Colorectal Carcinoma metastasizing to Scrotum: A series of five cases with unusual presentation and late recurrences from a single tertiary oncology centre of India

Colorectal Carcinoma metastasizing to Scrotum: A series of five cases with unusual presentation and late recurrences from a single tertiary oncology centre of India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Colorectal Carcinoma metastasizing to Scrotum: A series of five cases with unusual presentation and late recurrences from a single tertiary oncology centre of India Disha Bilala, Subhash Yadav, Suman Kumar Ankathi, Rajiv Kaushal, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3816250/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Colorectal carcinoma (CRC) is a common malignancy, frequently metastasizing to the liver, lungs, and regional lymph nodes. However, metastasis to the scrotum is exceedingly rare, with few cases reported in the literature. In this study, we present a series of five cases of colorectal carcinoma metastasizing to the scrotum, emphasizing their unusual clinical presentation and late recurrences. Methods We did a retrospective review of 7 years from 2015–2022 for cases of scrotal metastasis in cases of CRC. Results The means age in our study was 38 years (22–61 years) and the median time interval between the primary diagnosis and scrotal metastasis was 31.6 months (0-104 months). Case presentations included scrotal swelling initially misdiagnosed as a hydrocele (case 1), non-healing cutaneous ulcers (cases 3 and 5), a scrotal skin papilloma (case 4), and a cutaneous nodule (case 2). Conclusion This series of five cases highlights the rarity and diagnostic challenges associated with colorectal carcinoma metastasizing to the scrotum. The extended latency between primary tumor diagnosis and scrotal metastasis, coupled with atypical clinical presentations, underscores the importance of maintaining a high index of suspicion. Clinicians should be vigilant, especially when evaluating patients with a history of colorectal carcinoma, to promptly identify such uncommon metastatic sites. Colorectal carcinoma scrotum latency unusual presentation Figures Figure 1 Figure 2 Figure 3 Introduction Worldwide, colorectal carcinoma (CRC) is the third most common cancer in both sexes [ 1 ] with 20% of the patients presenting with metastasis at presentation [ 2 ]. Another 20% develop metachronous disease after the initial surgery; the commonest sites of metastasis include the liver (70%), thorax (32%), peritoneum (21%) and bone (12%) [ 3 , 4 ]. Despite the advancement in oncology practice, the prognosis of CRC is extremely poor with a 5-year overall survival of just 4% [ 3 , 5 ]. Scrotum occupies < 1% of the total body surface area [ 6 ]. Lookingbill et al.[ 7 ] reported an overall incidence of 0.02% of cutaneous scrotal metastasis from visceral solid malignancies. Hoyt et al.[ 6 ] conducted a literature review on 29 patients with scrotal metastasis and found that the most common primary site for scrotal metastasis was the genitourinary tract (13 cases), followed by the gastrointestinal tract (11 cases), with 10 cases arising from the colorectum and one from the stomach. The study also reported that most of the patients presented with advanced stages of the disease and had poor outcomes, emphasizing the importance of early diagnosis and intervention [ 6 ]. Most cases of scrotal metastasis are secondary to incisional site seeding following surgical resection [ 8 ]. This report presents a series of five cases of colorectal carcinoma (CRC) metastasizing to the scrotum, highlighting the rarity of this site as a metastatic location. The authors also provide a comprehensive review of all previously reported cases of metastatic CRC to the scrotum, summarizing the clinical details of patients, treatments received, and outcomes. The goal of this report is to better understand the pathobiology and prognosis of this rare form of the presentation. Methodology The authors used an electronic search of archived pathology records from 2015–2022 to identify cases of colorectal carcinoma (CRC) with scrotal metastasis. The search used keywords such as "adenocarcinoma", "metastasis", "scrotum", "hydrocele", "metastatic", "colorectal adenocarcinoma", and "mucinous adenocarcinoma" using Boolean logic. The search was done using the search engine portals “Sengine” and “Synoptic search engine”. Cases with testicular metastasis or both testicular and scrotal metastasis were excluded from the study. Immunohistochemistry (IHC) markers were studied whenever required on the routine formalin-fixed paraffin-embedded sections using a fully automated system (BenchmarkXT system, Ventana Medical System Inc, Tucson, Arizona). The antibody panel included cytokeratin 7 (CK7), cytokeratin 20 (CK20), caudal-related homeobox gene 2(CDX2), special adenine and thymine-rich sequence-binding protein-2 (SATB2), NKX3.1 and Thyroid transcription factor 1(TTF1). Information regarding the Microsatellite-instability panel which includes MutS homolog 2(MSH2), MutS homolog 6(MSH6), Postmeiotic segregation increased 2(PMS2), MutL homolog 1(MLH1) was documented whenever available. The clinical, radiological, follow-up and survival information for all the patients was obtained from the Electronic Medical Records (EMR). The histopathological parameters studied were tumour histology, grade, pattern, necrosis, presence of mucin, and immunohistochemistry details. Results The study identified five cases of colorectal carcinoma (CRC) with scrotal metastasis. The mean age of diagnosis of primary CRC was 38 years (range 22–61 years). The clinical profile of the patients is summarized in Table 1 . One patient (case 1) presented with a boggy scrotal swelling and was initially diagnosed with a hydrocele. After the excision of the hydrocele sac, histology and immunohistochemistry confirmed it to be metastatic CRC. The patient subsequently underwent additional testing, including a colonoscopy, and was found to have a rectal primary. Two cases (cases 3 and 5) presented with non-healing cutaneous ulcers on the scrotal skin, one case (case 4) presented as a skin papilloma, and case 2 presented as a cutaneous nodule on the scrotal skin. Radiology information was available for two patients. One revealed a right-sided hydrocele (case 1) while the other showed a fluorodeoxyglucose avid lesion in the lateral wall of the scrotum on positron emission tomography. (Fig. 1 ) Table 1 Clinical profile of all the patients Case Age at diagnosis Primary tumor Primary Rx Clinical manifestation Radiology Other sites of metastasis Interval between primary & scrotal metastasis Post scrotal metastasis workup Follow up 1 61 years AC APR Testicular pain and boggy swelling in right sided scrotum Right sided hydrocele NA 0 months CT 2 months; DOD 2 32 years AC APR + Adj. CTRT Cutaneous nodule over left