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She was not a smoker and denied ever abusing alcohol or recreational drugs in the past. On physical examination she had point tenderness in her thoracolumbar vertebrae (T7 through L5) as well as both scapulas. She had no focal deficits in her muscle strength or sensation. Her knee, ankle, biceps and brachioradialis reflexes were normal. Her rectal tone was normal. Her respiratory examination was unremarkable, while the cardiovascular examination revealed a grade 2/6 ejection systolic murmur, decrescendo type which was best heard in the second intercostal space. There were no skin changes appreciable. Her breast examination was normal as well. Investigations The CT chest did not reveal any abnormalities except for a calcified and non-calcified mediastinal and retroperitoneal lymphadenopathy as well as a stable ground glass nodule in the left lower lobe. The MRI of her cervical and thoracolumbar spine abnormal signals in the lower thoracic as well as the lumbar vertebras along with degeneration of the lumbar spine as seen in figure 1. A sample of L1 and L2 were taken and was sent for pathology and microbiology. The microbiological workup was negative for osteomyelitis; however, the pathology report came back as ��Metastatic Adenocarcinoma�� which was immunohistochemically positive for CAM5.2, AE1/3, Ber-EP4, EMA and carcinoembryonic antigen (mCEA). Figure?1 MRI Thoracolumbar spine revealing the abnormal MRI signals suggestive of metastatic bone disease. On seeing these results a bone scan was ordered which revealed abnormal uptake in the thoracic spine, lumbar spine, sacrum, pelvis, and third and 10th right ribs. A CT abdomen with pancreatic protocol was performed which showed no visceral neoplasm or metastases in the abdomen or pelvis. A colonoscopy and oesophagoduodenoscopy (EGD) was performed with biopsies from a lesion in the ascending colon (figure 2). Pathology from the EGD showed benign cells but the biopsy from the colon revealed poorly differentiated adenocarcinoma of the colon, which was Ki-67 positive. She also underwent a mammogram which revealed no signs of malignancy. Figure?2 Ascending colon mass which turned out to be the primary tumor. Differential diagnosis Our initial differentials included progression of spinal stenosis of her lumbar spine, progression of degeneration joint disease of her lumbosacral spine, compression fracture and aortic dissection. However, after the MRI was performed we were concerned that she may have a metastatic disease to the bone or osteomyelitis given the abnormal signal that was detected. The differentials for adenocarcinoma metastases included a primary from the lung, breast, SB431542 ic50 pancreas, ovaries, colon and stomach. Treatment The patient was initially treated with multiple sessions of radiotherapy to the spine and then followed up with the oncologists. She received one cycle of capecitabine 1000?mg two times a day.