the functionality of different organs. In
complex conditions such as cancer and thoracic complications, a proper imaging method is
needed (Swiderska et al. 014). This paper presents a case analysis of the medical imaging
technique for a colorectal cancer patient to ascertain the reliable options and the role of effective
medical imaging during diagnosis.
Colorectal Cancer
Colorectal cancer is one of the major neoplasm complications among men and women
across the globe. It is estimated that about 33.3% of those diagnosed with the condition die
because of the developed complications. The prevalence of the condition is witnessed in
developed countries when compared to low-income settings (Jung et al. 2018). Clinical evidence
links predisposed carcinogenesis to this condition; however, other factors such as low rate of
physical activity, sedentary lifestyle, high-calorie diet, high fat intake, and obesity are some of
the risk factors. CRC is assessed by evaluating historical experiences and per rectum
examination; however, this method depends on the experience of the practitioner. Endoscopy
techniques, such as sigmoidoscopy and colonoscopy, are common diagnostic methods (Nerad et
al. 2016). Sigmoidoscopy is used to examine the lower part of rectum and colon and is associated
with 92 to 97% sensitivity and specificity. Colonoscopy has the same sensitivity and allows
observation of the entire intestine. Additionally, the use of imaging interventions such as

Medical Imaging: Colorectal Cancer Case Analysis 3
roentgenography, magnetic resonance imaging, and computed tomography in severe focal lesion
cases. Non-invasive methods of diagnosis include a fecal occult blood test, lysosomal
exoglycosidases, and non-enzymatic tumor markers.
The price of an MRI machine ranges between $150,000 for a simple low-cost version and
$3 million for state-of-art models from Tesla (Glover 2014). A refurbished CT scan machine
goes at $65,000 and produces smaller images while advanced models could be as high as $2.5
million. On the other hand, fully digitalized portable X-ray machines could be acquired for
$125,000 to $235,000 (Webb 2014). Currently, these medical imaging machines are digitalized,
which implies that there are minimal operator interactions. The use of these imaging modalities
enhances the detection of abnormal tissues and the differentiation of diagnoses. MRI dose is
recommended to be between 20 and 60 minutes where each protocol frequency should include
five pulse sequences or more than that depending on the process (Edelstein et al. 2010). CT
effective radiation dose estimates depend on the region and procedure of the imaging. However,
the average dose ranges between 0.001 mSv for extremity x-ray of a bone to 25 mSv for positron
emission tomography CT in nuclear medicine. The actual dosage is based on the
recommendations of the CT Scan Radiation Dosage Chart (Radiology Info 2018).
Background of the Case
Patient X (for privacy purposes) is a 58 years old lady residing at a local urban village
called Heathrow Valley (not the actual place for privacy reasons). The patient was presented to
the healthcare facility complaining of intermittent headaches and painful facial spasm. The
headaches and facial spasm have been persistent for an extended period. Patient X also
experienced pain in the abdomen and changes in bowel habits. The abdominal changes and pain
caused discomfort, which affected the ability of the patient to move effectively. The patient also

Medical Imaging: Colorectal Cancer Case Analysis 4
complained of persistent tiredness and fatigue. Patient X also experienced sharp chest pain that
exacerbated when breathing. There were episodes of nausea and vomiting accompanies by
general chest discomfort. The patient, upon her presentation to the facility, had a continuous
cough and shortness of breath. Moreover, the patient experienced pain and tenderness around the
elbow, which increased with movement. A thorough physical assessment was done, which was
followed by the assessment of the history of the patient. The history showed how Patient X had
been to the hospital seven times in the past seven weeks. Her condition was not getting any better
during this period. Additionally, the patient had a known familial adenomatous polyposis (FAP).
Both the historical health condition and presented symptoms are essential during diagnosis and
subsequent treatment.
Diagnosis
Based on the presented symptoms, three imaging diagnostics were recommended. A CT
scan of the head, abdomen, chest, and pelvis was performed. MRI was carried out to further
assess the cervical spine. Additionally, X-ray of the elbow and chest was conducted for further
analysis of the presented pathophysiology. Efficient imaging enhances diagnostic outcomes
(Swiderska et al. 2014). The three imaging interventions and the process involved have been
described below.
Elbow X-ray Requested
The first medical imaging requested was elbow X-ray to determine whether the observed
physical symptom related to bone cancer. The patient had been presented with acute pain and
tenderness around the elbow, which exacerbated with any form of movement. The presented
signs pointed to a range of possible problems such as bone infection, bone trauma, or cancer. The
only sure intervention to obtain the exact diagnosis was by requesting an elbow X-ray. Bone

