A 45-year-old male patient, known to have white matter leukodystrophy and generalized spasticity of unknown etiology which started at the age of 14, was progressive and kept bedridden for the past 7 years for which a Baclofen pump was inserted. Also, he had mental disability. The patient was diagnosed with locally advanced low rectal cancer with distant metastasis to multiple organs including perineal and inguinal skin, lung, external iliac, colon, and inguinal lymph nodes metastasis. In 2018, about 1 month prior to referral to King Faisal Specialist Hospital and Research Center, the patient was following with Neurology regarding his condition, where he was found to have lower GI bleeding and surgery was involved. He underwent investigation for lower GI bleeding including colonoscopy, and he was found to have rectal mass and could not pass the scope above it as well as the skin lesion which was biopsied. The case was discussed in the multidisciplinary tumor board and planned for diversion loop colostomy as well as rectal biopsies and inguinal area skin biopsy followed by palliative radiation therapy to the pelvis. Computed Tomography (CT) scan of the abdomen and pelvis (,, ) demonstrated a circumferential enhancing wall thickening involving the whole rectum with ill-defined hypodense area seen 7–9 o’clock with possible involvement of the anal canal associated with diffuse edema and fat stranding of the mesorectum. There were multiple necrotic lymph nodes noted in the mesorectum and bilateral internal iliac region, the largest one in the right internal ilium measuring 2 cm. There were multiple necrotic lymph nodes seen on the right external iliac (measuring 1.6 cm) and bilateral inguinal area, the largest one on the left side measuring 3.4 × 3.3 cm. There were bilateral symmetrical hilar necrotic lymph nodes measuring on the right side 2.5 × 2 cm and on the left side 3.2 × 1.6 cm. At the perivascular space, they measured 1 cm, being at least T3 N2. Magnetic Resonance Imaging (MRI) for local staging was contraindicated as the patient was with an implanted pump. CT Chest () demonstrated multiple bilateral tiny pulmonary nodules, the largest one measuring 4 mm in the right upper lobe. Upon examination, the patient was bedridden with poor functional status. Glasgow coma score (GCS) was 15/15, having generalized spasticity. Perineal examination revealed multiple exophytic masses in the scrotal skin, inguinal folds, and perineum and gluteal folds, which were firm to hard in consistency with a few being ulcerated especially over scrotum with little oozing of the serosanguinous fluid. There was no mechanical obstruction of orifices (anal or urethral). The patient was in the general surgical ward to continue postoperative care and management. Histopathological exam of rectal biopsies revealed moderately differentiated rectal adenocarcinoma, while the skin of the right inguinal area showed metastatic cutaneous rectal adenocarcinoma (a, b, c). Unfortunately, later, the patient developed respiratory failure secondary to aspiration pneumonia which ended by cardiopulmonary arrest and death.