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Malignant melanoma metastatic to the mandible
MALIGNANT
MELANOMA
METASTATIC
TO THE MANDIBLE
Report of a Case LEONARD
I.
B.S., D.D.S.,*
BI~UESTONE,
BROOKLYN,
N.
Y.
T
HIS is the case of a 51-year-old white man, married, a self-employed sign painter by trade, whose chief complaint was a growth of the lower left gingivae. The patient had been bedridden for approximately four months prior to my visit. The lower left second premolar was described as loose and pyorrhetic and had been extracted under local anesthesia by the family dentist at t’he bedside, about one week previously. Bilateral numbness of the mandible was first observed by the patient about three or four days prior to the extraction. The lesion in question was first observed about one day following the removal of the tooth, at which time it was seen to be about the size of a pea, and protruding from the orifice of the socket. It grew larger in size, finally preventing occlusion of the teet,h, and interfering with mastication. Examination at the bedside revealed a pallid, waxy-looking patient showing marked debilitation. He was paraplegic, and had marked ptosis of the left eyelid. Extraorally, the lips were about 2 cm. apart at the midline, and there was marked bulging of the lower left lip at the commissure. In the left oral vestibule, a bluish mass was readily visualized “in situ. ” Intraoral examination revealed a growth, about the size of a walnut, elliptical in shape with the long axis anteroposteriorly. It appeared to be attached to the crest of the alveolar ridge, distal to the left lower cuspid. The lesion was characterized by bluish coloration of its distal surface. There was some hemorrhage and dried blood clots at the site of contact of the opposing tooth. The surface of the lesion was smooth and firm; it was somewhat fluctuant to touch. The mass was freely movable at its attachment, and nonpainful on manipulation. There appeared to be a line of demarcation at the periphery of its attachment, but no demonstrable pedicle. There was some suppuration from the free margin of the gingiva, at the anterior extremity of the lesion. The mouth was in a generally unhygienic condition, and the tongue abnormally dry. The patient was edentulous, with the exception of the presence of 432
1 J
5
3 23’
The edentulous
ridge
distal
to the lower left cuspid was
edematous and fluctuant. Submaxillary and submental lymph nodes were only moderately palpable. The past medical history is quite significant. In October, 1949, the patient consulted his family physician, complaining of a sore on his back of approximately three months’ duration. Examination at that time revealed several small moles distributed over the lumbar area. One brown mole, in particular, of which the patient complained, was described as having a fibroma-like mass *Oral
Surgeon,
Wyckoff
Heights
Hospital. 237
238
LEONARD
1. BLUESTONE
hanging from its center by a long stalk. This entire mass was completely removed by electrosurgery on Oct. 31, 1949, and the specimen submitted t,o the laboratory for biopsy examination. The pathologist* reported a junction type nevus, with evidence of malignant change (nevocarcinoma). The wound was kept under close observat,ion during repeated visits over a six-month postoperative period, at, the conclusion of which the surgeon reported a red, slightly raised scar, with complete healing. In October, 1951, two years following the removal of t,he original lesion, a mass was observed about 4 inches above the healed scar. This was removed by scalpel surgery, and the specimen again On this occasion, the pathologist’s”* report submitted for biopsy examination. was as follows : “Tissue from chest wall ; non-pigmented melanoblastoma.” This operation was followed np in Januaqv, 1952, by a radical dissection and exploration of the subcutaneous tissue of the back. The microscopic examination of this tissue was negative for tumor cells, but, exhibited only what was described as a foreign body tissue reaction. In February, 1952, the patient ‘S back pain became progressively more severe, and paraplegic symptoms were manifest. Finally, on March 12, 1952, a neurosurgeon performed a thoracolumbar laminectomy, with removal of extradural and extravertebral tumor mass, to relieve spinal cord compression. The patient was then discharged from the hospital, being beyond surgical help, and confined to bed at home, due to his paraplegia. With this history as a background, I decided, in consultation with the attending physician and the family dentist,, that removal of the oral mass was indicated, solely to provide the patient with symptomatic relief, and to allay his increasing anxiety. Thereupon, the following operation was performed. Under mandibular conductive anesthesia, an incision was made down to the bone, on the labial aspect, slightly below the periphery of the tumor mass, to allow a margin of safety. This incision was extended completely around the border of the tumor, freeing it from its attachment with the aid of mucoperiosteal elevators, A second incision was made along the crest of the alveolar ridge, for ahont 4 cm. posterior to t,he distal extremity of the tumor. A wedgeshaped section of tissue from this area, in addition to the entire tumor mass, were submitted for microscopic study. The soft tissues were retracted lingually and buccally, and carefully explored for underlying tumor tissue. B significant finding was that no periosteum was discernible, although the outer plate of bone appeared solid and of normal consistency. The socket of the recentI> extracted tooth was filled with a well-organized blood clot. The tumor mass itself, while being excised, resembled a mass of lipoid tissue, and the lips of The tissues were the wound billowed apart, following the initial incision. brought into good apposition, and the wound completely closed with interreport was as follows : Markedly anaplastic rupted sutures. The pathologist’s**” tumor compatible with malignant melanoma. Photomierographs of the oral metastasis of this malignant melanoma are illustrated in Fig. 1, A and B. *Dr. Hospital. **Dr. ***Dr.
