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Vol. 4 / Nº 12 - Diciembre 2015
Unexpected destinies:unusual sites of colorectal cancer metastasesLuciana Sánchez, Marcos Dellamea, Lorena Moreno, Carlos Osorio, Rodrigo González Toranzo, Mariano Sosa.
Pictorial essay
Resumen
El carcinoma colorectal (CCR) es una de las neoplasias
malignas más frecuentes y la segunda causa de muer-
te por cáncer en ambos sexos. El hígado y los pulmo-
nes son los sitios frecuente de metástasis. No obstante
ocasionalmente metastatiza a localizaciones atípicas
dificultando el diagnóstico.
Debido a la alta frecuencia del CR los sitios infrecuen-
tes de MTS resultan hallazgos habituales en la práctica
diaria debiendo el radiólogo admitir esta posibilidad
para realizar un correcto diagnóstico.
En este trabajo se exponen las características de
lesiones secundarias a nivel del cuello uterino, pene,
escroto, pared abdominal, ganglios retroperitoneales,
torácicos, y el compromiso linfático pulmonar.
La diseminación puede ocurrir por vía linfática, hema-
tógena o bien por contigüidad. La presencia de estas
Abstract
Colorectal carcinoma is one of the most common malig-
nant neoplasms and the second leading cause of death
in both female and male patients. The liver and lungs
are common sites of metastases; however, it occasio-
nally metastasizes in atypical sites making diagnosis
difficult.
Due to the high frequency of colorectal carcinoma, even
infrequent metastatic sites are common findings in
daily practice, so the radiologist must be aware of these
possibilities to make the correct diagnosis.
This paper presents the characteristics of secondary
lesions in the cervix, penis, scrotum, abdominal wall,
retroperitoneal and thoracic nodes, and pulmonary
lymphatic involvement.
They can be disseminated through lymphatic, hemato-
genous or contiguous spread, and the presence of these
Contact information:
Luciana Sánchez.
Hospital de Clínicas José de San Martín - Ciudad de Bs. As.
E-mail: lulutcht@hotmail.com
Recibido: 10 de agosto de 2015 / Aceptado: 15 de octubre de 2015
Received: August 10, 2015 / Accepted: October 15, 2015
Revista Argentina de Diagnóstico por Imágenes
Sánchez L. et al.
Unusual sites of colorectal
cancer metastases
IntroductionColorectal carcinoma is one of the most common
malignant neoplasms and the second leading cause
of death in both female and male patients (1).
The primary lesion is mainly located in the ascen-
ding and transverse colon in 40% of cases, followed
by the descending colon and sigma in 30% of cases
and the rectum in the remaining 30% (1).
The histological variant is adenocarcinoma, which
constitutes from 80 to 90% of the cases (1).
Dissemination can occur through hematogenous,
lymphatic, or contiguous spread, depending on the
location of the primary lesion, as well as the site of
the metastasis.
The most frequent sites of metastasis are the liver,
the lungs, and the adrenal glands, in a decreasing
order of affectation (2) (Figure 1).
However, there are other unusual sites of metasta-
sis that, even though they are rare compared to the
sites mentioned above, the high prevalence of colo-
rectal cancer makes them frequent findings in daily
radiology practice.
Uterine metastasis It is one of the rare sites of colorectal carcinoma me-
tastasis. The most frequent affected site is the cervix
and the most frequent dissemination occurs through
direct spread, followed by lymphatic and hematoge-
nous spread. The rareness of the metastases to the
cervix is attributed to the great amount of fibrous
content, which is an unfavorable medium for tumo-
ral growth, relative poor vascularization and distant
lymphatic drainage from the pelvis to the uterus. This
finding is associated with a disseminated disease at
the moment of the diagnosis, thus representing a
bad prognosis. By contiguity, the alteration is more
frequently seen in the body (Figure 2). Multimodal
therapy is required, including chemotherapy (3, 4).
Penile metastasisIt usually derives from neoplasm in genitourinary or-
gans, although in rare occasions they derive from
the colon, especially from cancer at the level of the
sigmoid colon, even though it is an organ with signi-
ficant vascularization. The prognosis and the survival
rate are bad, since it implies an advanced stage of the
disease and requires aggressive treatment. Its disse-
mination remains controversial. It was suggested that
it occurs through venous or lymphatic retrograde
spread, direct spread, implantation secondary to ins-
trumentation, or arterial spread. In 60% of the cases,
the lesions appear as multiple masses that are rigid,
palpable, infiltrative, and —occasionally— ulcerated
having a density of soft tissues with poor vasculariza-
tion in CT. It can cause priapism due to infiltration of
cavernous bodies or occlusion of venous drainage.
(5) (Figure 3).
MTS infrecuentes generalmente se encuentra acom-
pañada por MTS en sitios frecuentes que ayudan al
diagnóstico.
El objetivo en este trabajo es ejemplificar algunos si-
tios de MTS infrecuentes y describir sus características
en imágenes de TC y ecografía.