Medical Imaging: Colorectal Cancer Case Analysis 5
metastasis could appear as bone cancer (Xiang and Gilkes 2019). Bone tumors could result from
cancer that has spread from other parts of the body. Bone metastasis presents similar symptoms
and signs as the primary tumor. Examining the affected area using X-ray imaging and
conducting a microscopic cell review and assessment could assist the radiologist to distinguish
between bone metastasis and bone tumor (Gdowski et al. 2017). Based on Patient X’s case, there
was no history of trauma, which further justified the need for an X-ray to ascertained the
exhibited sign on the elbow as opposed to a bone scan. Conventional radiography is clinically
recommended for the characterization of the metastatic lesions (Dehghani et al. 2017). Before
the X-ray was carried out, the patient and her guardian have informed the reason why an X-ray is
needed. The patient was requested to have no jewels during the process to address image
modalities and reduce cases of artifacts, which could lead to misdiagnosis. X-ray, as a
conventional radiology method, is associated with different accuracy, sensitivity, and specificity
depending on the type of receptor. Photo-stimulable Phosphor Plate (PSP) with 70 kVp has 70%
accuracy, 54.2% sensitivity, and 84.6% specificity. PSP with 60 kVp has 69.0% accuracy, 62.8%
sensitivity, and 80% specificity. A film with 70 kVp has 71.0% accuracy, 42.8% sensitivity, and
90.7% specificity. A film with 60 kVp has 68.0% accuracy, 51.4% sensitivity, and 90.7%
specificity (Dehghani et al. 2017). Based on this medical imaging intervention, it was ascertained
that Patient X had a bone metastasis and not a bone tumor.
Head CT Scan Requested
When Patient X was brought to the facility, she was complaining of intermittent
headaches and painful facial spasm. Therefore, a head CT scan was the second medical imaging
intervention that was requested. Several factors are associated with headache and subsequent
facial spasms such as focal neurological deficits, parenchyma cysts, parkinsonism, intracranial

Medical Imaging: Colorectal Cancer Case Analysis 6
hypertension, altered mental status, and cranial nerve palsies. Therefore, to identify the specific
cause of the facial spasm and the accompanied headache, it is important to conduct a head CT
scan. Clinical assessments have shown that head CT scan is associated with 0.77 accuracy level
at 95% confidence interval, 0.98 sensitivity level at 95% confidential level, and 0.999 specificity
level at 95% confidential level (Dubosh et al. 2016). However, for patients with thunderclap
headache as well as normal neurological examination, cranial CT scan is highly sensitive
(Razdan et al. 2009). Patients with lung metastasis and colorectal cancer could exhibit abnormal
neurology at an advanced state of the condition. According to Tapia et al. (2017), the incidence
of neurological complications among colorectal cancer patients with lung metastasis is 0.6% to
3.2%. The head CT scan showed that Patient X had abnormal neurology, which caused the
locking of the jaw presented by the patient.
Cervical Spine MRI Requested
Since Patient X presented the characteristics of lung metastasis as depicted in the
previously conducted head CT scan, it was necessary to further carry out cervical spine MRI.
Studies have shown that the lung is the second most common site for metastasis among patients
with colorectal cancer (Li et al. 2019). Colonoscopies are discouraged in adenocarcinoma
especially when the primary diagnosis is not known; however, it is permitted when colonic
malignancy is ascertained by clinical symptoms and signs as presented by the patient (Jain et al.
2016). In colorectal cancer, the MRI T-stage accuracy, sensitivity, and specificity have been
identified as 82%, 86%, and 77% respectively (Cutsem et al. 2016). However, the clinical
analyses have ascertained that the inclusion of morphological criteria characterizing the nodes
being observed has enhanced these values to new estimates of N-Stage sensitivity and specificity
values standing at 85% and 98% respectively (Cutsem et al. 2016). According to Jain et al.