Charles
I?. Sims,
Senior
Dermatopathologist,
David Grayzel. Chief Pathologist. Margit Freund, Pathologist, New
Skin
and
Cancer
Brooklyn Jewish Hospital. York Institute of Clinical
Oral
Unit
of
Pathology.
Bellevue
MALIGNANT
MELANOMA
METASTATIC
TO
MANDIBLE
239
3 k
240
IxoNARl)
1. IKlxS'I'oSE
On the evening of the day of operation (May 9, 1952), the patient was reported as being in good condit,ion and resting comfortably. The following morning, however, he hecamc comatose and cl>-spneic, and was immediately hospitalized. The physical findings at the time of admission were as follows: Temperature, IO2 ; respiration, 40; pulse, 96; blood pressure, IOO/SO ; palpable mass on the right flank, left ptosis, left pupil dilated, left facial paralysis, left Homer’s syndrome, &es in chest, liver markedly enlarged. The admission diagnosis was malignant melanoma, metastat,ic to SII~CUtaneous tissue, lungs, liver, brain, spinal cord, mandible,
Fig. 2.
X-rays
taken at the time of admission revealed the following*
:
1. Anteropostwior and lcrteral erarnino.tion of the thorax: Both lung fields are the sites of extensive nodular infiltrative change. The nodules measure approximately 1 cm., and are widely disseminated throughout, both lung fields. Bilateral pleural effusion is present. Conclusion : Multiple nodular infiltrative disease, accompanied by bilateral pleural effusion, probably on the basis of metastatic neoplasm. 2. Examination of the left side of the mandible: The left side of the mandible is entirely edentulous ; an area of diminished density is demonstrated along the gingival margin, and there appears to be some interruption of the cortex at this point. The radiograph of the left side of the mandible is reproduced in Fig. 2. Oxygen was administered via mask, The patient was at this time moribund. and later by tent. Demerol and barbiturates were administered for sedation. *Dr.
Jerome
Zwanger,
Radiologist,
Long
Island
College
Hospital.
MALIGNANT
MELANOMA
RIETASTATIC
TO
MANDIELE
241
His blood pressure steadily descended until he finally expired on the morning of May 11. The final diagnosis was generalized malignant melanoma, complicated by pneumonitis.
Fig.
3.
Summary and Conclusions A case of a malignant melanoma in a 51-year-old white man has been presented; it had metastasized to the mandible, and manifested itself in the form of a peripheral tumor, following the extraction of a tooth. Boyd,l in his discussion of the melanoma, makes some rather pertinent remarks. He recognizes that “a mole, exposed to long continued irritation, friction, etc., is apt to become malignant, especially on the face, back, or foot.” He, further, states : “NO tumor presents a more varied picture than the melanoma, and it is not too much to say that it may simulate a carcinoma, Pigmentation is usually sarcoma, endothelioma, and even a lymphosarcoma. marked, but this cannot be regarded as an invaluable criterion, and the diagnosis
242
LEONARD
I.
