case_images: PMC6352049_01
case_images: Histological appearance of the primary sigmoid carcinoma revealing infiltration of malignant cells into all layers of the intestinal wall
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case_images: PMC6352049_01_aojnmb-7-089-g001.jpg
case_images: F1
case_images: The histopathology of the tumor was compatible with infiltrative, ulcerative adenocarcinoma with the mucin-producing features, involving full intestinal wall thickness as well as a corresponding mesocolic lymph node (pT3N1Mx), KRAS and NRAS wild-type (Figure 1).
case_images: 18FDG-PET/CT images. (A). Maximum intensity projection (MIP) image: There are foci of metabolically active lesions in the right paramedian submandibular region, bilateral proximal upper extremities, and posterior pelvic cavity. Metabolically active lesions are demonstrated in the (B). Trans-axial CT (left) and PET (right) images: Right submandibular region (right external lingual muscles) with invasion to the adjacent mandible, (C). Trans-axial Fused image: Posterior to the left biceps muscle, (D). Trans-axial CT (left) and PET (right) images: Right deltoid muscle, (E).
  Trans-axial CT (left) and PET (right) images: Pulmonary nodule in the apical segment of the right lung, (F).
  Trans-axial CT (left) and Fused (right) images: Left external oblique abdominis muscle, (G).
  Trans-axial CT (left) and PET (right) images: GI tract, above the anastomotic region (which was proved to be non-malignant in subsequent colonoscopic and biopsic evaluation).
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case_images: PMC6352049_01_aojnmb-7-089-g002.jpg
case_images: F2
case_images: In addition, a 9 mm pulmonary nodule revealing modest metabolic activity was detected in the apex of the right upper lobe, highly suggestive of metastasis (Figure 2).
case_images: Histopathologic findings of the hypermetabolic deltoid mass showing atypical glands lined by malignant cells concomitant with inflamed fibrotic stroma suggestive of muscle metastasis from the colon cancer. (A): Skeletal muscle fibers surrounded by inflammatory cells (B): Atypical glandular tissue with muscular fascicles in the top of the field. (C): Atypical glands lined by malignant cells
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case_images: F3
case_images: Confirmatory excisional surgery was carried out on the right deltoid lesion (Figure 3), the most hypermetabolic muscular metastasis, as well as the right submandibular mass (Figure 4).
case_images: Histopathologic findings of the hypermetabolic tumoral mass in the right chin, involving muscular and bone structures. Fibrocollagenous and skeletal muscle tissue are infiltrated by proliferating atypical neoplastic cells showing glandular differentiation. (A, B): Fibrocollagenous and muscular tissues infiltrated by atypical cells, glandular structures as well as inflammatory cells. (C): Glandular differentiation. (D): Atypical glandular structure formation
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case_images: PMC6352049_01_aojnmb-7-089-g004.jpg
case_images: F4
case_images: Confirmatory excisional surgery was carried out on the right deltoid lesion (Figure 3), the most hypermetabolic muscular metastasis, as well as the right submandibular mass (Figure 4).
case_images: 18FDG-PET/CT images. (A). Maximum intensity projection (MIP): Foci of metabolically active lesions are visualized superior to the right kidney, right mid abdominal region, and the posterior pelvic cavity. In addition, diffuse metabolic activity is noted in skeletal muscles owing to physical activity in the morning of the study. Of note, due to technical issues the imaging of the lower extremities was performed separately. (B). Trans-axial CT (left), PET (middle) and Fused (right) images: Comparing with the previous study, the mandibular bone lesion is healed without evidence of remaining tumoral lesion. (C).
  Trans-axial CT (left) and Fused (right) images: A mild metabolically active pulmonary nodule in the apical segment of the right lung shows stable size and metabolic activity. (D).
  Trans-axial CT (left) and Fused (right) images: A new metabolically active lesion in the right rectus abdominis muscle. (E).
  Trans-axial CT (left) and Fused (right) images: A metabolically inactive lesion in the left external oblique abdominis muscle probably reveals the metabolic response to the treatment. (F).
  Trans-axial CT (left) and Fused (right) images: Mild metabolic activity in the GI tract, above the anastomotic region, reveals no significant change in size and metabolic activity in comparison to the previous study (which has been proven to be non-malignant in recent colonoscopic and biopsic evaluation). (G).
  Trans-axial CT (left) and Fused (right) images: A new metabolically active metastasis in the left quadriceps muscle. (H).
  Trans-axial CT (left), Fused (middle), and Coronal Fused (right) images: A new metabolically active metastatic lesion in the right adrenal gland
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case_images: F5
case_images: Afterwards, the patient was reevaluated by 18FDG-PET/CT at the end of 2017 (Figure 5).