Adenocarcinoma of the caecum metastatic to the bladder: an unusual cause of haematuria
© Grey et al; licensee BioMed Central Ltd. 2006
Received: 21 May 2006
Accepted: 14 October 2006
Published: 14 October 2006
Primary malignancies of colorectal origin can metastasise to the bladder. Reports are however extremely rare, particularly from the caecum.
The report describes the case of a 45-year old male with Duke's B caecal carcinoma treated with a laparoscopically-assisted right hemicolectomy and adjuvant 5-Fluorouracil chemotherapy. Subsequently, a metastatic lesion to the bladder was demonstrated and successfully excised by partial cystectomy.
In order that optimal therapeutic options can be determined, it is important for clinicians to distinguish between primary disease of the bladder and other causes of haematuria. Various immunohistochemical techniques attempt to differentiate primary adenocarcinoma of the bladder from secondary colorectal adenocarcinoma. Suspicion of metastatic disease must be raised when histologically unusual bladder tumours are identified.
The vast majority of bladder tumours are primary transitional cell carcinomas. Primary adenocarcinomas of the bladder are rarer but well recognized. Secondary neoplastic growths of the bladder account for approximately 2% of bladder malignancies . Bladder involvement in patients with primary colorectal adenocarcinomas is most likely to be secondary to direct invasion from the adjacent recto-sigmoid. Isolated distant metastases to the bladder from colorectal primary disease have very rarely been reported [2–5]. This case presents a case of frank haematuria related to a bladder metastasis from a mucinous adenocarcinoma of the caecum.
A 45-year-old man presented with vague abdominal pain associated with a palpable mass. An ultrasound scan demonstrated a mass in the right iliac fossa but no evidence of hepatic metastases or lymphadenopathy. A plain X-ray film of the chest demonstrated no abnormality. A subsequent barium enema suggested a caecal carcinoma and he was subsequently treated for a pT3 N0 M0 (Dukes B) moderately differentiated mucinous adenocarcinoma of the caecum in July 2002 with a laparoscopically-assisted right hemicolectomy. A complete oncological resection was achieved with clear surgical resection margins of at least 4 centimetres. Fourteen lymph nodes were sampled but no metastatic disease was identified. In concordance with his high risk for microsatellite instability, he underwent 30 sessions of weekly adjuvant 5-Fluorouracil (5-FU) chemotherapy with minimal co-morbidity. Eight months post-operatively he was referred to the Urology Department with a 4-month history of irritative lower urinary tract symptoms that had culminated with a short history of frank haematuria.
Distant metastases to the bladder have been reported in patients with primary stomach [2, 6], skin [2, 7, 8], breast [2, 9–11], lung , pancreatic [2, 12], uterine [2, 13] and oesophageal malignancies . Caecal primaries are anatomically less likely to invade the bladder than neoplasms of the rectosigmoid. This rare case provides evidence consistent with distant metastases to the bladder which were subsequently treated surgically with clear resection margins (Figure 3).
A correct distinction between primary adenocarcinoma of the bladder and secondary colorectal adenocarcinoma is important for staging of disease, determining appropriate treatment and ultimate prognosis . In this case, the patient had already received treatment for a caecal tumour. If however the bladder metastasis was the presenting feature, it would be important to identify and evaluate the underlying primary in the colorectum. Immunohistochemical similarities between primary adenocarcinoma and secondary colorectal adenocarcinoma of the bladder however make this task difficult [15, 16].
This case highlights the rare complication of a distant bladder metastasis from a caecal carcinoma. This was successfully treated with a surgical resection and the patient had not suffered recurrence after twelve months of follow-up. Suspicion of metastatic disease must be considered when histologically unusual bladder tumours are identified. In the absence of pre-existing malignant disease immunohistochemical panels of antibodies are often required to try and identify the focus of primary disease thus allowing appropriate treatment regimen to be formulated.
Transurethral resection of bladder tumour
Written consent was obtained from the patient prior to publication of this case report.
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