Palabras clave: Colon, cáncer, metástasis.
metastases is usually accompanied by frequent metasta-
sis sites that contribute to making a diagnosis.
The purpose of this paper is to provide examples of
some rare sites of metastases and their characteristics
in order to alert the radiologist of their possibility and
contribute to making a diagnosis.
Key words: Colon, cancer, metastases.
Vol. 4 / Nº 12 - Diciembre 2015
Unusual sites of colorectal
cancer metastasesSánchez L. et al.
Scrotal metastasisIt is also a rare presentation of colorectal metasta-
sis. These lesions originate synchronically or imme-
diately after the disseminated colorectal carcinoma.
The dissemination occurs most probably through
direct extension, followed by lymphatic or hemato-
genous spread. Unfortunately, these patients present
a highly-disseminated disease at the moment of the
diagnosis, with a bad prognosis. Some anti-neoplasm
therapies have demonstrated a reduction and even di-
sappearance of some of these lesions (6) (Figure 4).
Prostatic metastasisProstatic metastasis deriving from colorectal carci-
noma is infrequent, even more so from non-conti-
guous lesions, since the most frequent dissemina-
tion is through direct extension. Both symptoms and
findings are unspecific, although patients generally
present a history of known primary neoplasm of the
colon. Some authors recommend prostatic evaluation
by transrectal ultrasound in patients with urological
symptoms after surgical resection of the colon (7)
(Figure 5).
Bladder metastasisAs well as prostatic metastasis, secondary involve-
ment of the bladder in patients with colon cancer
occurs through direct extension of the lesion, althou-
gh there are isolated cases of vesical metastasis in
patients with lesions in the distant colon. When dis-
semination occurs through direct extension, there is
a possibility that the content of the colon spreads to
the vesical lumen through a fistula with consequent
fecaluria. Tomographic findings can show diffuse
irregular vesical parietal thickening, which is more
evident in excretory phase (7) (Figure 6).
A
B
C
Figure 1. Frequent sites of colorectal carcinoma. Liver (A), lungs (B), suprarenal glands and spleen (C)
(arrows and asterisk).
40 Revista Argentina de Diagnóstico por Imágenes
Sánchez L. et al.
Unusual sites of colorectal
cancer metastases
A B
C
Figure 2. Uterine metastasis. Metastatic involvement of the body of the uterus due
to adenocarcinoma of intestinal origin by contiguous
spread, with presence of colonic content at the level
of the uterine cavity probably due to fistula (A and
B) (arrows). Ultrasound shows a solid hypoechoge-
nic expansive lesion that compromises the cervix (C)
(asterisk).
Figure 3. Penile metastasis. Diffuse infiltration of the penis due to adenocarcinoma
of intestinal origin in patient with primary tumor in the
sigmoid colon (arrows).
Figure 4. Scrotal ultrasound. Presence of vascularized solid nodule attached to the
internal margin of the scrotal sac (arrow) in a patient
with metastatic colorectal carcinoma. Presence of hy-
drocele as well (asterisk).
41Vol. 4 / Nº 12 - Diciembre 2015 41
Unusual sites of colorectal
cancer metastasesSánchez L. et al.
A B
Figure 5. Prostatic metastasis. Diffuse infiltration of the prostatic gland in patient with colon adenocarcinoma (A and B) (arrows).
Figure 6. Bladder metastasis. Diffuse infiltration of vesical walls (arrow) in patient
with colon adenocarcinoma.
Peritoneal pseudomyxomaPeritoneal pseudomyxoma is a rare disease charac-
terized by abundant mucinous and gel-like intra-pe-
ritoneal material associated with intraperitoneal ade-
nocarcinoma. Although the primary origin is more
frequent in mucinous adenocarcinoma of ovaries,
followed by appendicular mucocele, some mucinous
colorectal neoplasia can be produced by peritoneal
infiltration. Aggressive surgical treatment associated
with a resection of the primary tumor is the most
appropriate indication, although these patients gene-
rally present recurrence in the short term, requiring
new interventions (8) (Figure 7).
Abdominal wall metastasis The presence of metastasis in the abdominal wall
deriving from a colorectal carcinoma is an extremely
rare finding, except when it is found around the na-
vel. Cutaneous metastases located at the level of the
navel receive the name of Sister Mary Joseph nodu-
le. The dissemination occurs through direct or lym-
phatic spread and generally derives from malignant
neoplasia of the abdomen and pelvis. Generally, this
finding is associated with a bad prognosis. The cha-
racteristic finding is a palpable hypoechogenic no-
dule in ultrasound or of soft tissue density in CT, at
the level of the subcutaneous tissue in the umbilical
region (9) (Figure 8).
Bone metastasis Bone metastasis deriving from a colorectal primary
neoplasm is also rare and it is generally a late mani-
festation of the disease.
