Int J Colorectal Dis DOI 10.1007/s00384-015-2213-y
LETTER TO THE EDITOR
Rapid progressive colon cancer metastasized to the right epididymis and liver: report of a case and review of the literature René Fahrner 1 & Bernhard Theis 2 & Michael Ardelt 1 & Falk Rauchfuss 1 & Silke Schüle 1 & Utz Settmacher 1
Accepted: 11 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Colorectal cancer is the third most common malignancy with 1.2 million new patients per year [1]. Overall survival rates improved significantly over the last decades, and 5-year survival rate is actually about 65 % for all patients and tumor stages [1]. Depending on the tumor spread, survival rates decrease from 90 % in localized to about 70 % with regional metastases and to about 12 % with distant metastatic spread [2]. Apart from regional lymph nodes, the liver represents the most common site of distant metastases (with 15–25 % of all colorectal cancer patients) [3]. Metastases of colorectal cancer to the testes are uncommon and only 35 patients have been reported so far [4]. To shed light on this infrequent presentation of a colon cancer metastasis, we present this unusual case of a young patient with occlusive colorectal cancer undergoing emergency resection due to ileus with rapid progressive metastases to the right epididymis and liver.
Case report A 41-year-old healthy patient was referred to the emergency department due to a 1-week history of abdominal pain and disturbed gastrointestinal passage with vomiting and constipation. Further urgent diagnostic investigation with computed tomography revealed signs of an ileus with expanded small * René Fahrner [email protected] 1
Division of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740 Jena, Germany
2
Institute of Pathology, University Hospital Jena, 07743 Jena, Germany
intestine and colon caused by an occlusive tumor in the rectosigmoidal intersection. In addition, local lymph node metastases, a pararectal tumor nodule, and two liver metastases in segments II and VIII were detected. Due to the intestinal occlusion, urgent laparotomy was performed with anterior rectosigmoid resection, local lymphadenectomy, on-table lavage of the colon with finally primary colorectal anastomosis in the middle of the rectum, and protective loop ileostomy. Histological assessment revealed an advanced adenocarcinoma of the colon (pT3 N2b (14/17) L1 V1 M1 (liver)). Neither K- and N-RAS mutations nor microsatellite instability were seen. The patient was discharged after an uneventful postoperative course and readmission was planned 6 weeks later for liver resection. At the time of readmission, a tumorous testicular nodule was palpable and a massive progression of the hepatic metastases was seen in magnetic resonance imaging. For further diagnostics, a surgical exploration with orchiectomy and histological examination of the testicular tumor was performed and histology revealed a metastasis of the colorectal adenocarcinoma in the right epididymis. In view of the rapid tumor progression with diffuse and therefore unresectable liver metastases, systemic chemotherapy was initiated in palliative intent.
Discussion Metastases of colorectal cancer to the testes are rare and an uncommon finding [4]. In the current literature, 35 cases are reported. In general, testicular metastases are often incidental findings at autopsy or during histologic examination of orchiectomy specimens. In a large autopsy study, the incidence of metastatic tumor of the testis is reported in 0.02 to 0.06 % of all cases. Patients with testicular metastases of colorectal cancer are older than patients with primary urological
Int J Colorectal Dis
tumors, and tumors tend to appear as unilateral and solitary nodules [4]. Different possible pathways of tumor cell dissemination in colorectal cancer to the intrascrotal structures are discussed such as lymphatic or vascular dissemination, direct tumor cell invasion, or retrograde spermiduct tumor cell dissemination [4]. In addition, the lower temperature in the scrotum compared to the abdominal cavity is postulated to facilitate the formation of testicular metastasis. With respect to previously published case reports, sigmoidal tumors are more likely to metastasize to the testis than tumors of the cecum, rectum, or other sections of the colon [4]. Mostly, additional metastatic sites were reported such as the liver, lung, peritoneum, or lymph nodes and in some cases, testicular mass was the primary presentation of the colorectal cancer [4].
from surgical tumor mass reduction, systemic chemotherapy is mandatory in these patients with reduced survival rate in comparison to earlier stages in order to prolong overall survival or even achieve cure. Therefore, complete clinical and diagnostic evaluations of the patient as well as knowledge of possible metastatic pathways are fundamental to guide the further therapeutic approach.
Conflict of interest The authors declare that they have no conflict of interests.
References 1. 2.
Conclusion Metastases of colorectal cancer to the testes are rare but several metastatic pathways to the testis are postulated including lymphatic, vascular, or direct tumor cell invasion [4]. Apart
3.
4.
