unexpected destinies: unusual sites of colorectal cancer...

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: [email protected]

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


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.


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



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


Sánchez L. et al.


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



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).


Sánchez L. et al.


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



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