scrotum NA Inguinal Lymph nodes 104 months CTRT + WLE 6 months; DOD 3 46 years AC NACTRT + APR Non-healing lesion at scrotal base FDG-avid lesion along left lateral body of scrotum NA 10 months WLE 4 months; DOD 4 22 years AC NACTRT Skin papilloma over scrotum and groin NA NA 8 months Palliative 15 days; DOD 5 27 years AC NACTRT + APR Slow healing scrotal ulcer NA Presacral region 36 months Palliative 12 months; DOD Abbreviations: AC: Adenocarcinoma; NA: not available; APR: Abdominoperineal Resection; Adj: adjuvant; CTRT: Chemoradiotherapy; NACTRT: Neo-adjuvant chemoradiotherapy; CT: Chemotherapy; WLE: Wide local excision; DOD: died of diease Out of the five patients studied, four (80%) had undergone primary tumour resection with adjuvant or neoadjuvant chemotherapy and/or radiotherapy. None of the patients had a distant disease at the time of surgery. The mean time interval between diagnosis of the primary CRC and metastasis to the scrotum was 31.6 months with a range of 0-104 months. Two patients had other sites of metastasis such as the inguinal lymph node (case 2) and pre-sacral soft tissue (case 5). The clinical profile of the patients are summarized in Table 1 . Pathology: A detailed histological examination was performed on all five cases (Table 2). Histology showed a variable morphology ranging from well-formed glands to cribriform architecture lined by columnar intestinal-type epithelium with high-grade cytology. Few cases showed tumours arranged in solid sheets with poor or no glandular architecture and high-grade nuclear features. Extracellular mucin was present in 4 out of five cases; while two cases were mucinous adenocarcinoma with stromal mucin amounting to >50%. Lymphatic emboli or perineurial invasion were not identified in any of these cases. Immunohistochemistry for CK20 and CDX2 were consistently positive in these cases, confirming a colorectal primary. One case was also positive for SATB2; supporting a colorectal origin. (Figure 2 & 3) Molecular test results were available for three of the cases; two of these showed missense mutations in the KRAS gene and one showed a TP53 mutation. Molecular results for BRAF V600E were available in two cases, both of which were wild-type. The status of mismatch repair (MMR) gene by immunohistochemistry was done in three out of five cases, and all these cases were MMR protein proficient. (Table 2 ) Table 2 Pathological details of the cases Sr No Histology Grade Mucin CK7 CK20 CDX2/SATB2 MSI status Molecular 1 Met AC PD Absent Neg + +/+ Neg Missense mutation in KRAS and TP53 2 Met Mucinous AC NA Present Neg + + Neg ND 3 Met AC MD Present Neg + + NA ND 4 Mucinous AC MD Present Neg + + Neg KRAS mutation + BRAF V600E Neg 5 Mets AC PD Present NA NA NA NA KRAS Neg BRAF V600E Neg Abbreviation: - AC, Adenocarcinoma; Met, Metastatic; PD, Poorly differentiated; MD, Moderately differentiated; NEG, Negative; POS, Positive; NA, Not available; MSI, Microsatellite instability; +, Present; Treatment and follow-up: All the patients in the study were considered to have advanced disease due to the presence of scrotal metastasis, and a palliative treatment strategy was offered to all of them. Three of the patients underwent wide excision of the scrotal lesion, including case 1 who was initially misdiagnosed with a hydrocele and underwent surgery for that. The time interval between the primary diagnosis and scrotal involvement ranged from 0 to 104 months, with a mean of 33 months. Discussion There is limited information available from the various published case reports regarding scrotal metastasis and are often grouped under extrahepatic and/or extrapulmonary metastasis [9]. In general, metastatic carcinoma of the scrotum is extremely uncommon. Cutaneous scrotal metastasis can occur anytime during the disease; usually at an advanced stage or with extensive metastatic disease [10]. Most of these cases have a high tumor burden including metastasis at other sites and are discovered on follow-ups [9]. Kim et al.[11] reported five cases of CRC carcinoma metastasizing to the epididymis. The symptoms are often nonspecific and can mimic other conditions, making them difficult to diagnose. The most common presenting symptoms include swelling, lumps, pain or tenderness, and back pain or nodules or cutaneous lesions. The diagnosis is usually made through a biopsy or excision of the lesion. Regardless of the origin of the underlying tumour, cutaneous metastasis frequently manifests as nodules that often coalesce and resemble epidermal cysts, keratoacanthomas, or pyogenic granulomas. Approximately 10% of nodules develop ulceration. Very rarely they can present as warm erythematous indurated plaques simulating erysipelas, lymphangitis, or cellulitis. It is only after the failure to respond to antibiotics and local therapy in the absence of leukocytosis and fever; that a biopsy or excision is performed unravelling the diagnosis of metastatic disease [12]. Two of our cases presented as ulcers over the scrotum, one presented as a skin papilloma and another case had a nodule over the scrotal skin. Generally, these metastases occur rapidly after the initial diagnosis of primary CRC with a mean interval of five months and a range of 4-24 months [6]. The mean time interval between primary and scrotal disease in our study was 31.6 months and the longest time interval was 104 months; highlighting that metastasis usually develops after a very long time interval and can even mislead the diagnosis. The potential routes for metastasis to the spermatic cord, scrotum or para-testicular region include retrograde venous outflows, arterial emboli, retrograde spread via vas deferens, or lymphatics [13]. Other route includes spread via the patent processus vaginalis [14]. For gastrointestinal malignancies, the retrograde lymphatic spread through the retroperitoneal lymph nodes is the likely route of metastatic spread to the scrotum [15]. One of our patients (case 1) presented with a hydrocele with secondary metastasis. There was no other clinical sign or symptoms and was operated for the hydrocele which unfolded the colorectal malignancy. Bryan et al.[16] reported a similar case of sigmoid colon adenocarcinoma presenting as a scrotal mass with hydrocele. In their patient, although there was no patent processus vaginalis; however, there might be microscopic channels from the peritoneum, which can allow for the spread of the tumour through that route. Charles et al.