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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 152-154

Mandibular swelling: An uncommon site of presentation of metastatic disease


Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India

Date of Web Publication28-Dec-2017

Correspondence Address:
Dr. Balasubramanian Venkitaraman
Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_46_17

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  Abstract 


Metastatic tumors affecting the oral cavity are relatively uncommon. Isolated lesion of the mandible, especially those with soft tissue involvement, needs to be correctly differentiated from the benign lesion and primary malignant tumors of the oral cavity. Herein, we describe a patient who had presented with painful swelling of the jaw. On evaluation, she was diagnosed to have a metastatic tumor of the mandible with no other sites of metastasis. A high degree of suspicion is required to identify metastatic involvement of the mandible, especially in patients with a previous history of nonhead and neck malignancy.

Keywords: Breast cancer; mandibular metastasis; oral malignancies


How to cite this article:
Raja A, Venkitaraman B. Mandibular swelling: An uncommon site of presentation of metastatic disease. Indian J Multidiscip Dent 2017;7:152-4

How to cite this URL:
Raja A, Venkitaraman B. Mandibular swelling: An uncommon site of presentation of metastatic disease. Indian J Multidiscip Dent [serial online] 2017 [cited 2019 Jul 21];7:152-4. Available from: http://www.ijmdent.com/text.asp?2017/7/2/152/221769




  Introduction Top


Metastatic involvement of oral cavity region is very uncommon. Primary tumors of the oral cavity are more common than metastatic tumors with former accounting for only 1% of all oral malignancies.[1] Among various subsites, mandible is most commonly affected.[2] Although patients may have a variety of symptoms, in 23%–30% of patients, mandibular lesion is the primary manifestation of a malignant disease elsewhere in the body.[3] Adenocarcinoma is the most common histology to metastasize to the mandible.[2],[3]


  Case Report Top


A 46-year premenopausal, multiparous female with no addictions, presented to us with a painful swelling of the left side of the jaw for 2-month duration, with no other associated symptoms. She was initially treated for hormone receptor-negative carcinoma of the left breast (stage cT2N1M0) and underwent breast conservation surgery with adjuvant chemotherapy and radiation. On regular follow-up, after a disease-free interval of 10 years and 3 months, she had presented with left jaw swelling. Clinical examination revealed a swelling in the body of mandible on the left side, close to a molar region with intact overlying mucosa. Plain X-ray showed mixed lytic-sclerotic expansile lesion in the left side of mandible in the region of first molar region with no significant oral soft-tissue component. Bone scan done showed uptake only in the left side of the jaw [Figure 1]. Fine-needle aspiration cytology done from the swelling was suggestive of adenocarcinoma. Core-needle biopsy done was suggestive of metastatic adenocarcinoma and immune-histochemical analysis, and it was found to be compatible with breast primary.
Figure 1: Bone scan revealing a localized uptake in the left side of the jaw

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Complete metastatic workup revealed no other sites of metastatic disease. The patient was not willing for any surgical intervention. She received local radiotherapy with six cycles of anthracycline-based chemotherapy with satisfactory palliation. She received 24 doses of monthly injections of bisphosphonates. Bone scan taken 1 year later showed a significant reduction in the local uptake [Figure 2]. After a progression-free interval of 2 years, she developed liver metastasis. She was started on oral metronomic chemotherapy, but her condition deteriorated and succumbed to the disease.
Figure 2: Bone scan done 1-year posttherapy, showing a reduction in the uptake in the region corresponding to Figure 1

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  Discussion Top


Involvement of mandible by metastatic disease is rare in comparison to primary oral malignancies. In India, due to the high incidence of oral cancer, compared to western countries, primary tumor of the oral cavity is the first to be suspected in patients with suspicious oral cavity lesion. Various studies have reported the incidence rates of metastatic oral cavity tumors to be around 0.3% of all oral malignancies, compared to 1.5% among western literature.[1],[4] Among various sites in the oral cavity, the mandible is the most common site of metastasis, with the metastatic disease more commonly involving the bone than the soft tissue.[3] It is commonly seen in patients in the fourth and fifth decades,[3],[4] affecting both sexes equally.[3] Within mandible, the body of mandible is the most common site involved (around the molar region), followed by angle and ramus.[4] Hashimoto et al., in their autopsy series analysis of the pathological characteristics among patients with mandibular metastasis, reported increased frequency of lodgment of metastatic foci in hematopoietic areas of mandible, namely, the body.[5]