BLUESTONE
may have to be made from the histologic picture without the assistance of melanin. ” In this particular instance, it, has been demonstrated that, the primary, as well as the mctastatic. involvement were nonpigmented in character, and t’here was very litt,le difference in the comparative histologic pictures. Regarding spread, Boy-d’ significantly adds: “A melanoma is important not because of any local disturbance it produces, for it usually remains small. It kills by producing widespread metastasis. ” The incidence of metastasis to bone from other primary melanotic lesions has been variously reported. Thorna quotes a study of Geschickter and Copeland (1936) which brought out that 1.07 per cent of melanomas cause metastasis to bone. The findings of Dr. T. de Cholnoky in the series of the Postgraduate Hospital of Columbia University reveal 2 cases of melanoma involving the mandible from a series of 110 cases of melanoma. a research study presently being conducted by Dr. George T. Pack, working in collaboration wit,11Dr. Robert Sherman, provides the startlingly high figure of 49 per cent of melanotic tumors metastasizing to bone, based on post-mortem examinations at Memorial Hospital for the past twenty-five years. This would suggest, that the great majority of unsuspected metastases are overlooked in the absence of detailed post-mortem examination. Worthy of mention is the fact that, despite the high incidence of bone involvement in Dr. Pack’s series, he did not encounter a single case which involved the mandible. In any event, reports of metastasis to the mandible have been exceedingly rare, and, generally speaking, occur late in the course of the disease. Particularly noteworthy was the extreme rapidity of growt,h, and widespread involvement of the melanoma, in its terminal stages. It would appear in this instance that the dental extraction opened new blood channels for further invasion, although the patient was completely ravaged by the disease at the time the extraction was performed, so that t.he fatal prognosis was in no way altered. The central nervous system was involved by direct extension. Brain metastasis was evidenced by the clinical findings involving the third, fourth, fifth, sixth, and seventh cranial nerves. Gradually an involvement of the peripheral nerves was manifest in the form of paraplegia, numbness of the mandible, and facial Lung and liver involvement has also been not.ed, so that the paralysis. metastasis to the mandible is readily visualized as but one link in the entire sequence of events. An illustration of a case reported by the Sew York Institute of Clinical Oral Pathology is shown in Fig. 3.* References 1934, Lea & Febiger. Textbook of Pathology, ed. 2, Philadelphia, 1. Boyd, Wm.: Oral Pathology, ed. 2, St. Louis, 1944, The C. V. Mosby Company. 2. Thoma, K. K.: July, 1952. 3. Pack, George T.: Personal communication, 98 FORT GREENE
PLACE.
*A chart from an exhibit entitled “Local at the American Dental Association ScientiAc 1939.
and Systemic and Health
Aspects Exhibit
of Oral Lesions” shown Section in Milwaukee in
MELANOMA
METASTATIC
TO THE MANDIBLE
Report of a Case LEONARD
I.
B.S., D.D.S.,*
BI~UESTONE,
BROOKLYN,
N.
Y.
T
HIS is the case of a 51-year-old white man, married, a self-employed sign painter by trade, whose chief complaint was a growth of the lower left gingivae. The patient had been bedridden for approximately four months prior to my visit. The lower left second premolar was described as loose and pyorrhetic and had been extracted under local anesthesia by the family dentist at t’he bedside, about one week previously. Bilateral numbness of the mandible was first observed by the patient about three or four days prior to the extraction. The lesion in question was first observed about one day following the removal of the tooth, at which time it was seen to be about the size of a pea, and protruding from the orifice of the socket. It grew larger in size, finally preventing occlusion of the teet,h, and interfering with mastication. Examination at the bedside revealed a pallid, waxy-looking patient showing marked debilitation. He was paraplegic, and had marked ptosis of the left eyelid. Extraorally, the lips were about 2 cm. apart at the midline, and there was marked bulging of the lower left lip at the commissure. In the left oral vestibule, a bluish mass was readily visualized “in situ. ” Intraoral examination revealed a growth, about the size of a walnut, elliptical in shape with the long axis anteroposteriorly. It appeared to be attached to the crest of the alveolar ridge, distal to the left lower cuspid. The lesion was characterized by bluish coloration of its distal surface. There was some hemorrhage and dried blood clots at the site of contact of the opposing tooth. The surface of the lesion was smooth and firm; it was somewhat fluctuant to touch. The mass was freely movable at its attachment, and nonpainful on manipulation. There appeared to be a line of demarcation at the periphery of its attachment, but no demonstrable pedicle. There was some suppuration from the free margin of the gingiva, at the anterior extremity of the lesion. The mouth was in a generally unhygienic condition, and the tongue abnormally dry. The patient was edentulous, with the exception of the presence of 432
