Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jun 16, 2017; 9(6): 282-295
Published online Jun 16, 2017. doi: 10.4253/wjge.v9.i6.282
Bladder urothelial carcinoma extending to rectal mucosa and presenting with rectal bleeding
Andrew M Aneese, Vinayata Manuballa, Mitual Amin, Mitchell S Cappell
Andrew M Aneese, Vinayata Manuballa, Mitchell S Cappell, Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, MI 48073, United States
Mitual Amin, Department of Pathology, William Beaumont Hospital, Royal Oak, MI 48073, United States
Mitual Amin, Mitchell S Cappell, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
Author contributions: Aneese AM and Cappell MS are equal primary authors; Aneese AM wrote a large part of the case report, performed the initial literature search, and wrote a preliminary version of the tables and discussion; Cappell MS was one of the two gastroenterologists taking care of this patient; Cappell MS was the mentor for Aneese AM who was a resident while participating in writing this paper; As the mentor, Cappell MS conceived and initiated this project, and supervised the writing of the entire paper, including editing the introduction, case report, tables, and discussion sections; Manuballa V was one of the 2 gastroenterologists treating this patient, she wrote a large part of the case report section; Amin M performed all the pathology for this case report including the histopathology and immunohistochemistry, he retrospectively re-reviewed all the pathological slides.
Institutional review board statement: For case report by William Beaumont Hospital, Royal Oak, 8/27/15.
Informed consent statement: Informed written consent for publication was unobtainable from the patient because he had expired prior to writing this case report. IRB approval for case report obtained from William Beaumont Hospital, Royal Oak, 8/27/15.
Conflict-of-interest statement: None. In particular, Dr. Cappell, as a consultant of the United States Food and Drug Administration (FDA) Advisory Committee for Gastrointestinal Drugs, affirms that this paper does not discuss any proprietary, confidential, pharmaceutical data submitted to the FDA. Dr. Cappell is also a member of the speaker’s bureau for AstraZeneca and Daiichi Sankyo, co-marketers of Movantik. This work does not discuss any drug manufactured or marketed by AstraZeneca or Daiichi Sankyo.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mitchell S Cappell, MD, PhD, Director, Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, 3535 West Thirteen Mile Road, Royal Oak, MI 48073, United States. mscappell@yahoo.com
Telephone: +1-248-5511227 Fax: +1-248-5517581
Received: January 18, 2017
Peer-review started: January 19, 2017
First decision: March 8, 2017
Revised: March 30, 2017
Accepted: April 23, 2017
Article in press: April 24, 2017
Published online: June 16, 2017
Processing time: 149 Days and 5.3 Hours
Abstract

An 87-year-old-man with prostate-cancer-stage-T1c-Gleason-6 treated with radiotherapy in 1996, recurrent prostate cancer treated with leuprolide hormonal therapy in 2009, and bladder-urothelial-carcinoma in situ treated with Bacillus-Calmette-Guerin and adriamycin in 2010, presented in 2015 with painless, bright red blood per rectum coating stools daily for 5 mo. Rectal examination revealed bright red blood per rectum; and a hard, fixed, 2.5 cm × 2.5 cm mass at the normal prostate location. The hemoglobin was 7.6 g/dL (iron saturation = 8.4%, indicating iron-deficiency-anemia). Abdominopelvic-CT-angiography revealed focal wall thickening at the bladder neck; a mass containing an air cavity replacing the normal prostate; and adjacent rectal invasion. Colonoscopy demonstrated an ulcerated, oozing, multinodular, friable, 2.5 cm × 2.5 cm mass in anterior rectal wall, at the usual prostate location. Histologic and immunohistochemical analysis of colonoscopic biopsies of the mass revealed poorly-differentiated-carcinoma of urothelial origin. At visceral angiography, the right-superior-rectal-artery was embolized to achieve hemostasis. The patient subsequently developed multiple new metastases and expired 13 mo post-embolization. Comprehensive literature review revealed 16 previously reported cases of rectal involvement from bladder urothelial carcinoma, including 11 cases from direct extension and 5 cases from metastases. Patient age averaged 63.7 ± 9.6 years (all patients male). Rectal involvement was diagnosed on average 13.5 ± 11.8 mo after initial diagnosis of bladder urothelial carcinoma. Symptoms included constipation/gastrointestinal obstruction-6, weight loss-5, diarrhea-3, anorexia-3, pencil thin stools-3, tenesmus-2, anorectal pain-2, and other-5. Rectal examination in 9 patients revealed annular rectal constriction-6, and rectal mass-3. The current patient had the novel presentation of daily bright red blood per rectum coating the stools simulating hemorrhoidal bleeding; the novel mechanism of direct bladder urothelial carcinoma extension into rectal mucosa via the prostate; and the novel aforementioned colonoscopic findings underlying the clinical presentation.

Keywords: Bladder cancer; Urothelial; Uroepitheilal; Transitional cell; Rectum penetration; Cancer spread; Lower gastrointestinal bleeding; Colonoscopy

Core tip: Comprehensive literature review revealed 16 reported cases of bladder-urothelial-carcinoma involving rectum. None of these cases presented with daily rectal bleeding. Among 11 cases with direct extension, none had pathologically-proven rectal mucosal involvement. A case is reported of recurrent bladder-urothelial-carcinoma presenting with daily bright red blood per rectum coating stools from bladder-urothelial-carcinoma involving rectal mucosa. A hemorrhagic, multinodular, rectal mass, identified by colonoscopy, from direct extension of Bladder-Urothelial-Carcinoma via prostate to rectal mucosa underlies the presentation with daily bright red blood per rectum. This report shows that bladder-urothelial-carcinoma can cause rectal bleeding by directly extending to rectal mucosa.