Epithelial tumors are the most common primary lesions metastasizing to mandible, with adenocarcinoma being the most common histology.[6] There is a differential pattern among the primary tumor metastasizing to mandible among the two sexes, with breast cancer being the most common primary producing mandibular metastasis in women while lung cancer was the most common among males.[3],[6] There is also a differential pattern observed in the primary tumor with respect to age with brain, adrenal and bone tumors producing metastasis, more commonly in the first and second decades.[4]

Painful swelling, regional paresthesia, loosening of teeth, and persistent bleeding postdental extraction have been reported as the common presenting symptoms in literature.[2],[6],[7],[8] Paraesthesia over the area of lower lip and chin (“Numb Chin syndrome”) occurs due to the metastatic involvement of inferior alveolar nerve within mandible, resulting in sensory disturbance over its supply region.[9] Mandibular metastasis can be the first sign of malignant disease as per literature in almost 20%–60% of patients and the first sign of distant metastasis in 23%–26%.[2],[3],[6],[10] The disease-free interval from the diagnosis of the primary to detection of mandible metastasis is quite variable (40–42.7 months) and cannot be clearly defined, as in many cases, this is the presenting complaint of an indolent malignancy.[3],[4] Majority of patients also tend to have associated widespread metastasis at the time of presentation.

On radiological evaluation, a plain radiograph commonly reveals a lytic lesion with ill-defined margins (80%–86%) and osteoblastic lesion in 10.5%. Around 5% of cases may not reveal an obvious radiological abnormality.[3],[6]99- Technitium labeled bone scan reveals an area of uptake, in osteoblastic lesions, even before the lesions being evident on plain radiograph. It also has the advantage of picking up any additional bony metastasis in the rest of skeletal system. A contrast-enhanced computed tomography more clearly defines the morphology of lesion, site of involvement, extent of bony destruction along with any associated soft tissue component.[3],[6]

The treatment depends on the primary tumor and the presence or absence of coexisting metastasis elsewhere. With widespread metastatic disease, treatment is mainly aimed at improving quality of life and palliation of symptoms. Treatment options include radiation with or without systemic chemotherapy. Local radiotherapy helps in relieving pain, prevents loss of function, arrests hemorrhage, and retards the growth of tumor. Surgical resection may be contemplated in patients with isolated mandibular metastasis, in the presence of a long disease-free interval or as a palliative procedure.[4] The general outcome of patients is poor, irrespective of treatment offered, with median survival around 7–17 months from the diagnosis depending on the presence and absence of systemic metastasis.[3],[8],[9]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hirshberg A, Leibovich P, Buchner A. Metastatic tumors to the jawbones: Analysis of 390 cases. J Oral Pathol Med 1994;23:337-41.  Back to cited text no. 1
    
2.
D'Silva NJ, Summerlin DJ, Cordell KG, Abdelsayed RA, Tomich CE, Hanks CT, et al. Metastatic tumors in the jaws: A retrospective study of 114 cases. J Am Dent Assoc 2006;137:1667-72.  Back to cited text no. 2
    
3.
Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic tumours to the oral cavity – Pathogenesis and analysis of 673 cases. Oral Oncol 2008;44:743-52.  Back to cited text no. 3
    
4.
Muttagi SS, Chaturvedi P, D'Cruz A, Kane S, Chaukar D, Pai P, et al. Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center. Indian J Cancer 2011;48:234-9.  Back to cited text no. 4
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5.
Hashimoto N, Kurihara K, Yamasaki H, Ohba S, Sakai H, Yoshida S, et al. Pathological characteristics of metastatic carcinoma in the human mandible. J Oral Pathol 1987;16:362-7.  Back to cited text no. 5
    
6.
Akinbami BO. Metastatic carcinoma of the jaws: A review of literature. Niger J Med 2009;18:139-42.  Back to cited text no. 6
    
7.
Nishimura Y, Yakata H, Kawasaki T, Nakajima T. Metastatic tumours of the mouth and jaws. A review of the Japanese literature. J Maxillofac Surg 1982;10:253-8.  Back to cited text no. 7
    
8.
Pruckmayer M, Glaser C, Marosi C, Leitha T. Mandibular pain as the leading clinical symptom for metastatic disease: Nine cases and review of the literature. Ann Oncol 1998;9:559-64.  Back to cited text no. 8
    
9.
Schwartz ML, Baredes S, Mignogna FV. Metastatic disease to the mandible. Laryngoscope 1988;98:270-3.  Back to cited text no. 9
    
10.
van der Waal RI, Buter J, van der Waal I. Oral metastases: Report of 24 cases. Br J Oral Maxillofac Surg 2003;41:3-6.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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