[17] also reported a case of CRC presenting with hydrocele as its primary presentation. Other likely routes for metastasis to the scrotum are venous, emboli and transduction routes [15,16,18]. The reason for the relatively low incidence of scrotal metastasis in cases of visceral cancers is not well understood. However, one theory is that the lower regional temperature of the scrotum may not be conducive for tumour cells to grow. Other factors that may play a role include the blood supply to the scrotal region and the lack of lymphatic drainage in the area [19]. The management of scrotal metastasis from visceral cancers is usually palliative, with treatment modalities such as surgery, chemotherapy, and radiotherapy. However, the survival benefits of these treatments are still controversial and the overall prognosis for patients with scrotal metastasis is poor. Most patients with scrotal metastasis die within 1-1.5 years from the time of diagnosis. The treatment options are usually selected based on the patient's overall health, the size and stage of the tumour, and the patient's preferences. The treatment aims to provide the patient with symptom relief and prolong survival, but a cure is usually not possible [20]. Most of our patients received adjuvant palliative chemotherapy. All our patients died due to the widespread metastasis. The follow-up duration in our cases ranged from 15 days to 12 months with a mean of 4.9 months. Early diagnosis of a scrotal disease can have some impact on survival and management. Research has shown that the survival of patients diagnosed with scrotal metastasis on follow-up is better than those diagnosed at presentation (13 months vs. 4.5 months). The mean survival in our patients was also 4.9 months; similar to the quoted literature. This highlights the importance of regular follow-up and monitoring for patients with a history of visceral cancer, as well as performing a thorough examination of the scrotal area in patients with known or suspected cancer. Early diagnosis and intervention can improve the patient's chance of survival and quality of life [9]. (Table 3) Table 3 : A comprehensive review of literature Sr. No Author Study type Age Primary Rx Local exam of scrotum Other sites of metastasis Interval betwn primary and metastasis (months) Post scrotal metastasis workup Follow-up (months) S Status 1 Lookingbill et al.[7] 1990 Case report NR NA Nodules NA 0 NR NR NR 2 Bryan et al.[16] 1996 Case report 75 Orchidectomy Hydrocele with nodule adjacent to epididymal cyst Peritoneal seedings, lymphadenopathy and liver 0 Sigmoid colectomy 3 Died 3 Shetty et al.[21] 1988 Case report 60 APR Multiple nodes Lymph nodes, groin nodes 18 NR NR NR 4 Boucher et al.[22] 2001 Case report 30 NACTRT + APR Ulcerated papules and plaques Lung NR NR NR NR 5 Melis et al.[12] 2002 Case report 41 NACTRT + APR Erythematous plaques Anal sphincter, prostate, hepatic lobes, lymphatic and vascular vessels NR NR NR NR 6 Hayashi et al.[23] 2003 Case report 50 Sx Slightly reddish nodules Inguinal lymph node 4 NR 7 NR 7 Reuter et al.[24] 2007 Case report 69 NACTRT + APR Erythematous soft plaques Groin, generalized lymphogenic spread 5 NR 6 Died 8 Gazoni et al.[25] 2008 Case series 55 NR NR Liver, lung NR Palliative NR NR 72 NR NR Nr NR Palliative NR NR 78 NR NR Liver NR Palliative NR NR 9 Mcweeny et al.[26] 2009 Case report 72 Sx + Adj CTRT Nodules Mesorectal lymph node, liver 11 WLE NR NR 10 Goris gbenou et al.[27] 2011 Case report 79 Sx Papule Penis, pubis 33 Palliative 6 Died 11 Balta et al.[28] 2012 Case report 46 Sx Multiple eroded nodules and ulcer Left inguinal, perianal regon, prostate 12 NR NR NR 12 Ozgen et al.[20] 2013 Case report 65 Sx + Adj CTRT Hazelnut sized reddish nodules Rectal recurrences, spermatic cord 22 CT 12 alive 13 Udkoff et al.[29]2016 Case report 56 Sx + Adj CTRT Papules and nodules Abdomen skin CT 18 14 Dehal et al.[10] 2016 Case report 47 Palliative Nodules Aortocaval,left inguinal and retroperitoneal lymphadenopathy, 16 Palliative radiation therapy 12 Alive 15 Wu et al.[30] 2016 Case report 36 APR Ulcerated papules and plaques Penis, liver 28 Palliative chemotherapy 12 Died 16 Swofford et al.[31] 2017 Case report 74 Sx + Adj CTRT Mass, necrotic wound and sinus Penis,liver,lungs, peritoneum,bone 0 Palliative NR NR 17 Moghimi et al.[32] 2018 Case report 59 Sx + Adj CTRT Nodulo-papular lesion Prostate, brain 13 CT 3 Died 18 Abdollahi et al.[33] 2022 Case report 58 NACTRT + APR Indurated erythema NR 10 CT NR Alive 19 Schroeder et al.[8] 2021 Case report 74 CTRT Skin thickening and vesicles Liver, inguinal lymph nodes, right iliac bone, peritoneum, penis 3 Palliative 1 Died 20 Kasahara et al.[34] 2022 Case report 75 Sx + Adj CTRT Scrotal swelling with tenderness Lung, liver, lymph nodes, spermatic cord 12 Orchiectomy 2 Died 21 Yadav et al. 2023 Case series 61 years Surgery for hydrocele Boggy swelling in right sided scrotum NA 0 Ct 2 DOD 32 years APR + Adj CTRT Cutaneous nodule over left scrotum NA 0 CTRT + WLE 6 DOD 46 years Sx + Adj CTRT Non healing lesion at scrotal base Lymph nodes 104 WLE 4 DOD 22 years NACTRT Skin papilloma over scrotum and groin NA 10 Palliative 15 days DOD 27 years NACTRT + APR Ulcer NA 8 Palliative 12 DOD Abbreviations:- NR, Not recorded; APR, Abdominoperineal resection; Sx, Surgery; NCR, Neo-adjuvant chemoradiation; F/B, followed by; Adj., Adjuavant; CTRT, Chemoradiation; CT, Chemotherapy; NA, Not available; EXAM, Examination; Met, Metastasis; Dx, Diagnosis Conclusion In conclusion, scrotal metastasis from colorectal cancer is an extremely rare event, with limited information available in the literature. Our study highlights the need for a high index of suspicion for scrotal metastasis in patients with known colorectal cancer, especially in cases of persistent or recurrent scrotal lesions. The clinical presentation of scrotal metastasis is variable, and the diagnosis is often delayed due to its rarity and nonspecific symptoms. Histopathological examination and immunohistochemistry are essential for confirmation of the diagnosis. The management of scrotal metastasis is mainly palliative, and wide excision of the scrotal lesion is the mainstay of treatment. Declarations Competing Interest: I declare that the authors have no competing interests as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Funding sources: None of the authors have any relevant financial disclosures References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F.,. 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Rare Metastasis of Rectal Cancer to Scrotal Skin: A Case Report, and Literature Review. Iran Red Crescent Med J . 2022;24(5):5-7. doi:10.32592/ircmj.2022.24.5.1489 Kasahara M, Shimizu T, Aoki H, et al. Colon Cancer Metastasis to the Right Testis: Case Report and Review of Literature. Case Rep Urol . 