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

Table 1 Direct extension of bladder urothelial carcinoma to rectum

Patient No., age and sex	Prior oncologic history	Clinical presentation with GI involvement	Radiologic imaging subsequent endoscopy/surgery	Metastatic location:Pathologic diagnosis	Treatment	Outcome	Ref.
1. 87-year-old man	Nineteen years PTA underwent external beam radiotherapy and leuprolide hormonal therapy for prostate cancer stage T1c Gleason 6. Five years PTA underwent Bacillus Calmette-Guérin immunotherapy and adriamycin chemotherapy for bladder urothelial carcinoma in situ stage Ta G1-2	Painless, bright red blood coating stools for 5 mo. Rectal exam: Bright red blood per rectum and large, hard, fixed, multinodular, “prostate” mass. Hemoglobin = 7.6 g/dL	CT angiography: Mass containing air-fluid cavity replacing prostate, with rectal invasion. Colonoscopy: Ulcerated, friable, oozing, multinodular, hemorrhagic, 2.5 cm × 2.5 cm mass on anterior rectal wall, just proximal to dentate line	Rectum: Poorly differentiated carcinoma of urothelial origin	Abdominopelvic angiography: Successful right-superior-rectal-artery embolization using embolospheres	Stopped bleeding for 3 mo. Subsequently rebled. Underwent palliative colostomy for the rebleeding. Died 13 mo after diagnosis of rectal lesion	Current report
2. 64-year-old man	Sixteen month PTA, underwent radical cystectomy, left nephroureterectomy, and right ureterocutaneostomy for Grade 3 urothelial carcinoma Stage pT3aN0. 11 mo PTA, received 3 courses of MVAC chemotherapy for lymph node metastases	Anorexia, tenesmus	Abdominopelvic CT: Focal, annular thickening of rectal wall	Rectum: Urothelial carcinoma	Fecal diversion	Died 2 mo later	Katayama et al[1]
3. 60-year-old man	Prior high grade bladder urothelial carcinoma	Anal pain, fatigue, weight loss, and anorexia. Rectal exam: Hard, fixed, annular, constrictive mass, 6 cm from anal verge. Hemoglobin = 11.6 g/dL	Pelvic CT: Mass posterior to bladder. Perirectal wall thickening	Rectum: Grade 4 urothelial carcinoma	Chemotherapy with VP-16 and cisplatin in 3 mo cycles and external beam RT	Died 9 mo after initiating RT	Stillwell et al[2]
4. 58-year-old man	Two year PTA underwent partial cystectomy for grade 3 N0 bladder urothelial carcinoma	Anorexia, weight loss, fatigue, straining with bowel movements, narrow-caliber stools, rectal pain, and tenesmus for several months. Rectal exam: hard, annular, constrict-ing lesion with a narrowed lumen, at 8 cm from anal verge	Pelvic CT: Large mass encircling rectum, lytic lesion in third lumbar vertebra, and bilateral hydronephrosis. Proctoscopy: Constricting lesion with normal overlying mucosa, suggestive of extrinsic compression. Exploratory laparotomy: Hard mass extending from posterior bladder wall, obliterating rectovesical pouch, and encompassing rectum	Rectum: Biopsy during proctos-copy showed normal mucosal tissue. Transrectal (deep) and transperineal biopsy: Poorly differentiated grade 3 urothelial cancer	Sigmoid loop colostomy, RT to pelvis and lumbar spine, followed by single dose of cisplatin	Died 3 mo later from liver metastasis	Stillwell et al[2]