Medical Imaging: Colorectal Cancer Case Analysis 7
(2016), vertebral metastasis is part of the initial manifestations of colorectal cancer, which could
exacerbate with time as the condition enters a critical stage. For Patient X, the MRI showed the
presence of vertebral lesion revealing adenocarcinoma with mucin. Such an occurrence was
associated with the exhibited cervical pathology and cord compression causing the discomfort
symptoms. It is possible to detect this through MRI because tumor cells are negative for
Cytokine Receptor-7 (CK7), Thyroid Transcription Factor-1 (TTF-1), Breast-2 (BRST-2), and
Periodic Acidic Shift-8 (PAS-8); however, it is positive for Intestine-specific Transcription
Factor-2 (CDX-2), Cytokeratin-20 (CK20), and Cytokeratin-19 (CK19) (Jain et al. 2016).
Chest, Abdomen, and Pelvis CT Scan with Contrast Requested
Patients presenting multiple developments of metastasis require a comprehensive CT
scan to identify the progression of the pathophysiology (Jimi et al. 2013). Since Patient X
presented lung metastasis that impacted abnormal neurology, lung metastasis, vertebral
metastasis, and colorectal carcinoma coexisting and contributing to the evident symptoms and
signs, it was necessary to determine the degree of progression. Therefore, a chest, abdomen, and
pelvis CT scan with contrast was requested. It was ascertained that the patient’s condition was
critical and required multidimensional intervention because of the level of progression. Based on
the outcome, Patient X had metastatic colorectal carcinoma with a slow volume of progression
with lung metastasis. The patient had a known familial adenomatous polyposis (FAP). By
understanding the nature of disease progression in colorectal cancer, it is possible to design
targeted and multidisciplinary healthcare interventions to guarantee effective and quality patient
outcomes (Leach et al. 2014). Although the condition of Patient X was critical, the
comprehensive CT scan with contrast showed a steady volume of progression, which implies that
control measures could be adopted to prevent further exacerbation. Proper post-treatment

Medical Imaging: Colorectal Cancer Case Analysis 8
outcomes and management of patients depend on the assessment of progression and linking the
recommended treatment to the mitigation of presented symptoms and causative elements. The
treatment interventions are equally informed by the assessment of metastatic progression (Leach
et al. 2014).
Chest X-Ray Requested
An additional chest X-ray was requested since the patient was admitted with vomiting
and a productive cough. It was necessary to establish the pathophysiology characterizing the
cough. The patient had previous video-assisted thoracoscopic surgery. At the same time, the
patient exhibited pyrexia, which together with increased white blood cell count increased the
presented symptoms. The X-ray confirmed community-acquired pneumonia and lung metastasis.
Scholars have ascertained that post-operative pneumonia is common among patients who present
lung metastasis. For most clinical cases, there is a 2% chance of being diagnosed with post-
operative pneumonia (Jung et al. 2018). A similar scenario is witnessed among breast cancer,
gastric cancer, lung cancer, and hepatocellular carcinoma (Jung et al. 2018). Cho et al. (2011)
found out that Chest CT sensitivity and accuracy stand at 83.9% and 99.0% respectively among
colorectal cancer patients.
Abdomen and Pelvis CT Scan Requested
Additional imaging intervention was necessary to determine the liver function, the nature
of bowel obstruction, and other causes and impacts of presented pathophysiology. Therefore,
abdomen and pelvis CT scan were also requested because of the confirmed metastatic bowel
carcinoma. The justification was this medical imaging stemmed from total colectomy and
previously conducted Video-Assisted Thoracoscopic surgery. The patient also had a previous
adhesion bowel obstruction, which was getting worse. Deranged liver function test (LFTs) was

