J
Oral Maxillofac
Surg
49:79-90.1991
Metastatic Endometrial Carcinoma the Mandible:
to
A Case Report W.G. MAXYMIW,
DDS,* AND RI.
WOOD, DDS, MSc, DIP ORAL RAD MRCDCt
Metastatic carcinoma is reported to be the most common malignant tumor of bone.’ Most metastases occur in the spine, pelvis, skull, ribs, and humerus.2 However, metastases to the jaws from distant sites are comparatively rare, accounting for only 1% of all malignant tumors of the oral cavity.3 In patients for whom data are available, a metastasis to the jaws is the initial manifestation of malignancy in approximately 36% of cases.4 Two qualities of malignant cells enhance the frequency for metastasis. These are 1) lack of cohesiveness of malignant cells to each other and 2) adhesiveness, the ability of malignant cells to adhere to a new surface.5 Malignant tumors metastasize by various routes. Carcinomas spread via the lymphatic system to regional lymph nodes and subsequently via the lymphatics and bloodstream to distant organs.6 The tumor may gain access to the vascular network by direct invasion of vessels at the primary site. They may reach the maxilla or mandible through the vertebral venous or portal circulation. In the vertebral circulation, the tumor can enter the jugular vein via the cervical vein from the vertebral venous system of Batson. The other access is the superior mesenteric vein as it drains the cecum. Tumor cells can then enter bone through nutrient arteries and proliferate in medullary spaces. Cortical perforation then allows for tumor invasion to adjacent soft tissue.’ Reviews of mandibular metastases have implicated the following primary sites in descending order of frequency: breast, kidney, lung, colon and
rectum, prostate, thyroid, stomach, skin, and testes.’ To qualify as a metastatic lesion to the jaws, the lesion should be localized to bone, as distinguished from mucosal to bone invasion by an overlying primary or metastatic soft-tissue tumor. Second, it should be a microscopically verified carcinoma, and, third, the location of the primary tumor should be known.’ Of the reported cases involving the female reproductive organs, ours satisfies the above criteria, with the endometrium the primary site. 3,10,11,12 Report of a Case Mrs B, a 63-year-old woman, presented to the dental clinic in July 1989 for investigation of a swelling of the right mandible. She was gravida 5 para 5 and had ceased menstruation by age 50. She had been in good health until age 55, when she experienced postmenopausal bleeding in March 1989. She then had a total abdominal hysterectomy and salpingo-oophorectomy, which revealed a poorly differentiated carcinoma involving the entire uterus, with extension to the cervix, left ovary, and fallopian tube. Microscopic examination of the specimen demonstrated a poorly differentiated adenocarcinoma (Fig 1). Chest radiography and bilateral mammography were normal, and examination of the axillary nodes was negative. Complete examination resulted in a classification of stage IV adenocarcinoma of the endometrium. The patient was a nonsmoker without allergies, but was an insulin-dependent diabetic. Oral examination, in July 1989, showed the patient to be edentulous. There was a firm, fixed mass 2.5 cm in diameter on the buccal aspect of the right mandibular premolar region (Fig 2). The mass was not tender, but prevented the patient from wearing her lower denture. A periapical radiograph of the region showed a radiolucent lesion in the mental foramen area (Fig 3). Microscopic examination of a specimen removed from the area demonstrated features similar to those of the endometrial tumor (Fig 4). A single radiotherapy fraction (800 cGy) was delivered shortly thereafter to the right mandible, providing symptomatic relief. The buccal flange of the denture was also removed to facilitate it being worn. The patient subsequently developed metastatic lesions in the left hip; retroperitoneal, h&u, abdominal, inguinal and supraclavicular nodes; and in the lumbar spine, and was provided
Received from the Department of Dentistry, Ontario Cancer Institute Incorporating, The Princess Margaret Hospital, Toronto, Ontario, Canada. * Chief. f Staff. Address correspondence and reprint requests to Dr Maxymiw: Department of Dentistry. Ontario Cancer Institute Incorporating, The Princess Margaret Hospital, 500 Sherbourne St, Toronto, Ontario, Canada M4X lK9. 0 1991 American
Association
of Oral and Maxillofacial
Sur-
geons 0278-2391/91/4901-0013$3.00/0
78
MAXYMIW ET AL
79
FIGURE 1. Microscopic section from uterine tumor shows a poorly differentiated adenocarcinoma replacing the endometrium (hematoxylin-eosin stain, original magnification x63). with palliative
care until she died shortly thereafter
in
October 1989.