1 J
5
3 23’
The edentulous
ridge
distal
to the lower left cuspid was
edematous and fluctuant. Submaxillary and submental lymph nodes were only moderately palpable. The past medical history is quite significant. In October, 1949, the patient consulted his family physician, complaining of a sore on his back of approximately three months’ duration. Examination at that time revealed several small moles distributed over the lumbar area. One brown mole, in particular, of which the patient complained, was described as having a fibroma-like mass *Oral
Surgeon,
Wyckoff
Heights
Hospital. 237
238
LEONARD
1. BLUESTONE
hanging from its center by a long stalk. This entire mass was completely removed by electrosurgery on Oct. 31, 1949, and the specimen submitted t,o the laboratory for biopsy examination. The pathologist* reported a junction type nevus, with evidence of malignant change (nevocarcinoma). The wound was kept under close observat,ion during repeated visits over a six-month postoperative period, at, the conclusion of which the surgeon reported a red, slightly raised scar, with complete healing. In October, 1951, two years following the removal of t,he original lesion, a mass was observed about 4 inches above the healed scar. This was removed by scalpel surgery, and the specimen again On this occasion, the pathologist’s”* report submitted for biopsy examination. was as follows : “Tissue from chest wall ; non-pigmented melanoblastoma.” This operation was followed np in Januaqv, 1952, by a radical dissection and exploration of the subcutaneous tissue of the back. The microscopic examination of this tissue was negative for tumor cells, but, exhibited only what was described as a foreign body tissue reaction. In February, 1952, the patient ‘S back pain became progressively more severe, and paraplegic symptoms were manifest. Finally, on March 12, 1952, a neurosurgeon performed a thoracolumbar laminectomy, with removal of extradural and extravertebral tumor mass, to relieve spinal cord compression. The patient was then discharged from the hospital, being beyond surgical help, and confined to bed at home, due to his paraplegia. With this history as a background, I decided, in consultation with the attending physician and the family dentist,, that removal of the oral mass was indicated, solely to provide the patient with symptomatic relief, and to allay his increasing anxiety. Thereupon, the following operation was performed. Under mandibular conductive anesthesia, an incision was made down to the bone, on the labial aspect, slightly below the periphery of the tumor mass, to allow a margin of safety. This incision was extended completely around the border of the tumor, freeing it from its attachment with the aid of mucoperiosteal elevators, A second incision was made along the crest of the alveolar ridge, for ahont 4 cm. posterior to t,he distal extremity of the tumor. A wedgeshaped section of tissue from this area, in addition to the entire tumor mass, were submitted for microscopic study. The soft tissues were retracted lingually and buccally, and carefully explored for underlying tumor tissue. B significant finding was that no periosteum was discernible, although the outer plate of bone appeared solid and of normal consistency. The socket of the recentI> extracted tooth was filled with a well-organized blood clot. The tumor mass itself, while being excised, resembled a mass of lipoid tissue, and the lips of The tissues were the wound billowed apart, following the initial incision. brought into good apposition, and the wound completely closed with interreport was as follows : Markedly anaplastic rupted sutures. The pathologist’s**” tumor compatible with malignant melanoma. Photomierographs of the oral metastasis of this malignant melanoma are illustrated in Fig. 1, A and B. *Dr. Hospital. **Dr. ***Dr.
Charles
I?. Sims,
Senior
Dermatopathologist,
David Grayzel. Chief Pathologist. Margit Freund, Pathologist, New
Skin
and
Cancer
Brooklyn Jewish Hospital. York Institute of Clinical
Oral
Unit
of
Pathology.
Bellevue
MALIGNANT
MELANOMA
METASTATIC
TO
MANDIBLE
239
3 k
240
IxoNARl)
1. IKlxS'I'oSE
On the evening of the day of operation (May 9, 1952), the patient was reported as being in good condit,ion and resting comfortably. The following morning, however, he hecamc comatose and cl>-spneic, and was immediately hospitalized. The physical findings at the time of admission were as follows: Temperature, IO2 ; respiration, 40; pulse, 96; blood pressure, IOO/SO ; palpable mass on the right flank, left ptosis, left pupil dilated, left facial paralysis, left Homer’s syndrome, &es in chest, liver markedly enlarged. The admission diagnosis was malignant melanoma, metastat,ic to SII~CUtaneous tissue, lungs, liver, brain, spinal cord, mandible,
Fig. 2.