Medical Imaging: Colorectal Cancer Case Analysis 9
performed. Based on the outcomes, it was confirmed that Patient X had a subacute bowel
obstruction, abdomen distention, cholecystitis, and liver abscess or metastasis. Jiang et al. (2018)
found out that space-occupying lesions lead to several adverse oncology outcomes, especially in
colorectal cancer liver metastases. LFTS leads to poor prognosis among this population.
Abdomen and Chest X-ray Requested
Furthermore, abdomen and chest X-ray was carried out to further have a clear diagnosis
owing to the known familial adenomatous polyposis (PAP) and subsequent seven
hospitalizations within seven weeks. The patient had an infection and unresolved hospital-
acquired pneumonia (HAP) accompanied by abdominal source with adhesion and periumbilical
tenderness. During this time, the patient’s status was critical and it was confirmed that she was
clostridium septicum sepsis case. Sepsis among colorectal cancer is caused by septic infection
and colorectal malignancies (Mirza et al. 2009). Tumor perforations and the associated HAP
combined with critical bowel obstruction is linked to high morbidity and mortality rates.
Treatment Options and Future Management
Since colorectal cancer is presented as a systemic disease, a multidimensional
intervention is needed especially in critical cases as seen with Patient X. The first consideration
is enhancing survival, which is achieved through a complete surgical process geared towards the
resection of pulmonary metastases. Before resection, there should be a comprehensive restaging
and subsequent verification by the practitioner to ascertain the preoperative fitness of the
affected patient (Zisis et al. 2013). The surgical approach is directed by the anatomical nature,
location, and progressiveness of the metastases. The objective of surgical operation is to
guarantee complete removal of the metastases while preserving the optimum lung parenchyma.

Medical Imaging: Colorectal Cancer Case Analysis 10
Additionally, colorectal cancer patients require non-pharmacological interventions to
enhance treatment outcomes and recovery. In this case, multidisciplinary care is considered the
most efficacious approach (Villeneuve et al. 2009). Patient involvement is needed through
collaboration and education to ensure that he/she is aware of the treatment process and
implications. As part of the future management process, the patient should be linked to local
social workers to ensure continuous monitoring and support during the post-treatment period.
Psychosocial and behavioral changes are part of the palliative care considerations for such
patients.
Role of Diagnostic Imaging in this Case Scenario
Diagnostic imaging plays a key role in clinical interventions in lien with the experiences
and needs of a patient. In this case example, diagnostic imaging enhanced the process of
detecting the actual problem that Patient X was facing. Complex diseases require effective and
accurate diagnosis (Nerad et al. 2016). The existence of differential diagnoses calls for the need
to identify the specific causes of the exhibited pathophysiology. Computed tomography enabled
the identification of the abnormal tissues and their specific location and sizes, which guarantees
effective treatment. Additionally, in this case, it was possible to identify the source of
intermittent headaches and painful facial spasm as well as the origin of the exhibited thoracic
pain and breathing difficulties (Nerad et al. 2016). By examining the chest using medical
imaging intervention such as CT scan and X-ray, it was possible to have a clear picture of the
manifested airway obstruction. Effective medical imagining also informed the exact
pharmacological interventions needed to assist Patient X to recover within the shortest period
(Nerad et al. 2016). At the same time, through medical imagining it was possible to set a future
management plan with the objective of fostering positive self-monitored coping.