Discussion For a metastatic lesion to develop within bone there is a partial dependence upon the presence of red marrow. Therefore, metastasis to the jaws should most often occur distal to the canines. The actual low incidence of metastasis to the jaw bones is associated with an anatomic factor: the relative lack of red marrow in the elderly patient. However, within the jaws, the mandible is by far the most common metastatic site, with the highest concentration of metastases (75%).13 The average age of patients developing metastatic jaw lesions is 56 years, with a range of 16 to 79 years. l4 The frequency of metastatic carcinoma of the jaws is higher among women than men, presumably because metastasis from carcinoma of the breast constitutes nearly one third of the total num-
_ FIGURE 2. presentation.
Clinical photograph of patient at the time of initial Note the large sessile mass.
FIGURE 3. Periapical radiograph of lesion at time of presentation reveals a radiolucent area corresponding to the mandibular mass.
ber of cases.’ Adenocarcinoma is the most common metastatic tumor occurring in the jaws, comprising 70% of reported cases.15 The symptoms of jaw metastases are nonspecific and may include pain, swelling, sensory changes, and loss or mobility of teeth in the absence of periodontal disease.’ Metastases to the mouth and jaws have on occasion been thought to be infections, cysts, traumatic lesions, osteomyelitis, benign neoplasms, or primary malignancies .6 It is difficult for the clinician to suspect a jaw metastasis for two reasons. First, symptoms from early metastatic lesions are often vague. Secondly, the radiographic appearance of a jaw metastasis may not be specific.‘6 Factors that should cause the clinician to include a metastatic neoplasm in the differential diagnosis are age, altered blood chemistries, positive nuclear medicine scans, pain, paresthesia, and a history of malignancy. The radiographic findings can vary, and may be either bone forming (osteoblastic), bone destroying (osteolytic),
FIGURE 4. Microscopic section of mandibular lesion that has similar features as identified in Figure I (hematoxylin-eosin stain, original magnification X40).
80 or a combination of both.i7 Occasionally, radiolucent areas unrelated to pulpal pathosis are observed adjacent to the apices of teeth.” Radiographic examination may not be the best method to detect metastases, which suggests that mandibular metastases oc.cur more often than observed. l5 A Tc99-MDP bone scan in conjunction with radiographs is helpful in determining the presence of other sites of bone involvement.” The degree of uptake of radionuclide by a bone lesion is contingent on the amount of new bone formation in response to the lesion. In bone metastases, the scan demonstrates increased uptake, regardless of whether the lesions are osteobiastic or osteolytic.” Treatment of a metastasis as a primary lesion is inadequate. i3 Radiation therapy and/or surgery may be used to decrease the size of the metastatic lesion, if it is interfering with nutrition or respiration. It may also be beneficial for the reduction of neuroto logical symptoms. 2o Appropriate radiotherapy the metastatic lesion and chemotherapy can result in control, with an improved quality of life.2’ The prognosis is grave for a patient with metastases to the jaws. Treatment is palliative, with the intention to provide relief from pain and lengthen time for survival.22 More than two thirds of patients with metastatic carcinoma of the jaws are dead within 1 year of diagnosis of the metastatic lesion. The 4-year survival rate is approximately 1o%.22 References
1. Worth HM: Principles and Practices of Oral Radiologic Interpretation (ed 2). Chicago, IL, Year Book Medical, 1972, p 746 2. Nishimura Y, Nakajima T, Yakata H, et al: Metastatic thyroid carcinoma of the mandible. J Oral Maxillofac Surg 40:221, 1982 3. Curtin J: Mandibular metastasis from a primary adenocarci-
METASTATIC ENDOMETRIAL
CARCINOMA TO THE JAWS
noma of the fallopian tube. J Oral Maxillofac Surg 43:636, 1985
