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.