2022;2022:1-4. doi:10.1155/2022/2649259 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3816250","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264669310,"identity":"07939ca4-45a4-4a70-a9f7-4a8fda4a508d","order_by":0,"name":"Disha Bilala","email":"","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Disha","middleName":"","lastName":"Bilala","suffix":""},{"id":264669311,"identity":"69e49a74-0977-4f0a-9b16-87ffff2b33be","order_by":1,"name":"Subhash Yadav","email":"data:image/png;base64,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","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":true,"prefix":"","firstName":"Subhash","middleName":"","lastName":"Yadav","suffix":""},{"id":264669312,"identity":"9022c166-3817-4a11-969d-512790059980","order_by":2,"name":"Suman Kumar Ankathi","email":"","orcid":"","institution":"Department of Radiodiagnosis, Tata Memorial Hospital, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Suman","middleName":"Kumar","lastName":"Ankathi","suffix":""},{"id":264669313,"identity":"c7f220ab-9c2e-4d00-b25a-cc607295d36f","order_by":3,"name":"Rajiv Kaushal","email":"","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Rajiv","middleName":"","lastName":"Kaushal","suffix":""},{"id":264669314,"identity":"3767aee9-9cf1-4f5c-94e7-f8ba0887d6d5","order_by":4,"name":"Gauri Deshpande","email":"","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Gauri","middleName":"","lastName":"Deshpande","suffix":""},{"id":264669315,"identity":"8f4615e3-209b-493b-8006-d01daef7c244","order_by":5,"name":"Munita Bal","email":"","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Munita","middleName":"","lastName":"Bal","suffix":""},{"id":264669316,"identity":"1982b2f2-d952-48f5-9176-a318d7e51271","order_by":6,"name":"Kedar Deodhar","email":"","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Kedar","middleName":"","lastName":"Deodhar","suffix":""},{"id":264669317,"identity":"6e525432-5ba4-4e5b-bbfd-2850087820ba","order_by":7,"name":"Santosh Menon","email":"","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Santosh","middleName":"","lastName":"Menon","suffix":""},{"id":264669318,"identity":"9d64bf95-f973-4d8f-a571-0d3728396aea","order_by":8,"name":"Mukta Ramadwar","email":"","orcid":"","institution":"Department of Pathology, Tata Memorial Hospital \u0026 ACTREC, A CI of Homi Bhabha National Institute, India","correspondingAuthor":false,"prefix":"","firstName":"Mukta","middleName":"","lastName":"Ramadwar","suffix":""}],"badges":[],"createdAt":"2023-12-28 10:44:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3816250/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3816250/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49140822,"identity":"906912c8-cdd2-443f-99f3-65ca5feb6645","added_by":"auto","created_at":"2024-01-03 18:23:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2902169,"visible":true,"origin":"","legend":"\u003cp\u003eA CECT showing a solid mass in the scrotum involving almost the entire scrotal sac. B. PET images showing a distinct and a strong uptake in the same mass. C. Images shows presence of Liver metastasis.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3816250/v1/ea9f357f5ea577c86c754d59.png"},{"id":49140824,"identity":"53e239fa-497d-4af3-a6ea-478f295a7392","added_by":"auto","created_at":"2024-01-03 18:23:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":8758078,"visible":true,"origin":"","legend":"\u003cp\u003eHistology from the scrotal mass shows a conventional adenocarcinoma with a glandulo papillary and fused cribriform architecture (A;x40). The higher power images show fused glandular architecture lined with tall columnar cells with hyperchromatic nuclei and scant cytoplasm. Stroma appears fibrotic. (B; 200x, C; 400x). By immunohistochemistry, the tumor was brilliantly positive for CK20 (D), CDX2 (E) and SATB2 (F).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3816250/v1/399d55b33ad6b7af3ffc31c2.png"},{"id":49140823,"identity":"0552a464-4897-4e76-bc97-bc26e0b1164e","added_by":"auto","created_at":"2024-01-03 18:23:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5179587,"visible":true,"origin":"","legend":"\u003cp\u003eThe microphotograph also showed an adenocarcinoma composed of tubules and lined by dysplastic columnar epithelium in a fibrotic stroma. (A; 40x, B; 200x). By immunohistochemistry, the tumor showed a colorectal profile of CK20 (C) and CDX2 (D)\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3816250/v1/803bca9ef0b5c0721f266057.png"},{"id":49269554,"identity":"903330f7-bc01-41dc-baf5-3bb9294f56a8","added_by":"auto","created_at":"2024-01-07 04:22:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6953964,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3816250/v1/3b82c3e6-4298-4b53-ae24-7e1a858d1c1a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Colorectal Carcinoma metastasizing to Scrotum: A series of five cases with unusual presentation and late recurrences from a single tertiary oncology centre of India","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWorldwide, colorectal carcinoma (CRC) is the third most common cancer in both sexes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] with 20% of the patients presenting with metastasis at presentation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Another 20% develop metachronous disease after the initial surgery; the commonest sites of metastasis include the liver (70%), thorax (32%), peritoneum (21%) and bone (12%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite the advancement in oncology practice, the prognosis of CRC is extremely poor with a 5-year overall survival of just 4% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Scrotum occupies\u0026thinsp;\u0026lt;\u0026thinsp;1% of the total body surface area [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Lookingbill et al.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported an overall incidence of 0.02% of cutaneous scrotal metastasis from visceral solid malignancies. Hoyt et al.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] conducted a literature review on 29 patients with scrotal metastasis and found that the most common primary site for scrotal metastasis was the genitourinary tract (13 cases), followed by the gastrointestinal tract (11 cases), with 10 cases arising from the colorectum and one from the stomach. The study also reported that most of the patients presented with advanced stages of the disease and had poor outcomes, emphasizing the importance of early diagnosis and intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Most cases of scrotal metastasis are secondary to incisional site seeding following surgical resection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This report presents a series of five cases of colorectal carcinoma (CRC) metastasizing to the scrotum, highlighting the rarity of this site as a metastatic location. The authors also provide a comprehensive review of all previously reported cases of metastatic CRC to the scrotum, summarizing the clinical details of patients, treatments received, and outcomes. The goal of this report is to better understand the pathobiology and prognosis of this rare form of the presentation.