4. Vigneul JC, Moue1 0, Klap P, et al: Metastatic hepatocellular carcinoma of the mandible. J Oral Maxillofac Surg 40~745, 1982 5. Jacobs H, Ruben, MP, Lyon J: Renal-cell carcinoma metastatic to the mandible and gingiva. Oral Surg Oral Med Oral Path01 22649, 1966 6. Carl W: Metastatic cancers to the mouth. Compend Contin Educ Dent 7:738, 1986 7. Mast HL, Nissenblatt MJ: Metastatic colon carcinoma to the jaw: A case report and review of the literature. J Surg Oncol34:202 1987 8. Rubin MM, Jui V, Cozzi GM: Metastatic carcinoma of the mandibular condyle presenting as temporomandibular joint syndrome. J Oral Maxillofac Surg 47:507, 1989 9. Clausen F, Paulsen H: Metastatic carcinoma to the jaws. Acta Path01 Microbial Stand 57:361, 1963 10. Nortje CJ, Wood RE, Padayachee A: Soft tissue proliferation in a nonhealing extraction site. A sign of metastatic malignancy. Denotomaxillofac Radio1 16:109. 1987 11. Orlian AI: Metastatic endometrial carcinoma to’the maxilla. NY State Dent J 43:528, 1977 12. Uhler IV, Fahs GR, Dolan LA: Metastasis of cervical carcinoma to the mandible: Report of a case. J Am Dent Assoc 85:363, 1972 13. Birkholz H: Metastatic bronchogenic carcinoma to the maxilla. J Oral Maxillofac Surg 40:532, 1982 14. Rohrer MD, Colyer J: Mental nerve paresthesia: Symptom for a widespread skeletal metastatic adenocarcinoma. J Oral Surg 39442, 1981 15. Hashimoto N, Kurihara K, Yamasaki H, et al: Pathological characteristics of metastatic carcinoma in the human mandible. J Oral Path01 16:362, 1987 16. Wolujewicz MA: Condylar metastasis from a carcinoma of the prostate gland. Br J Oral Surg 18: 175, 1980 17. Nevins A, Ruden S, Pruden P, et al: Metastatic carcinoma of the mandible mimicking periapical lesion of endodontic origin. Endod Dent Traumatol 4:238, 1988 18. Martis C, Karakasis D, Lazaridis N: Metastatic adenocarcinoma to the mandible: report of case. J Am Dent Assoc 94:1163, 1977 19. Yagan R, Bellon EM, Radivoyevitch M: Breast carcinoma metastatic to the mandible mimicking ameloblastoma. Oral Surg Oral Med Oral Path01 57:189. 1984 20. Reed MWR, Furniss A: Mandibular metastasis from gastrointestinal carcinoma. J R Co11 Surg Edinh 32:177. 1987 21. Horie Y, Suou T, Hirayama C, et al: Hepatocellular carcinoma metastatic to the oral cavity including the maxilla and the mandible: Report of two cases and review of the literature. Gastroenterol Jpn 20:604, 1985 22. Batsakis JG, McBumey TA: Metastatic neoplasms to the head and neck. Surg Gynecol Obstet 133:673, 1971
Oral Maxillofac
Surg
49:79-90.1991
Metastatic Endometrial Carcinoma the Mandible:
to
A Case Report W.G. MAXYMIW,
DDS,* AND RI.
WOOD, DDS, MSc, DIP ORAL RAD MRCDCt
Metastatic carcinoma is reported to be the most common malignant tumor of bone.’ Most metastases occur in the spine, pelvis, skull, ribs, and humerus.2 However, metastases to the jaws from distant sites are comparatively rare, accounting for only 1% of all malignant tumors of the oral cavity.3 In patients for whom data are available, a metastasis to the jaws is the initial manifestation of malignancy in approximately 36% of cases.4 Two qualities of malignant cells enhance the frequency for metastasis. These are 1) lack of cohesiveness of malignant cells to each other and 2) adhesiveness, the ability of malignant cells to adhere to a new surface.5 Malignant tumors metastasize by various routes. Carcinomas spread via the lymphatic system to regional lymph nodes and subsequently via the lymphatics and bloodstream to distant organs.6 The tumor may gain access to the vascular network by direct invasion of vessels at the primary site. They may reach the maxilla or mandible through the vertebral venous or portal circulation. In the vertebral circulation, the tumor can enter the jugular vein via the cervical vein from the vertebral venous system of Batson. The other access is the superior mesenteric vein as it drains the cecum. Tumor cells can then enter bone through nutrient arteries and proliferate in medullary spaces. Cortical perforation then allows for tumor invasion to adjacent soft tissue.’ Reviews of mandibular metastases have implicated the following primary sites in descending order of frequency: breast, kidney, lung, colon and
rectum, prostate, thyroid, stomach, skin, and testes.’ To qualify as a metastatic lesion to the jaws, the lesion should be localized to bone, as distinguished from mucosal to bone invasion by an overlying primary or metastatic soft-tissue tumor. Second, it should be a microscopically verified carcinoma, and, third, the location of the primary tumor should be known.’ Of the reported cases involving the female reproductive organs, ours satisfies the above criteria, with the endometrium the primary site. 3,10,11,12 Report of a Case Mrs B, a 63-year-old woman, presented to the dental clinic in July 1989 for investigation of a swelling of the right mandible. She was gravida 5 para 5 and had ceased menstruation by age 50. She had been in good health until age 55, when she experienced postmenopausal bleeding in March 1989. She then had a total abdominal hysterectomy and salpingo-oophorectomy, which revealed a poorly differentiated carcinoma involving the entire uterus, with extension to the cervix, left ovary, and fallopian tube. Microscopic examination of the specimen demonstrated a poorly differentiated adenocarcinoma (Fig 1). Chest radiography and bilateral mammography were normal, and examination of the axillary nodes was negative. Complete examination resulted in a classification of stage IV adenocarcinoma of the endometrium. The patient was a nonsmoker without allergies, but was an insulin-dependent diabetic. Oral examination, in July 1989, showed the patient to be edentulous. There was a firm, fixed mass 2.5 cm in diameter on the buccal aspect of the right mandibular premolar region (Fig 2). The mass was not tender, but prevented the patient from wearing her lower denture. A periapical radiograph of the region showed a radiolucent lesion in the mental foramen area (Fig 3). Microscopic examination of a specimen removed from the area demonstrated features similar to those of the endometrial tumor (Fig 4). A single radiotherapy fraction (800 cGy) was delivered shortly thereafter to the right mandible, providing symptomatic relief. The buccal flange of the denture was also removed to facilitate it being worn. The patient subsequently developed metastatic lesions in the left hip; retroperitoneal, h&u, abdominal, inguinal and supraclavicular nodes; and in the lumbar spine, and was provided
Received from the Department of Dentistry, Ontario Cancer Institute Incorporating, The Princess Margaret Hospital, Toronto, Ontario, Canada. * Chief. f Staff. Address correspondence and reprint requests to Dr Maxymiw: Department of Dentistry. Ontario Cancer Institute Incorporating, The Princess Margaret Hospital, 500 Sherbourne St, Toronto, Ontario, Canada M4X lK9. 0 1991 American
Association
of Oral and Maxillofacial
Sur-
geons 0278-2391/91/4901-0013$3.00/0
78
MAXYMIW ET AL
79
FIGURE 1. Microscopic section from uterine tumor shows a poorly differentiated adenocarcinoma replacing the endometrium (hematoxylin-eosin stain, original magnification x63). with palliative
care until she died shortly thereafter
in
October 1989.
Discussion For a metastatic lesion to develop within bone there is a partial dependence upon the presence of red marrow. Therefore, metastasis to the jaws should most often occur distal to the canines. The actual low incidence of metastasis to the jaw bones is associated with an anatomic factor: the relative lack of red marrow in the elderly patient. However, within the jaws, the mandible is by far the most common metastatic site, with the highest concentration of metastases (75%).13 The average age of patients developing metastatic jaw lesions is 56 years, with a range of 16 to 79 years. l4 The frequency of metastatic carcinoma of the jaws is higher among women than men, presumably because metastasis from carcinoma of the breast constitutes nearly one third of the total num-
_ FIGURE 2. presentation.
Clinical photograph of patient at the time of initial Note the large sessile mass.
FIGURE 3. Periapical radiograph of lesion at time of presentation reveals a radiolucent area corresponding to the mandibular mass.
ber of cases.’ Adenocarcinoma is the most common metastatic tumor occurring in the jaws, comprising 70% of reported cases.15 The symptoms of jaw metastases are nonspecific and may include pain, swelling, sensory changes, and loss or mobility of teeth in the absence of periodontal disease.’ Metastases to the mouth and jaws have on occasion been thought to be infections, cysts, traumatic lesions, osteomyelitis, benign neoplasms, or primary malignancies .6 It is difficult for the clinician to suspect a jaw metastasis for two reasons. First, symptoms from early metastatic lesions are often vague. Secondly, the radiographic appearance of a jaw metastasis may not be specific.‘6 Factors that should cause the clinician to include a metastatic neoplasm in the differential diagnosis are age, altered blood chemistries, positive nuclear medicine scans, pain, paresthesia, and a history of malignancy. The radiographic findings can vary, and may be either bone forming (osteoblastic), bone destroying (osteolytic),
FIGURE 4. Microscopic section of mandibular lesion that has similar features as identified in Figure I (hematoxylin-eosin stain, original magnification X40).