Bone lesions secondary to colorectal cancer can
present diverse patterns, including lytic lesions, ex-
pansive lesions with soft tissue components, pseudo-
sarcomatous lesions or soft tissues lesions with ossi-
fication signs. The detection of masses deriving from
soft tissues associated with cortical destruction and
periosteal reaction (pseudosarcomatous lesions) lead
to the diagnosis of primary lesion to the bone instead
of a diagnosis of metastatic lesion. However, bone
42 Revista Argentina de Diagnóstico por Imágenes
Sánchez L. et al.
Unusual sites of colorectal
cancer metastases
metastasis deriving from colon cancer can appear
with lesions of such characteristics (10) (Figure 9).
Carcinomatous lymphangitis Even though metastatic pulmonary involvement is fre-
quent in patients with colorectal carcinoma, the pre-
sence of carcinomatous lymphangitis is not. This in-
volvement is produced by lymphatic spread generally
associated with pre-existent metastatic areas. Findings
in high-resolution CT are multinodular thickening of
interlobular septa and fissures (11) (Figure 10).
Adenopathies Lymph node metastasis is a topic of discussion regar-
ding colon cancer staging. Lymph nodes count and
location determine the staging and subsequent prog-
nosis of these patients. There are several theories
about how dissemination occurs: One suggests that
the presence of metastatic adenopathies precedes
an indirect dissemination and proposes a lympha-
tic spread; the other one suggests a dissemination
to distant lymph nodes without evidence of regional
lymph nodes produced through lymphatic spread
(skip metastasis) or through re-metastasis from other
metastatic sites, such as liver and lungs. The presen-
ce of adenopathies generally requires chemotherapy
treatment associated to surgical resection of the pri-
mary lesion.
Mediastinal lymphadenopathyThe presence of mediastinal lymph nodes in patients
with metastatic disease to the liver or lung is not fre-
quent and it is produced through a re-metastatic me-
chanism as previously described. However, metasta-
tic involvement of mediastinal lymph nodes without
involvement of other organs is extremely rare, with
isolated cases reported. In this case, the dissemination
is not clear, although a lymphatic drainage para-aortic
spread is suggested as skip metastasis (12) (Figure 11).
Retroperitoneal adenopathiesColorectal carcinoma occasionally appears with retro-
peritoneal adenopathies. The dissemination proposed
is through mesocolic lymph nodes, with prior involve-
ment of mesenteric lymph nodes, or through direct lym-
phatic dissemination from the rectum (12) (Figure 12).
Pancreatic metastasis The presence of pancreatic metastasis represents from
1 to 3% of the cases of pancreatic neoplasia. Colon
carcinoma is the most frequent third primary origin.
Occasionally, the pancreatic lesion precedes the diag-
nosis of primary neoplasia. Some studies suggest a
benefit from surgical resection with respect to an iso-
lated lesion, although the prognosis and survival rate
is not well-known due to the small amount of lesions
in daily practice. Radiological findings are unspecific
and are indistinguishable frequently from a pancreatic
adenocarcinoma, presented as an expansive hypovas-
cular lesion of poorly-defined edges (13) (Figure 13).
Figure 7. Peritoneal pseudomyxoma. Intermediate density ascites in peritoneal recesses and
partially compresses of anatomical structures, with peri-
toneal thickening (asterisk), related to pseudomyxoma
secondary to adenocarcinoma.
4Vol. 4 / Nº 12 - Diciembre 2015 4
Unusual sites of colorectal
cancer metastasesSánchez L. et al.
Figure 8. Abdominal wall metastasis. A hypoechogenic subcutaneous nodule is seen
with irregular edges and vascularization in color
Doppler at the level of the abdominal wall in a
patient with disseminated colon adenocarcino-
ma (arrow).
A B
Figure 9. Bone metastasis. Axial CT of the pelvis in two patients with colon adenocarcinoma. Presence of osteolytic lesions with significant
component of soft tissue and a pseudosarcomatous aspect of the sacrum (A) and the right iliac bone (B) (arrows).
Figure 10. Carcinomatous lymphangitis. Micronodular thickening of interlobular septa in a
young patient with disseminated colon carcinoma
(arrow).
44 Revista Argentina de Diagnóstico por Imágenes
Sánchez L. et al.
Unusual sites of colorectal
cancer metastases
ConclusionIt is necessary to know the atypical forms and sites of
presentation of colorectal cancer metastases in order
to make a correct staging of this neoplasm and for
the indication of adequate treatment for each stage
of the disease.
Figure 12. Metastatic retroperitoneal adeno-pathies.Patient with colorectal carcinoma (arrow).
Figure 13. Pancreatic metastasis. Presence of expansive hypodense lesion at the level of
the pancreatic body-tail (asterisk) of metastatic origin
in a patient with disseminated colon cancer. There is a
large metastatic hypodense hepatic lesion (arrow).
Figure 11. Metastatic mediastinal adenopa-thies. Patient with colorectal carcinoma (arrow).
45Vol. 4 / Nº 12 - Diciembre 2015 45
Unusual sites of colorectal
cancer metastasesSánchez L. et al.
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