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThe authors used an electronic search of archived pathology records from 2015\u0026ndash;2022 to identify cases of colorectal carcinoma (CRC) with scrotal metastasis. The search used keywords such as \"adenocarcinoma\", \"metastasis\", \"scrotum\", \"hydrocele\", \"metastatic\", \"colorectal adenocarcinoma\", and \"mucinous adenocarcinoma\" using Boolean logic. The search was done using the search engine portals \u0026ldquo;Sengine\u0026rdquo; and \u0026ldquo;Synoptic search engine\u0026rdquo;. Cases with testicular metastasis or both testicular and scrotal metastasis were excluded from the study.\u003c/p\u003e \u003cp\u003eImmunohistochemistry (IHC) markers were studied whenever required on the routine formalin-fixed paraffin-embedded sections using a fully automated system (BenchmarkXT system, Ventana Medical System Inc, Tucson, Arizona). The antibody panel included cytokeratin 7 (CK7), cytokeratin 20 (CK20), caudal-related homeobox gene 2(CDX2), special adenine and thymine-rich sequence-binding protein-2 (SATB2), NKX3.1 and Thyroid transcription factor 1(TTF1). Information regarding the Microsatellite-instability panel which includes MutS homolog 2(MSH2), MutS homolog 6(MSH6), Postmeiotic segregation increased 2(PMS2), MutL homolog 1(MLH1) was documented whenever available. The clinical, radiological, follow-up and survival information for all the patients was obtained from the Electronic Medical Records (EMR). The histopathological parameters studied were tumour histology, grade, pattern, necrosis, presence of mucin, and immunohistochemistry details.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study identified five cases of colorectal carcinoma (CRC) with scrotal metastasis. The mean age of diagnosis of primary CRC was 38 years (range 22\u0026ndash;61 years). The clinical profile of the patients is summarized in Table \u003cspan\u003e1\u003c/span\u003e. One patient (case 1) presented with a boggy scrotal swelling and was initially diagnosed with a hydrocele. After the excision of the hydrocele sac, histology and immunohistochemistry confirmed it to be metastatic CRC. The patient subsequently underwent additional testing, including a colonoscopy, and was found to have a rectal primary. Two cases (cases 3 and 5) presented with non-healing cutaneous ulcers on the scrotal skin, one case (case 4) presented as a skin papilloma, and case 2 presented as a cutaneous nodule on the scrotal skin. Radiology information was available for two patients. One revealed a right-sided hydrocele (case 1) while the other showed a fluorodeoxyglucose avid lesion in the lateral wall of the scrotum on positron emission tomography. (Fig. \u003cspan\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eClinical profile of all the patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge at diagnosis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePrimary tumor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePrimary Rx\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClinical manifestation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRadiology\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOther sites of metastasis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInterval between primary \u0026amp; scrotal metastasis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost scrotal metastasis workup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow up\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTesticular pain and boggy swelling in right sided scrotum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight sided hydrocele\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 months; DOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAPR\u0026thinsp;+\u0026thinsp;Adj. CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCutaneous nodule over left scrotum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInguinal Lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCTRT\u0026thinsp;+\u0026thinsp;WLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 months; DOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNACTRT\u0026thinsp;+\u0026thinsp;APR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-healing lesion at scrotal base\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFDG-avid lesion along left lateral body of scrotum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 months; DOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNACTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin papilloma over scrotum and groin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 days; DOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNACTRT\u0026thinsp;+\u0026thinsp;APR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSlow healing scrotal ulcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresacral region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months; DOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003eAbbreviations: AC: Adenocarcinoma; NA: not available; APR: Abdominoperineal Resection; Adj: adjuvant; CTRT: Chemoradiotherapy; NACTRT: Neo-adjuvant chemoradiotherapy; CT: Chemotherapy; WLE: Wide local excision; DOD: died of diease\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOut of the five patients studied, four (80%) had undergone primary tumour resection with adjuvant or neoadjuvant chemotherapy and/or radiotherapy. None of the patients had a distant disease at the time of surgery. The mean time interval between diagnosis of the primary CRC and metastasis to the scrotum was 31.6 months with a range of 0-104 months. Two patients had other sites of metastasis such as the inguinal lymph node (case 2) and pre-sacral soft tissue (case 5). The clinical profile of the patients are summarized in Table \u003cspan\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cstrong\u003ePathology:\u003c/strong\u003e A detailed histological examination was performed on all five cases (Table 2). Histology showed a variable morphology ranging from well-formed glands to cribriform architecture lined by columnar intestinal-type epithelium with high-grade cytology. \u0026nbsp;Few cases showed tumours arranged in solid sheets with poor or no glandular architecture and high-grade nuclear features. Extracellular mucin was present in 4 out of five cases; while two cases were mucinous adenocarcinoma with stromal mucin amounting to \u0026gt;50%. Lymphatic emboli or perineurial invasion were not identified in any of these cases. Immunohistochemistry for CK20 and CDX2 were consistently positive in these cases, confirming a colorectal primary. One case was also positive for SATB2; supporting a colorectal origin. (Figure 2 \u0026amp; 3)\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eMolecular test results were available for three of the cases; two of these showed missense mutations in the KRAS gene and one showed a TP53 mutation. Molecular results for BRAF V600E were available in two cases, both of which were wild-type. The status of mismatch repair (MMR) gene by immunohistochemistry was done in three out of five cases, and all these cases were MMR protein proficient. (Table \u003cspan\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePathological details of the cases\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"9\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSr No\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHistology\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGrade\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMucin\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCK7\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCK20\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCDX2/SATB2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMSI status\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMolecular\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMet AC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+/+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissense mutation in KRAS and TP53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMet Mucinous AC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMet AC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMucinous AC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKRAS mutation +\u003c/p\u003e\n \u003cp\u003eBRAF V600E Neg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMets AC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKRAS Neg\u003c/p\u003e\n \u003cp\u003eBRAF V600E Neg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviation: - AC, Adenocarcinoma; Met, Metastatic; PD, Poorly differentiated; MD, Moderately differentiated; NEG, Negative; POS, Positive; NA, Not available; MSI, Microsatellite instability; +, Present;\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment and follow-up:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAll the patients in the study were considered to have advanced disease due to the presence of scrotal metastasis, and a palliative treatment strategy was offered to all of them. Three of the patients underwent wide excision of the scrotal lesion, including case 1 who was initially misdiagnosed with a hydrocele and underwent surgery for that. The time interval between the primary diagnosis and scrotal involvement ranged from 0 to 104 months, with a mean of 33 months.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThere is limited information available from the various published case reports regarding scrotal metastasis and are often grouped under extrahepatic and/or extrapulmonary metastasis [9]. In general, metastatic carcinoma of the scrotum is extremely uncommon. \u0026nbsp;Cutaneous scrotal metastasis can occur anytime during the disease; usually at an advanced stage or with extensive metastatic disease [10]. Most of these cases have a high tumor burden including metastasis at other sites and are discovered on follow-ups [9]. Kim et al.[11] reported five cases of CRC carcinoma metastasizing to the epididymis. The symptoms are often nonspecific and can mimic other conditions, making them difficult to diagnose. The most common presenting symptoms include swelling, lumps, pain or tenderness, and back pain or nodules or cutaneous lesions. The diagnosis is usually made through a biopsy or excision of the lesion. Regardless of the origin of the underlying tumour, cutaneous metastasis frequently manifests as nodules that often coalesce and resemble epidermal cysts, keratoacanthomas, or pyogenic granulomas. Approximately 10% of nodules develop ulceration. Very rarely they can present as warm erythematous indurated plaques simulating erysipelas, lymphangitis, or cellulitis. It is only after the failure to respond to antibiotics and local therapy in the absence of leukocytosis and fever; that a biopsy or excision is performed unravelling the diagnosis of metastatic disease [12]. Two of our cases presented as ulcers over the scrotum, one presented as a skin papilloma and another case had a nodule over the scrotal skin. Generally, these metastases occur rapidly after the initial diagnosis of primary CRC with a mean interval of five months and a range of 4-24 months [6]. The mean time interval between primary and scrotal disease in our study was 31.6 months and the longest time interval was 104 months; highlighting that metastasis usually develops after a very long time interval and can even mislead the diagnosis.\u003c/p\u003e\n\u003cp\u003eThe potential routes for metastasis to the spermatic cord, scrotum or para-testicular region include retrograde venous outflows, arterial emboli, retrograde spread via vas deferens, or lymphatics [13]. Other route includes spread via the patent processus vaginalis [14]. For gastrointestinal malignancies, the retrograde lymphatic spread through the retroperitoneal lymph nodes is the likely route of metastatic spread to the scrotum [15]. One of our patients (case 1) presented with a hydrocele with secondary metastasis. There was no other clinical sign or symptoms and was operated for the hydrocele which unfolded the colorectal malignancy. Bryan et al.[16] reported a similar case of sigmoid colon adenocarcinoma presenting as a scrotal mass with hydrocele. In their patient, although there was no patent processus vaginalis; however, there might be microscopic channels from the peritoneum, which can allow for the spread of the tumour through that route. Charles et al.[17] also reported a case of CRC presenting with hydrocele as its primary presentation. Other likely routes for metastasis to the scrotum are venous, emboli and transduction routes [15,16,18]. \u0026nbsp;The reason for the relatively low incidence of scrotal metastasis in cases of visceral cancers is not well understood. However, one theory is that the lower regional temperature of the scrotum may not be conducive for tumour cells to grow. Other factors that may play a role include the blood supply to the scrotal region and the lack of lymphatic drainage in the area [19].\u003c/p\u003e\n\u003cp\u003eThe management of scrotal metastasis from visceral cancers is usually palliative, with treatment modalities such as surgery, chemotherapy, and radiotherapy. However, the survival benefits of these treatments are still controversial and the overall prognosis for patients with scrotal metastasis is poor. Most patients with scrotal metastasis die within 1-1.5 years from the time of diagnosis. The treatment options are usually selected based on the patient\u0026apos;s overall health, the size and stage of the tumour, and the patient\u0026apos;s preferences. The treatment aims to provide the patient with symptom relief and prolong survival, but a cure is usually not possible [20]. Most of our patients received adjuvant palliative chemotherapy. All our patients died due to the widespread metastasis. The follow-up duration in our cases ranged from 15 days to 12 months with a mean of 4.9 months. Early diagnosis of a scrotal disease can have some impact on survival and management. Research has shown that the survival of patients diagnosed with scrotal metastasis on follow-up is better than those diagnosed at presentation (13 months vs. 4.5 months). The mean survival in our patients was also 4.9 months; similar to the quoted literature. This highlights the importance of regular follow-up and monitoring for patients with a history of visceral cancer, as well as performing a thorough examination of the scrotal area in patients with known or suspected cancer. Early diagnosis and intervention can improve the patient\u0026apos;s chance of survival and quality of life [9]. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 : A comprehensive review of literature\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"715\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"708\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSr. No\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal exam of scrotum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther sites of metastasis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterval betwn primary and metastasis (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost scrotal metastasis workup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eLookingbill et al.[7] 1990\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNodules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eBryan et al.[16] 1996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eOrchidectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eHydrocele with nodule adjacent to epididymal cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003ePeritoneal seedings, lymphadenopathy and liver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eSigmoid colectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eShetty et al.[21] 1988\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eAPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLymph nodes, groin nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eBoucher et al.[22] 2001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNACTRT + APR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eUlcerated papules and plaques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eMelis et al.[12] 2002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNACTRT + APR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eErythematous plaques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eAnal sphincter, prostate, hepatic lobes, lymphatic and vascular vessels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eHayashi et al.[23] 2003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSlightly reddish nodules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eInguinal lymph node\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eReuter et al.[24] 2007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNACTRT + APR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eErythematous soft plaques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eGroin, generalized lymphogenic spread\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eGazoni et al.[25] 2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase series\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLiver, lung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eNr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLiver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eMcweeny et al.[26] 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNodules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eMesorectal lymph node, liver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eWLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eGoris gbenou et al.[27] 2011\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003ePapule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003ePenis, pubis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eBalta et al.[28] 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple eroded nodules and ulcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLeft inguinal, perianal regon, prostate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eOzgen et al.[20] 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eHazelnut sized reddish nodules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eRectal recurrences, spermatic cord\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; alive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eUdkoff et al.[29]2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003ePapules and nodules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eAbdomen skin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eDehal et al.[10] 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNodules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eAortocaval,left inguinal and retroperitoneal lymphadenopathy,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative radiation therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eWu et al.[30] 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eAPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eUlcerated papules and plaques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003ePenis, liver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eSwofford et al.[31] 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eMass, necrotic wound and sinus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003ePenis,liver,lungs, peritoneum,bone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eMoghimi et al.[32] 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Nodulo-papular lesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eProstate, brain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDied\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eAbdollahi et al.[33] 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNACTRT + APR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eIndurated erythema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eSchroeder et al.[8] 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eCTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSkin thickening and vesicles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLiver, inguinal lymph nodes, right iliac bone, peritoneum, penis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eKasahara et al.[34] 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eScrotal swelling with tenderness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLung, liver, lymph nodes, spermatic cord\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eOrchiectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\n \u003cp\u003eYadav et al. 