Odontoid peg metastasis from an oesophageal adenocarcinoma.

Metastasis to the odontoid peg is a rare condition. We report a case where such a metastasis from an oesophageal adenocarcinoma caused problems in both diagnosis and management. This is the first case to our knowledge to originate from a primary oesophageal adenocarcinoma. CASE REPORT. A 58 year old male was admitted with dysphagia and weight loss. Investigations revealed a lower oesophageal adenocarcinoma and he underwent oesophagogastrectomy. Histopathology of the resected specimen confirmed a poorly differentiated infiltrating adenocarcinoma extending through to the serosal fat. The resection limits were clear and there was no evidence of distant metastases. On the thirteenth postoperative day he complained of neck pain and paraesthesiae in the C3 distribution bilaterally; he stated that he had experienced these symptoms before. Cervical spine X-rays showed only degenerative changes, although details of the odontoid area were partially obscured. He was treated with simple analgesics and a soft cervical collar followed by gentle mobilization. He was discharged well on the twenty-fifth postoperative day but still had some neck pain. Three months later, he presented again with a three day exacerbation of neck pain, localised to the base of the skull posteriorly and with no associated neurological symptoms. Examination revealed cachexia, tenderness over C2/3, markedly reduced cervical spine movements but no abnormal neurological findings. X-rays now showed the odontoid peg to be very ill-defined with marked atlanto-axial subluxation. Attempted per-oral fixation of the odontoid fracture in the Regional Neurosurgical Unit proved unsuccessful due to the degree of bony erosion, and bone biopsy only was performed, which showed adenocarcinoma consistent with gastrointestinal origin. His condition condition continued to deteriorate until his death ten days later from bronchopneumonia.