Medical Imaging: Colorectal Cancer Case Analysis 11
Conclusion
In conclusion, as seen in this case example on Patient X, medical imaging enhances the
diagnosis and treatment of the critical condition. It is possible to isolate the actual problems from
a list of differential diagnoses. At the same time, medical imaging assist practitioners to identify
a series of coexisting conditions. Accurate diagnosis enhances patient outcomes in critical
conditions since appropriate intervention measures are used to mitigate the presented problems.
As seen in this case example, medical imaging played a key role in identifying the exact
conditions that affected the patient.

Medical Imaging: Colorectal Cancer Case Analysis 12
References
Cho, Y. K., Lee, W. Y., Yi, L. J., Park, J. H., Yun, H. R., Cho, Y. B., Yun, S. H., Kim, H. C., and
Chun, H. K. (2011) Routine chest computed tomography as a preoperative workup for
primary colorectal cancer: is there any benefit in short-term outcomes? Journal of the
Korean Surgical Society [Online], 80(5), pp. 327–333. [Accessed 17 April 2020].
Cutsem, E., Verheul, H. M., Flamen, P., Rougier, P., Beets-Tan, R., Glynne-Jones, R., and
Seufferlein, T. (2016) Imaging in Colorectal Cancer: Progress and Challenges for the
Clinicians. Cancers [Online], 8(9), p. 81. [Accessed 17 April 2020].
Dehghani, M., Barzegari, R., Tabatabai, H., and Ghanea, S. (2017) Diagnostic Value of
Conventional and Digital Radiography for Detection of Cavitated and Non-Cavitated
Proximal Caries. Journal of dentistry (Tehran, Iran) [Online], 14(1), pp. 21–30.
[Accessed 17 April 2020].
Dubosh, N. M., Bellolio, M. F., Rabinstein, A. A., and Edlow, J. A. (2016) The Sensitivity of
Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage
A Systematic Review and Meta-Analysis. Stroke [Online], 47; pp. 750-755. [Accessed 17
April 2020].
Edelstein, W. A., Mahesh, M., and Carrino, J. A. (2010). MRI: time is dose--and money and
versatility. Journal of the American College of Radiology: JACR [Online], 7(8), pp. 650–
652. [Accessed 17 April 2020].
Gdowski, A. S., Ranjan, A., and Vishwanatha, J. K. (2017). Current concepts in bone metastasis,
contemporary therapeutic strategies, and ongoing clinical trials. Journal of experimental
& clinical cancer research: CR [Online], 36(1), p. 108. [Accessed 17 April 2020].

Medical Imaging: Colorectal Cancer Case Analysis 13
Glover, L. (2014) Why Does an MRI Cost so Dran Much? Money. Available from:
https://money.com/why-does-mri-cost-so-much/ [Accessed 17 April 2020].
Jain, T., Williams, R., Liechty, B., and Ann Chen, L. (2016) Vertebral Metastasis as the Initial
Manifestation of Colon Cancer. ACG case reports journal [Online], 3(4), p. e122.
[Accessed 17 April 2020].
Jimi S, Yasui T, and Hotokezaka M. (2013) Clinical features and prognostic factors of bone
metastases from colorectal cancer. Surg Today [Online], 43, pp. 751–6. [Accessed 17
April 2020].
Jung, J., Moon, S. M., Jang, H. C., Kang, C. I., Jun, J. B., Cho, Y. K., Kang, S. J., Seo, B. J.,
Kim, Y. J., Park, S. B., Lee, J., Yu, C. S., and Kim, S. H. (2018) Incidence and risk
factors of postoperative pneumonia following cancer surgery in adult patients with
selected solid cancer: results of the "Cancer POP" study. Cancer medicine [Online], 7(1),
pp. 261–269. [Accessed 17 April 2020].
Leach, M. R., Lau, D., La Marca, F., and Park, P. (2014) Outcomes after surgery for spinal
metastasis of colorectal origin: case series. Asian spine journal [Online], 8(3), pp. 267–
272. [Accessed 17 April 2020].
Li, J., Yuan, Y., Yang, F., Wang, Y., Zhu, X., Wang, Z., Zheng, S., Wan, D., He, J., Wang, J.,
Bai, Y., Bai, C., Bai, L., Bai, W., Bi, F., Cai, K., Cai, M., Cai, S., Chen, G., Chen, K., and
Shen, L. (2019) Expert consensus on multidisciplinary therapy of colorectal cancer with
lung metastases (2019 edition). Journal of hematology & oncology [Online], 12(1), p. 16.
[Accessed 17 April 2020].