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\n \u003cp\u003eCase series\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e61 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSurgery for hydrocele\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eBoggy swelling in right sided scrotum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eCt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e32 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eAPR + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eCutaneous nodule over left scrotum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eCTRT + WLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e46 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSx + Adj CTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNon healing lesion at scrotal base\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eLymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003eWLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e22 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNACTRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eSkin papilloma over scrotum and groin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e15 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.232294617563739%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.34844192634561%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.515580736543909%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.090651558073654%\" valign=\"top\"\u003e\n \u003cp\u003e27 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eNACTRT + APR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.331444759206798%\" valign=\"top\"\u003e\n \u003cp\u003eUlcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.305949008498583%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.490084985835693%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.614730878186968%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.215297450424929%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.524079320113314%\" valign=\"top\"\u003e\n \u003cp\u003eDOD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAbbreviations:- NR, Not recorded; APR, Abdominoperineal resection; Sx, Surgery; NCR, Neo-adjuvant chemoradiation; F/B, followed by; Adj., Adjuavant; CTRT, Chemoradiation; CT, Chemotherapy; NA, Not available; EXAM, Examination; Met, Metastasis; Dx, Diagnosis\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, scrotal metastasis from colorectal cancer is an extremely rare event, with limited information available in the literature. Our study highlights the need for a high index of suspicion for scrotal metastasis in patients with known colorectal cancer, especially in cases of persistent or recurrent scrotal lesions. The clinical presentation of scrotal metastasis is variable, and the diagnosis is often delayed due to its rarity and nonspecific symptoms. Histopathological examination and immunohistochemistry are essential for confirmation of the diagnosis. The management of scrotal metastasis is mainly palliative, and wide excision of the scrotal lesion is the mainstay of treatment.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interest:\u003c/strong\u003e I declare that the authors have no competing interests as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources:\u0026nbsp;\u003c/strong\u003eNone of the authors have any relevant financial disclosures\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F.,. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 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Epidemiology of colorectal cancer: Incidence, mortality, survival, and risk factors. \u003cem\u003ePrz Gastroenterol\u003c/em\u003e. 2019;14(2):89-103. doi:10.5114/pg.2018.81072\u003c/li\u003e\n\u003cli\u003eHoyt BS, Cohen PR. Cutaneous scrotal metastasis: Origins and clinical characteristics of visceral malignancies that metastasize to the scrotum. \u003cem\u003eInt J Dermatol\u003c/em\u003e. 2013;52(4):398-405. doi:10.1111/j.1365-4632.2012.05717.x\u003c/li\u003e\n\u003cli\u003eLookingbill DP, Spangler N, Sexton FM . Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. \u003cem\u003eJ Am Acad Dermatol\u003c/em\u003e. 1990;22(1):19-26.\u003c/li\u003e\n\u003cli\u003eSchroeder T, Plambeck B, Bowdino C, DiMaio D, Christiansen A. 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Colon Cancer Metastasis to the Right Testis: Case Report and Review of Literature. \u003cem\u003eCase Rep Urol\u003c/em\u003e. 2022;2022:1-4. doi:10.1155/2022/2649259\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Colorectal carcinoma, scrotum, latency, unusual presentation","lastPublishedDoi":"10.21203/rs.3.rs-3816250/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3816250/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eColorectal carcinoma (CRC) is a common malignancy, frequently metastasizing to the liver, lungs, and regional lymph nodes. However, metastasis to the scrotum is exceedingly rare, with few cases reported in the literature. In this study, we present a series of five cases of colorectal carcinoma metastasizing to the scrotum, emphasizing their unusual clinical presentation and late recurrences.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe did a retrospective review of 7 years from 2015\u0026ndash;2022 for cases of scrotal metastasis in cases of CRC.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe means age in our study was 38 years (22\u0026ndash;61 years) and the median time interval between the primary diagnosis and scrotal metastasis was 31.6 months (0-104 months). Case presentations included scrotal swelling initially misdiagnosed as a hydrocele (case 1), non-healing cutaneous ulcers (cases 3 and 5), a scrotal skin papilloma (case 4), and a cutaneous nodule (case 2).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis series of five cases highlights the rarity and diagnostic challenges associated with colorectal carcinoma metastasizing to the scrotum. The extended latency between primary tumor diagnosis and scrotal metastasis, coupled with atypical clinical presentations, underscores the importance of maintaining a high index of suspicion. Clinicians should be vigilant, especially when evaluating patients with a history of colorectal carcinoma, to promptly identify such uncommon metastatic sites.\u003c/p\u003e","manuscriptTitle":"Colorectal Carcinoma metastasizing to Scrotum: A series of five cases with unusual presentation and late recurrences from a single tertiary oncology centre of India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 18:23:01","doi":"10.21203/rs.3.rs-3816250/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7955ac3b-0b11-4b8c-a5d4-d63f56bc5738","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-07T04:14:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 18:23:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3816250","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3816250","identity":"rs-3816250","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}