Bladder urothelial carcinoma extending to rectal mucosa and presenting with rectal bleeding

Table 2 Metastases of urothelial bladder carcinoma to the colorectum

Patient age, sex	Prior oncologic history	Clinical presentation with GI involvement	Radiologic imaging, endoscopy, surgery	Metastasis location: Pathologic diagnosis	Treatment	Outcome	Ref.
1. 63-year-old man	Ten months PTA underwent radical cystectomy and MVAC chemotherapy for bladder urothelial carcinoma	Painless jaundice, 5-kg weight loss, and constipation for 2 wk. Physical exam: mild right upper quadrant tenderness. Laboratory: Elevated liver function tests	Abdominopelvic CT: Concentric thickening of rectal wall; bile duct hilar stricture with diffuse intrahepatic ductal dilation. MRI: Diffusely thickened common hepatic duct with extension into secondary branch ducts suspicious for cholangiocarcinoma. Colonoscopy: Concentric rectal constriction blocking colonoscopic intubation. ERCP: Strictures of common hepatic and right intrahepatic ducts; obstructed left intrahepatic duct	Rectum and hepatic duct: Micropapillary variant of transitional cell (urothelial) carcinoma	Rectal tumor: RT with external beam and brachy-therapy. Hepatic tumor: Polyethylene stent placed in intrahepatic bile duct. RT is planned	Alive at 4 mo	Hong et al[7]
2. 55-year-old man	Fifteen months PTA underwent TURBT and 6 wk of mitomycin C, followed by 4 rounds of gemcitabine and cisplatin chemotherapy for high grade urothelial carcinoma of bladder with iliac lymph node chain involvement. Six months PTA underwent radical cystoprostatectomy with neobladder creation and pelvic lymphadenectomy	Worsening constipation, abdominal distention, anorexia, and dyschezia. Rectal exam: palpable mass 3 cm from anal verge	Abdominopelvic CT: Pelvic and omental nodules. PET: Increased uptake at these nodules. Flexible sigmoidoscopy: 3 cm wide rectal lesion near anal verge	Rectum, omentum, other pelvic structures: Urothelial carcinoma	Diverting loop colostomy	Brain and lung metastases	Asfour et al[8]
3. 77-year-old man	Eleven years PTA underwent resection of papillary bladder urothelial carcinoma. Eight years PTA underwent TURBT and RT for recurrence. Underwent periodic cystoscopies and bladder biopsies thereafter	Progressive constipation, weight loss, and malaise	Barium enema: barium could not pass beyond sigmoid colon. Laparotomy: Sigmoid colon obstructed due to adherent tumor of terminal ileum and cecum	Sigmoid, right-transverse colon, cecum, ileum, appendix, omentum: Urothelial carcinoma	Ileotransverse colostomy and loop colostomy of descending colon	NR	Aigen et al[9]
4. 60-year-old man	Five months PTA underwent radical cystectomy with ileal conduit for invasive bladder urothelial carcinoma	Painless hematochezia. Rectal exam: Red blood in rectal vault. No externally visible or palpable hemorrhoids. Hemoglobin declined from 11.6 g/dL to 8.7 g/dL	Necrotic pelvic lesions suspicious for metastases vs abscess. Colonoscopy: Irregular, friable, partially obstructing mass at splenic flexure	Splenic flexure: Urothelial carcinoma	None	Refused treatment. Transferred to hospice	Kumar et al[10]
5. 57-year-old man	Five years PTA underwent total cystectomy for bladder urothelial carcinoma. One year PTA underwent lymph node resection, RFA, bone cement injection, and chemotherapy for left obturator lymph node and several pulmonary and left pelvic bone metastasis. Five months PTA underwent RT for regrowth of left obturator lymph node metastasis	Massive melena, HR = 120 beats/min, BP = 76/39 mmHg, Hemoglobin = 9.2 g/dL	Abdominopelvic CT: Malignant lymph node invading sigmoid colon, with pseudoaneurysm of mesenteric artery supplying sigmoid Colonoscopy: Large, oozing, ulcerated colonic tumor	Sigmoid colon: NA	Pelvic angiogram: 10 mm × 8 mm pseudoaneurysm of left inferior gluteal artery successfully embolized using microcoils and vasopressin	Alive at 5 mo	Kakizawa et al[11]
6. 83-year-old man	No prior oncologic history	Diarrhea and weight loss during prior 6 mo. Rectal exam: Mass 3 cm from anal verge	Abdominopelvic CT: Thickened right posterior wall of bladder, circumferential rectal wall thickening, and infiltrative lesions in multiple skeletal muscles Proctoscopy: Mass 3 cm from rectal verge	Rectum and skeletal muscles: Poorly differentiated urothelial carcinoma	Chemotherapy (regimen not specified)	NR	Ying-Yue et al[12]
7. 54-year-old man	Two years PTA underwent radical cystectomy and ileal neobladder reconstruction for grade 3 bladder urothelial carcinoma	Change in bowel habits	Abdominopelvic MRI: Circumferential thickening and high-grade stenosis of rectal wall. Sigmoidoscopy: Luminal narrowing with erythematous and edematous folds. EUS: Hypoechoic, circumferential, rectal wall thickening, mimicking primary rectal cancer. No evident direct cancer extension from bladder	Rectum: Urothelial carcinoma	Chemotherapy (regimen not specified)	NR	Yusuf et al[13]
8. 73-year old man	Two years PTA underwent resection of grade 2 bladder urothelial carcinoma	Severe constipation	Sigmoidoscopy: Friable, erythematous, and thickened distal rectal wall, with nearly obstructed lumen. EUS: Hypoechoic, symmetric, circumferential wall thickening, with loss of deep wall layers, and pseudopodia-like extensions into perirectal tissues. No evident direct tumor extension from bladder	Rectum: Poorly differentiated urothelial carcinoma	Total pelvic exenteration and chemotherapy (regimen not specified)	NR	Yusuf et al[13]
9. 67-year-old man	Eighteen months PTA underwent transurethral excisional biopsy of bladder cancer. Ten months PTA underwent partial cystectomy, chemotherapy with gemcitabine, and RT. 1 mo PTA, nephrostomy tubes inserted for bilateral hydronephrosis	Massive rectal bleeding and altered mental status for one day. HR = 106 beats/min, BP = 65 mmHg/palpable. Rectal exam: Rectal mass and large amount of bright red blood and clots. Hemoglobin = 8.0 g/dL	Selective angiography of celiac trunk, superior mesenteric artery and inferior mesenteric artery: No bleeding source identified. Colonoscopy: Large amount of bright red blood in colon. Emergency laparotomy: Indurated, fixed, mass involving cecum, right lower retroperitoneum, and right pelvic side wall. Dilated colon. Active bleeding from fistula between iliac artery and cecum	Cecum: Urothelial carcinoma	Resection of cecum and terminal ileum, ligation of right external iliac artery, end-ileostomy	Alive at 6 mo	Chin et al[14]

BP: Blood pressure; CT: Computed tomography; ERCP: Endoscopic retrograde cholangiopancreatography; GI: Gastrointestinal; HR: Heart rate; M-VAC: Methotrexate, vinblastine, Adriamycin; NR: Not reported; PET: Positive electron tomography; PTA: Prior to admission; RFA: Radiofrequency ablation; RT: Radiation therapy; TURBT: Transurethral resection of bladder tumor; EUS: Endoscopic ultrasound; NA: Not available.