5. 73-year-old man	Three years PTA underwent radical cystoprostatectomy, with clear margins, and ileal loop urinary diversion for Stage pT3a N0 bladder urothelial carcinoma. At that time, biopsy also demonstrated areas of adenocarcinoma and signet ring cell carcinoma	Diarrhea, rectal pain, fatigue, weight loss, and fecal incontinence for 1 mo. Physical exam: Thin elderly male, bilateral lower extremity edema. Rectal exam: rectal stenosis 1 cm from anal verge. Guaiac negative stool	Abdominopelvic CT: annular rectal mass. Exploratory laparoscopy: Solid pelvic tumor adherent to sacrum	Rectum: Urothelial cancer invading muscularis propria of rectal wall	Diverting loop colostomy	Chemotherapy planned, but patient developed lower extremi- ty ischemia, requiring leg amputation. Died shortly thereafter	Langenstroer et al[3]
6. 76-year-old man	Underwent left nephroureter-ectomy. 1 mo PTA underwent right ureteral diverting cutaneostomy for grade 3 bladder urothelial carcinoma. Bladder mass firmly attached to pelvic wall and to thickened lateral pedicles	Symptoms of rectal obstruction. Rectal exam: Stenosis with intact rectal mucosa	Pelvic CT: Annular thickening of rectal wall and thickened lateral pedicles, bilaterally	Rectum: Urothelial carcinoma	Diverting colostomy and unspecified immunotherapy	Died 5 mo later	Kobayashi et al[4]
7. 66-year-old man	No prior oncologic history	Rectal exam: Severe rectal stenosis with intact rectal mucosa	Abdominopelvic CT: Thickened bladder and rectal walls, bilateral hydronephrosis. Colonoscopy: Narrow rectal lumen with edematous mucosa, suggesting extrinsic compression	Rectum: Grade 3 urothelial carcinoma	Ileal-conduit and colostomy	Died 3 mo after surgery	Kobayashi et al[4]
8. 51-year-old man	1 mo PTA underwent ureterocutaneostomy for unresectable grade 3 bladder urothelial carcinoma attached to pelvic wall, causing bilateral hydronephrosis	Thin stools. Rectal exam: Narrow rectal lumen	Pelvic CT: Annular constriction of rectum	Rectum: Grade 3 urothelial carcinoma	Diverting colostomy and one course of M-VAC chemotherapy	Died 10 mo after surgery	Kobayashi et al[4]
9. 74-year-old man	Eleven months PTA underwent radical cystectomy for grade 3 urothelial carcinoma of bladder	Continuous watery rectal discharge and thin stools	Barium enema: Stenosis of lower rectum Pelvic MRI: Thickened rectal mucosa and muscle layer without evident tumor	Rectum: Grade 3 pT3a urothelial carcinoma	Colostomy, MVAC chemotherapy, and radiation	Died 7 mo after presentation	Ito et al[5]
10. 54-year-old man	Underwent radical cystoprostatectomy with neobladder for grade 3 bladder urothelial carcinoma	Presumed refractory ulcerative proctitis	Pelvic MRI: Circumferential thickening of rectum. Endoscopy: Circumferential rectal wall thickening 11 cm from anal verge. EUS: Circumferential hypoechoic infiltrate extending through all rectal wall layers	Rectum: Urothelial carcinoma	Chemotherapy	NR	Gleeson et al[6]
11. 55-year-old man	Underwent radical cystoprostatectomy with neobladder for grade 3 bladder urothelial carcinoma	Constipation	Abdominopelvic CT: No evident metastasis Endoscopy: Circumferential rectal wall thickening with stricture 16 cm from anal sphincter EUS: Diffuse circumferential thickening of rectal wall	Rectum: urothelial carcinoma	Chemotherapy	NR	Gleeson et al[6]
12. 60-year-old man	Underwent radical cystoprostatectomy with neobladder, for grade 3 urothelial cancer of bladder	Constipation	Abdominopelvic CT: Abnormal perirectal lymph nodes. Endoscopy: Circumferential rectal wall thickening. EUS: Diffuse circumferential thickening of all layers of rectal wall with several hypoechoic lymph nodes in extraluminal space	Rectum: Urothelial carcinoma	Chemotherapy	NR	Gleeson et al[6]

