Aneese Andrew M, Manuballa Vinayata, Amin Mitual, Cappell Mitchell S
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.
World J Gastrointest Endosc. 2017 Jun 16;9(6):282-295. doi: 10.4253/wjge.v9.i6.282.
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 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 the prostate; and the novel aforementioned colonoscopic findings underlying the clinical presentation.
一名87岁男性，1996年因前列腺癌T1c期Gleason 6级接受放疗，2009年因复发性前列腺癌接受亮丙瑞林激素治疗，2010年因膀胱尿路上皮癌接受卡介苗和阿霉素治疗。2015年就诊时，患者每天排出无痛性鲜红色血便，便纸上带血，持续5个月。直肠指检发现直肠内有鲜红色血液，在正常前列腺位置可触及一个坚硬、固定的2.5 cm×2.5 cm肿物。血红蛋白为7.6 g/dL（铁饱和度=8.4%，提示缺铁性贫血）。腹盆腔CT血管造影显示膀胱颈部局部壁增厚，一个含气腔的肿物取代了正常前列腺，并侵犯相邻直肠。结肠镜检查显示在直肠前壁、正常前列腺位置有一个溃疡、渗血、多结节、质脆的2.5 cm×2.5 cm肿物。对肿物进行结肠镜活检的组织学和免疫组化分析显示为低分化尿路上皮癌。在内脏血管造影时，栓塞了右直肠上动脉以实现止血。患者随后出现多处新转移灶，栓塞后13个月死亡。全面的文献回顾显示，此前有16例膀胱尿路上皮癌累及直肠的病例报道，其中11例为直接蔓延，5例为转移。患者平均年龄为63.7±9.6岁（所有患者均为男性）。直肠受累平均在膀胱尿路上皮癌初诊后13.5±11.8个月被诊断出来。症状包括便秘/胃肠道梗阻6例、体重减轻5例、腹泻3例、厌食3例、铅笔样便3例、里急后重2例、肛门直肠疼痛2例，其他5例。9例患者的直肠指检显示环形直肠狭窄6例，直肠肿物3例。本例患者有每天排出无痛性鲜红色血便、便纸上带血这一类似痔出血的新表现；有膀胱尿路上皮癌直接蔓延至直肠黏膜及前列腺这一新机制；以及有上述支持临床表现的结肠镜新发现。
