An unusual presentation of metastasis from a rectal adenocarcinoma.

A 70-year-old retired gentleman presented with a 3-week history of right-sided jaw pain, numbness, difficulty swallowing and an enlarging mass along his lower jaw. He noted some bleeding from the mass just prior to admission. He had recently experienced a reduced appetite, difficulty swallowing and approximately one stone in weight loss. Three weeks prior to admission, he noticed increasing shortness of breath and a reduced exercise tolerance. There were no symptoms affecting his vocal cords, nose or ears. His past medical history included a triple heart bypass, pacemaker insertion, hypertension and insulin-dependent diabetes mellitus. He was a nonsmoker and non-drinker. His medication included aspirin, bisoprolol, doxasozin, furosemide, metformin, insulin, ramipril and simvastatin. On initial examination, there was a lesion on his right mandible measuring 5 6 cm with protrusion into the gingivae (Figures 1 and 2). His abdomen was soft and non-tender and there was mild epigastric pain on palpation but no obvious masses. There was no obvious organomegaly. The oral mass was non-tender with bloody discharge from the lesion. There was no obvious lymphadenopathy. He was mildly anaemic with haemoglobin of nine, and his inflammatory markers were raised with a C-reactive protein (CRP) of 96. He received a blood transfusion for symptomatic anaemia and a trial of tranexamic acid was given in an attempt to reduce the bleeding. This patient was initially treated as having a suspected abscess. However, aspiration attempts found only solid matter. After an orthopantomogram X-ray (Figure 3), an urgent maxillary-facial biopsy was carried out. After the biopsy he developed septic shock and responded to fluid resuscitation and intravenous antibiotics. Biopsies from the lesion were consistent with adenocarcinoma of the colorectum. A subsequent computerized tomography (CT) scan of the neck/thorax/abdomen and pelvis was consistent with a probable rectal primary with liver and bone metastasis (Figures 4–6), extraosseous extension including the mandible and left 3rd, 8th and right 12th rib invasion. Given the extent of metastasis, curative surgery was not an option. Trans-oral laser debulking of the right mandibular metastases was performed. He received palliative care for symptomatic relief and subsequently died 3 months later.