80 or a combination of both.i7 Occasionally, radiolucent areas unrelated to pulpal pathosis are observed adjacent to the apices of teeth.” Radiographic examination may not be the best method to detect metastases, which suggests that mandibular metastases oc.cur more often than observed. l5 A Tc99-MDP bone scan in conjunction with radiographs is helpful in determining the presence of other sites of bone involvement.” The degree of uptake of radionuclide by a bone lesion is contingent on the amount of new bone formation in response to the lesion. In bone metastases, the scan demonstrates increased uptake, regardless of whether the lesions are osteobiastic or osteolytic.” Treatment of a metastasis as a primary lesion is inadequate. i3 Radiation therapy and/or surgery may be used to decrease the size of the metastatic lesion, if it is interfering with nutrition or respiration. It may also be beneficial for the reduction of neuroto logical symptoms. 2o Appropriate radiotherapy the metastatic lesion and chemotherapy can result in control, with an improved quality of life.2’ The prognosis is grave for a patient with metastases to the jaws. Treatment is palliative, with the intention to provide relief from pain and lengthen time for survival.22 More than two thirds of patients with metastatic carcinoma of the jaws are dead within 1 year of diagnosis of the metastatic lesion. The 4-year survival rate is approximately 1o%.22 References
1. Worth HM: Principles and Practices of Oral Radiologic Interpretation (ed 2). Chicago, IL, Year Book Medical, 1972, p 746 2. Nishimura Y, Nakajima T, Yakata H, et al: Metastatic thyroid carcinoma of the mandible. J Oral Maxillofac Surg 40:221, 1982 3. Curtin J: Mandibular metastasis from a primary adenocarci-
METASTATIC ENDOMETRIAL
CARCINOMA TO THE JAWS
noma of the fallopian tube. J Oral Maxillofac Surg 43:636, 1985
4. Vigneul JC, Moue1 0, Klap P, et al: Metastatic hepatocellular carcinoma of the mandible. J Oral Maxillofac Surg 40~745, 1982 5. Jacobs H, Ruben, MP, Lyon J: Renal-cell carcinoma metastatic to the mandible and gingiva. Oral Surg Oral Med Oral Path01 22649, 1966 6. Carl W: Metastatic cancers to the mouth. Compend Contin Educ Dent 7:738, 1986 7. Mast HL, Nissenblatt MJ: Metastatic colon carcinoma to the jaw: A case report and review of the literature. J Surg Oncol34:202 1987 8. Rubin MM, Jui V, Cozzi GM: Metastatic carcinoma of the mandibular condyle presenting as temporomandibular joint syndrome. J Oral Maxillofac Surg 47:507, 1989 9. Clausen F, Paulsen H: Metastatic carcinoma to the jaws. Acta Path01 Microbial Stand 57:361, 1963 10. Nortje CJ, Wood RE, Padayachee A: Soft tissue proliferation in a nonhealing extraction site. A sign of metastatic malignancy. Denotomaxillofac Radio1 16:109. 1987 11. Orlian AI: Metastatic endometrial carcinoma to’the maxilla. NY State Dent J 43:528, 1977 12. Uhler IV, Fahs GR, Dolan LA: Metastasis of cervical carcinoma to the mandible: Report of a case. J Am Dent Assoc 85:363, 1972 13. Birkholz H: Metastatic bronchogenic carcinoma to the maxilla. J Oral Maxillofac Surg 40:532, 1982 14. Rohrer MD, Colyer J: Mental nerve paresthesia: Symptom for a widespread skeletal metastatic adenocarcinoma. J Oral Surg 39442, 1981 15. Hashimoto N, Kurihara K, Yamasaki H, et al: Pathological characteristics of metastatic carcinoma in the human mandible. J Oral Path01 16:362, 1987 16. Wolujewicz MA: Condylar metastasis from a carcinoma of the prostate gland. Br J Oral Surg 18: 175, 1980 17. Nevins A, Ruden S, Pruden P, et al: Metastatic carcinoma of the mandible mimicking periapical lesion of endodontic origin. Endod Dent Traumatol 4:238, 1988 18. Martis C, Karakasis D, Lazaridis N: Metastatic adenocarcinoma to the mandible: report of case. J Am Dent Assoc 94:1163, 1977 19. Yagan R, Bellon EM, Radivoyevitch M: Breast carcinoma metastatic to the mandible mimicking ameloblastoma. Oral Surg Oral Med Oral Path01 57:189. 1984 20. Reed MWR, Furniss A: Mandibular metastasis from gastrointestinal carcinoma. J R Co11 Surg Edinh 32:177. 1987 21. Horie Y, Suou T, Hirayama C, et al: Hepatocellular carcinoma metastatic to the oral cavity including the maxilla and the mandible: Report of two cases and review of the literature. Gastroenterol Jpn 20:604, 1985 22. Batsakis JG, McBumey TA: Metastatic neoplasms to the head and neck. Surg Gynecol Obstet 133:673, 1971