X-rays
taken at the time of admission revealed the following*
:
1. Anteropostwior and lcrteral erarnino.tion of the thorax: Both lung fields are the sites of extensive nodular infiltrative change. The nodules measure approximately 1 cm., and are widely disseminated throughout, both lung fields. Bilateral pleural effusion is present. Conclusion : Multiple nodular infiltrative disease, accompanied by bilateral pleural effusion, probably on the basis of metastatic neoplasm. 2. Examination of the left side of the mandible: The left side of the mandible is entirely edentulous ; an area of diminished density is demonstrated along the gingival margin, and there appears to be some interruption of the cortex at this point. The radiograph of the left side of the mandible is reproduced in Fig. 2. Oxygen was administered via mask, The patient was at this time moribund. and later by tent. Demerol and barbiturates were administered for sedation. *Dr.
Jerome
Zwanger,
Radiologist,
Long
Island
College
Hospital.
MALIGNANT
MELANOMA
RIETASTATIC
TO
MANDIELE
241
His blood pressure steadily descended until he finally expired on the morning of May 11. The final diagnosis was generalized malignant melanoma, complicated by pneumonitis.
Fig.
3.
Summary and Conclusions A case of a malignant melanoma in a 51-year-old white man has been presented; it had metastasized to the mandible, and manifested itself in the form of a peripheral tumor, following the extraction of a tooth. Boyd,l in his discussion of the melanoma, makes some rather pertinent remarks. He recognizes that “a mole, exposed to long continued irritation, friction, etc., is apt to become malignant, especially on the face, back, or foot.” He, further, states : “NO tumor presents a more varied picture than the melanoma, and it is not too much to say that it may simulate a carcinoma, Pigmentation is usually sarcoma, endothelioma, and even a lymphosarcoma. marked, but this cannot be regarded as an invaluable criterion, and the diagnosis
242
LEONARD
I.
BLUESTONE
may have to be made from the histologic picture without the assistance of melanin. ” In this particular instance, it, has been demonstrated that, the primary, as well as the mctastatic. involvement were nonpigmented in character, and t’here was very litt,le difference in the comparative histologic pictures. Regarding spread, Boy-d’ significantly adds: “A melanoma is important not because of any local disturbance it produces, for it usually remains small. It kills by producing widespread metastasis. ” The incidence of metastasis to bone from other primary melanotic lesions has been variously reported. Thorna quotes a study of Geschickter and Copeland (1936) which brought out that 1.07 per cent of melanomas cause metastasis to bone. The findings of Dr. T. de Cholnoky in the series of the Postgraduate Hospital of Columbia University reveal 2 cases of melanoma involving the mandible from a series of 110 cases of melanoma. a research study presently being conducted by Dr. George T. Pack, working in collaboration wit,11Dr. Robert Sherman, provides the startlingly high figure of 49 per cent of melanotic tumors metastasizing to bone, based on post-mortem examinations at Memorial Hospital for the past twenty-five years. This would suggest, that the great majority of unsuspected metastases are overlooked in the absence of detailed post-mortem examination. Worthy of mention is the fact that, despite the high incidence of bone involvement in Dr. Pack’s series, he did not encounter a single case which involved the mandible. In any event, reports of metastasis to the mandible have been exceedingly rare, and, generally speaking, occur late in the course of the disease. Particularly noteworthy was the extreme rapidity of growt,h, and widespread involvement of the melanoma, in its terminal stages. It would appear in this instance that the dental extraction opened new blood channels for further invasion, although the patient was completely ravaged by the disease at the time the extraction was performed, so that t.he fatal prognosis was in no way altered. The central nervous system was involved by direct extension. Brain metastasis was evidenced by the clinical findings involving the third, fourth, fifth, sixth, and seventh cranial nerves. Gradually an involvement of the peripheral nerves was manifest in the form of paraplegia, numbness of the mandible, and facial Lung and liver involvement has also been not.ed, so that the paralysis. metastasis to the mandible is readily visualized as but one link in the entire sequence of events. An illustration of a case reported by the Sew York Institute of Clinical Oral Pathology is shown in Fig. 3.* References 1934, Lea & Febiger. Textbook of Pathology, ed. 2, Philadelphia, 1. Boyd, Wm.: Oral Pathology, ed. 2, St. Louis, 1944, The C. V. Mosby Company. 2. Thoma, K. K.: July, 1952. 3. Pack, George T.: Personal communication, 98 FORT GREENE
PLACE.
*A chart from an exhibit entitled “Local at the American Dental Association ScientiAc 1939.
and Systemic and Health
Aspects Exhibit
of Oral Lesions” shown Section in Milwaukee in