CT: Computed tomography; GI: Gastrointestinal; M-VAC: Methotrexate, vinblastine, Adriamycin; NR: Not reported; PTA: Prior to admission; RT: Radiation therapy; MRI: Magnetic resonance imaging.

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.

Table 3 Metastases of urothelial bladder carcinoma to the esophagus, stomach, and small intestine

Patient age and sex	Prior oncologic history	Clinical presentation with GI involvement	Radiologic imaging, endoscopy, surgery	Metastasis location: Pathologic diagnosis	Treatment	Outcome	Ref.
1. 55-year-old man	1 mo PTA underwent total cystoprostatectomy, bilateral ilio-obturator lymphadenectomy, and bladder reconstruction for bladder urothelial carcinoma pT3-GIII, N0	Hematemesis 8 d after surgery	Chest and abdominopelvic CT: Esophageal mass. EGD: 2-cm-wide mass in proximal esophagus. EUS: No lymphadenopathy	Esophagus: Urothelial carcinoma infiltrating submucosa	Chemotherapy with M-VAC, and RT of metastasis	Developed radiation pericarditis but recovered. Alive at 2 yr	Jung et al[15]
2. 66-year-old man	No prior oncologic history	Dysphagia, anorexia, weight loss, headaches, and lightheadedness for 6 wk. Palpable, tender, 2 cm mass on left neck	Neck and thoracic CT: 3 cm × 2 cm soft tissue mass with dilation and thickening of proximal esophagus. EGD: Focal stricture at 25 cm from incisors with a 2 cm × 1 cm ulcer with irregular margins	Esophagus: Poorly differentiated urothelial carcinoma	None	Died 10 d after discharge from hospital	Dy et al[16]
3. 80-year-old man	Four years PTA underwent RT and chemotherapy (after declining radical cystectomy) for bladder urothelial carcinoma. Three years PTA underwent lung lobe wedge resection for solitary lung metastasis. 1 mo PTA had a normal EGD and colonoscopy in evaluation of anemia	Malaise, dizziness, dyspnea, melena. Rectal exam: Positive occult blood in stool. Hemoglobin = 5.4 g/dL	Small bowel enteroscopy: 3 cm, ulcerated, infiltrating tumor in distal duodenum. Tumor has an adherent, friable, clot	Duodenum: High-grade urothelial carcinoma	Duodenectomy and duodenomy jejunostomy	PET scan 2 mo later: Metastases to liver and lungs. Patient expired soon thereafter from cardiac arrhythmia	Girotra et al[17]
4. 62-year-old man	Two years PTA underwent partial cystectomy with lymph node dissection and adjuvant chemotherapy for stage IIIb bladder urothelial carcinoma	Hematemesis, hemoglobin = 7.0 g/dL	EGD: Large bleeding mass in descending duodenum. Treated with proton pump inhibitor therapy. Repeat EGD 4 d later: large partly obstructing, 7-cm-long mass in descending duodenum	Duodenum: Poorly differentiated urothelial carcinoma	Palliative radiation	Died 6 wk later	Chan et al[18]
5. 74-year-old man	Four years PTA underwent exploratory laparotomy which demonstrated nodal metastasis. Completed preoperative chemotherapy, but declined surgical resection	Abdominal pain, bloating, distention, nausea, and vomiting	Serial pelvic CT (to monitor cancer progression): Stable bladder wall thickening Small bowel barium contrast radiography: Narrowing of third portion of duodenum Gastroscopy: Fluid-filled, dilated, stomach without obstruction. EGD: Luminal narrowing with overlying normal mucosa in third portion of duodenum. EUS: Circumferential wall thickening	Duodenum: urothelial carcinoma	Enteral stent and palliative chemotherapy	Died 9 mo later	Yusuf et al[13]
6. 42-year-old woman	No prior oncologic history	Nausea, vomiting, abdominal discomfort, and 6-kg weight loss for 2 mo	Barium meal: Abrupt stricture at junction between second and third portion of duodenum. Abdominopelvic CT: Infiltrative soft tissue mass around duodenum, calcified bladder wall. No pelvic lymphadenopathy. EGD: Gastric outlet obstruction with distorted and erythematous duodenum without ulceration, or mucosal tumor	Duodenum: Micropapillary variant of poorly differentiated urothelial carcinoma	Duodenal stent and RT to periduode-nal lesion. Administered palliative gemcitabine and carboplatin	Died 15 mo after diagnosis	Hawtin et al[19]
7. 87-year-old man	Sixteen months PTA underwent TURBT for grade 3, pT2bN0M0, bladder urothelial carcinoma	Ileus	Abdominopelvic CT: Pneumoperitoneum due to GI perforation Laparotomy: Elastic hard tumor at site of ileal perforation	Ileum: Metastatic urothelial carcinoma	Partial resection of ileum	NA	Hoshi et al[20] (in Ja-panese)
8. 53-year-old man	No prior oncologic history	Gross hematuria	Abdominopelvic CT: Bladder tumor invading prostate. Cystoscopy: Non-papillary, broad based, tumor in right wall of bladder	Ileum and prostate: Urothelial carcinoma pT4aN1M0	Total cystec--tomy and creation of ileal conduit. Neoadjuvant chemotherapy	NA	Hoshi et al[20] (article in Japanese)
9. 56-year-old man	Fifty-nine months PTA underwent TURBT for bladder urothelial carcinoma	Abdominal pain and GI perforation	NA	Small intestine, lymph nodes, lung, and liver: Urothelial carcinoma	NA	NA	Hoshi et al[20] (Case from table 2)
10. 63-year-old woman	Seven months PTA underwent total cystectomy for pT3b bladder urothelial carcinoma	Abdominal pain	NR	Small intestine: Urothelial carcinoma	NR	NR	Hoshi et al[20] (Case from table 2)
11. 46-year-old man	Thirty-eight months PTA underwent RT and chemotherapy for pT3b bladder urothelial carcinoma	Ileus	NR	Small intestine: Urothelial carcinoma	NR	NR	Hoshi et al[20] (Case from table 2)
12. 71-year-old man	Thirty-six months PTA underwent total cystectomy for bladder urothelial carcinoma	Melena and anemia	NR	Small intestine: Urothelial carcinoma	NR	NR	Hoshi et al[20] (Case from table 2)
13. 55-year-old man	Seven years PTA underwent total cystectomy, pelvic lymphadenectomy, and neobladder reconstruction. Underwent two cycles of adjuvant chemotherapy for pT3apN0 G2 bladder urothelial carcinoma	Massive melena, HR = 120 beats/min, BP = 72/36 mmHg. Hemoglobin = 7.9 g/dL	Abdominopelvic CT: Right hydronephrosis from external iliac lymph node metastasis invading ileum. Angiography: Right external iliac artery successfully embolized using microcoils and n-butyl cyanoacrylate. Then developed ischemic colitis, treated with iliac artery bypass grafting, and right common and internal iliac artery embolization	Ileum: NR	Three cycles of unspecified chemotherapy	Died 4 mo after embolization	Honda et al[21]

BC: Bladder cancer; BP: Blood pressure; CT: Computed tomography; EGD: Esophagogastroduodenoscopy; GI: Gastrointestinal, HR: Heart rate; M-VAC: Methotrexate, vinblastine, Adriamycin; NR: Not reported; PTA: Prior to admission; RT: Radiation therapy; TURBT: Transurethral resection of bladder tumor; EUS: Endoscopic ultrasound.