Adenocarcinoma of rectosigmoid junction metastatic to testis.

A 50 year old gentleman presented to our surgical outpatient department with two years history of bleeding per rectum with off and on lower abdominal pain. He was pale, lethargic and emaciated. On digital rectal examination, hard fungating cauliflower like growth was found at anorectal junction. Systemic examination revealed no significant findings. Laboratory investigations showed Hb l0gm/dI. LFT’s blood urea, creatinine and glucose level were all within normal limits. CEA level was l9ng/ml. Chest x-ray showed apical fibrosis and calcification consistent with old T.B. Colonoscopy/flexible sigmoidoscopy revealed fungating mass obliterating lumen approximately 15 cm from anal verge. CT abdomen / pelvis showed rectal mass with probable early extension beyond the wall with single right pelvic lymph node. Biopsy revealed well differentiated adeno carcinoma. He underwent lower anterior resection and histopathology revealed adeno carcinoma with negative margins. Post op CEA level was 6 ng/ml. He was offered adjuvant pelvic radiotherapy 5OGy/5 weeks with concomitant 5-Flurouracil @ 500 mg/m2, first and last three days of radiotherapy, followed by further 5 courses of 5Fluorouracil. However, chemotherapy was withheld after 3 cycles because of poor tolerance while concurrent therapy for pulmonary tuberculosis was continued. He was on regular follow-up in surgical clinic and medical oncology, when serial rise in CEA level was noted. Meanwhile he developed right testicular swell ing. There were no gastrointestinal tract related symptoms. Sonogram showed right hydrocele. On examination hard irregular epididymis swelling was felt. Provisional diagnosis of epididymo-orchitis was made. It was planned to get right testicular biopsy to rule out genital tuberculosis. Biopsy revealed metastatic adenocarcinoma (invasive mucinous adenocarcinoma, identical with previous histology).