Brenner H, Kloor M, Pox CP (2014) Colorectal cancer. Lancet 383: 1490–1502 Siegel R, Naishadham D, Jemal A (2012) Cancer statistics, 2012. CA Cancer J Clin 62:10–29 Lykoudis PM, O'Reilly D, Nastos K, Fusai G (2014) Systematic review of surgical management of synchronous colorectal liver metastases. Br J Surg 101:605–612 Hatoum HA, Abi Saad GS, Otrock ZK, Barada KA, Shamseddine AI (2011) Metastasis of colorectal carcinoma to the testes: clinical presentation and possible pathways. Int J Clin Oncol 16:203–209
LETTER TO THE EDITOR
Rapid progressive colon cancer metastasized to the right epididymis and liver: report of a case and review of the literature René Fahrner 1 & Bernhard Theis 2 & Michael Ardelt 1 & Falk Rauchfuss 1 & Silke Schüle 1 & Utz Settmacher 1
Accepted: 11 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Colorectal cancer is the third most common malignancy with 1.2 million new patients per year [1]. Overall survival rates improved significantly over the last decades, and 5-year survival rate is actually about 65 % for all patients and tumor stages [1]. Depending on the tumor spread, survival rates decrease from 90 % in localized to about 70 % with regional metastases and to about 12 % with distant metastatic spread [2]. Apart from regional lymph nodes, the liver represents the most common site of distant metastases (with 15–25 % of all colorectal cancer patients) [3]. Metastases of colorectal cancer to the testes are uncommon and only 35 patients have been reported so far [4]. To shed light on this infrequent presentation of a colon cancer metastasis, we present this unusual case of a young patient with occlusive colorectal cancer undergoing emergency resection due to ileus with rapid progressive metastases to the right epididymis and liver.
Case report A 41-year-old healthy patient was referred to the emergency department due to a 1-week history of abdominal pain and disturbed gastrointestinal passage with vomiting and constipation. Further urgent diagnostic investigation with computed tomography revealed signs of an ileus with expanded small * René Fahrner [email protected] 1
Division of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740 Jena, Germany
2
Institute of Pathology, University Hospital Jena, 07743 Jena, Germany
intestine and colon caused by an occlusive tumor in the rectosigmoidal intersection. In addition, local lymph node metastases, a pararectal tumor nodule, and two liver metastases in segments II and VIII were detected. Due to the intestinal occlusion, urgent laparotomy was performed with anterior rectosigmoid resection, local lymphadenectomy, on-table lavage of the colon with finally primary colorectal anastomosis in the middle of the rectum, and protective loop ileostomy. Histological assessment revealed an advanced adenocarcinoma of the colon (pT3 N2b (14/17) L1 V1 M1 (liver)). Neither K- and N-RAS mutations nor microsatellite instability were seen. The patient was discharged after an uneventful postoperative course and readmission was planned 6 weeks later for liver resection. At the time of readmission, a tumorous testicular nodule was palpable and a massive progression of the hepatic metastases was seen in magnetic resonance imaging. For further diagnostics, a surgical exploration with orchiectomy and histological examination of the testicular tumor was performed and histology revealed a metastasis of the colorectal adenocarcinoma in the right epididymis. In view of the rapid tumor progression with diffuse and therefore unresectable liver metastases, systemic chemotherapy was initiated in palliative intent.
Discussion Metastases of colorectal cancer to the testes are rare and an uncommon finding [4]. In the current literature, 35 cases are reported. In general, testicular metastases are often incidental findings at autopsy or during histologic examination of orchiectomy specimens. In a large autopsy study, the incidence of metastatic tumor of the testis is reported in 0.02 to 0.06 % of all cases. Patients with testicular metastases of colorectal cancer are older than patients with primary urological
Int J Colorectal Dis
tumors, and tumors tend to appear as unilateral and solitary nodules [4]. Different possible pathways of tumor cell dissemination in colorectal cancer to the intrascrotal structures are discussed such as lymphatic or vascular dissemination, direct tumor cell invasion, or retrograde spermiduct tumor cell dissemination [4]. In addition, the lower temperature in the scrotum compared to the abdominal cavity is postulated to facilitate the formation of testicular metastasis. With respect to previously published case reports, sigmoidal tumors are more likely to metastasize to the testis than tumors of the cecum, rectum, or other sections of the colon [4]. Mostly, additional metastatic sites were reported such as the liver, lung, peritoneum, or lymph nodes and in some cases, testicular mass was the primary presentation of the colorectal cancer [4].
from surgical tumor mass reduction, systemic chemotherapy is mandatory in these patients with reduced survival rate in comparison to earlier stages in order to prolong overall survival or even achieve cure. Therefore, complete clinical and diagnostic evaluations of the patient as well as knowledge of possible metastatic pathways are fundamental to guide the further therapeutic approach.
Conflict of interest The authors declare that they have no conflict of interests.
References 1. 2.
Conclusion Metastases of colorectal cancer to the testes are rare but several metastatic pathways to the testis are postulated including lymphatic, vascular, or direct tumor cell invasion [4]. Apart
3.
4.
Brenner H, Kloor M, Pox CP (2014) Colorectal cancer. Lancet 383: 1490–1502 Siegel R, Naishadham D, Jemal A (2012) Cancer statistics, 2012. CA Cancer J Clin 62:10–29 Lykoudis PM, O'Reilly D, Nastos K, Fusai G (2014) Systematic review of surgical management of synchronous colorectal liver metastases. Br J Surg 101:605–612 Hatoum HA, Abi Saad GS, Otrock ZK, Barada KA, Shamseddine AI (2011) Metastasis of colorectal carcinoma to the testes: clinical presentation and possible pathways. Int J Clin Oncol 16:203–209