Medical Imaging: Colorectal Cancer Case Analysis 14
Mirza, N. N., McCloud, J. M., and Cheetham, M. J. (2009) Clostridium septicum sepsis and
colorectal cancer - a reminder. World journal of surgical oncology [Online], 7, p. 73.
[Accessed 17 April 2020].
Nerad, E., Lahaye, M. J., Maas, M., Nelemans, P., Bakers, F. C., Beets, G. L., and Beets-Tan, R.
G. (2016) Diagnostic Accuracy of CT for Local Staging of Colon Cancer: A Systematic
Review and Meta-Analysis. AJR. American journal of roentgenology [Online], 207(5),
pp. 984–995. [Accessed 17 April 2020].
Radiology Infor. (2018) Radiation Dose in X-ray and CT Exams. Radiology Info Organization.
Available from: https://www.radiologyinfo.org/en/info.cfm?pg=safety-xray [Accessed 17
April 2020].
Razdan, S., Pandita, K. K., and Pandita, S. (2009) Reversible hemifacial spasm due to
neurocysticercosis. Annals of Indian Academy of Neurology [Online], 12(3), pp. 191–
192. [Accessed 17 April 2020].
Swiderska, M., Choromańska, B., Dąbrowska, E., Konarzewska-Duchnowska, E., Choromańska,
K., Szczurko, G., Myśliwiec, P., Dadan, J., Ladny, J. R., and Zwierz, K. (2014) The
diagnostics of colorectal cancer. Contemporary oncology (Poznan, Poland)
[Online], 18(1), pp. 1–6. [Accessed 17 April 2020].
Tapia, R., G., Price, T. J., Karapetis, C., Piantadosi, C., Padbury, R., Roy, A., Maddern, G.,
Moore, J., Carruthers, S., Roder, D., and Townsend, A. R. (2017) Brain metastasis in
advanced colorectal cancer: results from the South Australian metastatic colorectal cancer
(SAmCRC) registry. Cancer biology & medicine [Online], 14(4), pp. 371–376.
[Accessed 17 April 2020].

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Villeneuve, P. J. and Sundaresan, R. S. (2009) Surgical management of colorectal lung
metastasis. Clinics in colon and rectal surgery [Online], 22(4), pp. 233–241. [Accessed
17 April 2020].
Webb, L. (2014) Purchasing Insight: Portable X-ray. Healthcare Finance. Available from:
https://www.healthcarefinancenews.com/blog/purchasing-insight-portable-x-ray
[Accessed 17 April 2020].
Xiang, L. and Gilkes, D. M. (2019) The Contribution of the Immune System in Bone Metastasis
Pathogenesis. International journal of molecular sciences [Online], 20(4), p. 999.
[Accessed 17 April 2020].
Zisis, C., Tsakiridis, K., Kougioumtzi, I., Zarogoulidis, P., Darwiche, K., Machairiotis, N., Zaric,
B., Katsikogiannis, N., Kesisis, G., Stylianaki, A., Li, Z., and Zarogoulidis, K. (2013)
The management of the advanced colorectal cancer: management of the pulmonary
metastases. Journal of thoracic disease [Online], 5 Suppl 4(Suppl 4), pp. S383–S388.
[Accessed 17 April 2020].