Metastatic adenocarcinoma of mandible

Oral SURGERY VOLUME

OralMEDICINE

NUMBER AND&al

JULY,

PATHOLOGY

24 1 1967

Operative oral surgery Metastatic adenocarcinoma of mandible Report

of a case

with

a confusing

history

and

symptoms

A

lthongh nlet.ast.atic adrnocarcinomas of the mantlihlr arc not rmc, the following ca.se is of particular interest hecause of the rapidity of its manifcstatio’ii, its concurrent, confusing symptoms, anal a wccnt, cwitribnt,ory tr'illlll~~l.

CASE

REPORT

On Feb. 5, 1965, a white 60.year-old Italian housewife was admitted to the hospital II> IIP~ physician for treatment of a possible viral pneumonia and for evaluation of a swelling over the right mandible. She was known to have hyp&cnsion, which was under fair control, and she also had a hypertrophic arthritis of t,he spiw. On *Tan. 1, 1965, the patient fell in the bathroom, striking her forehead and the right side of her mandible. Examination of those areas following the’ fxll rwcalt~l no serious injury. During the nest 3 weeks a swelling developed over the rigllt side of the mandiblr, with moderate discomfort (Fig. 1). The lower right first molar became slightly sensitive and loosr. and an area over the left frontal region became slightly swollen (, E’ig. 2). The patient felt, that the swelling over the mandible had decreased somewhat and that, there had been some bloody discharge into the mouth during the last 2 days. The patient’s physician asked for a consultation and examination by the oral surgeon on Feb. 8, 1965. X-ray films of the mandible made on the day of admission (first reportcxll as normal) revealed, on c~losc examination, a mild periodontal bone loss about the cervical portion of the teeth in the right mandible involving the bifurcation of the roots of the flrs~ and second molars. There was loss of the lamina dura about tire root ends of the first molar. The normal canwllous bone structure was lacking below an11 both mesial and ~listal to 111~ first molar. There was no evidence of fracture (Fig. 3). Examination revealed a rather firm, slightly tender swelling owr the right. rnan~lilllo 1

from the medal region to the angle of tile rrr;c~~(lil~lc a11411~1~~~ its lo\~~r lw~~d~~r. Esl~wmlly. the area revealed no discoloration or fluctuation. Oral esamina( ion wvcaled a full complemc~~~l of periodontally involved teeth. Tn the lower right vestibule thcx buccsl sulcus \\as oblitrratrxl by a rather firm, slightly boggy swelling of the nlucopc,riostPur,I, extending from the cuspi~i to the third molar area. The gingival margins :A the b~ux~:tl :\slwct were thi(~kenctl and un att~ached in the first molar area. ‘rherr was slight fluctuation. 7’11~ first molar WRS wnsitivc 10 p~ercussion. ZrnprcssiolL: Past periodontal root infection with wccnt c:cdral osteomyelitis: rwent sub periosteal abscess ; recent organizul subperiustwd Ilrmatonm from fall, with beginning liquc~faction. Following induction of mandibular nerve block anesthesia, an incision was ma& through the buccal mucoperiosteum in the first molar region and 2.0 ml. of serous, pal(b pink fluill

of right side of ma.ndil)lc, showing periodontal bonc~ 105s iuvolviux I$!/. ,i. H~wntgrnogram I)ifurcation of roots of first and swond molars, loss of lamina du7x about root rolls of first au11 nrohn. Tlrcw is no inrlivafion of molar, md loss of c~ancellous bone brlow prcmolars prriostitis.

\vas rvacuatecl with two or thrrc: small c~lumps of wsvous ulatc~rial. ‘1’11(~first tnc~lar I!ils (‘Straded. Introduction of a curctte into the apical arca uf tllc alwolus rrwalc~l no ~~ancrll~~us I)onr ant1 producctl no granu!xtions or purult,nt mKt&aI. A vuwttc introcluwtl tJlrougl1 tIlla Iwval incision revealed denudation of the cortical bone but, no bone excavation or ot~hcr carosion of the hone surface. A rubber drain was placed in the buwal in&ion. Subsequently the swelling did not subside but the patient was more comfortable. In viw she was ilisehargecl from the hosof the patient’s unhappy mental state and her insistewe, Ibital for office a.nd home care on Fch. 13, 1965. House caalls rc~vealrd no discharge from the iwision, but thcwt was a slight increase in tile swelling over the n~~ntliblo ant1 also t,he forohead. One week later x-ray examination agxin revealed loss of cancellous bone of the right 1t was thought that thcb suhpcriostc~al llematom:~ mxndiblr: and no witlonco of wquestration. 1,as undergoing organization and that curctt;tgc was indicated. Opercltion

1Tntler nerve block anesthesia, the drain was remorwl ant1 an incision ~2s mwle in tile buwal sulnus through the buccal mucoperiodwum f ram the wspiil to the third molar arca. The mucoperiostrum was found to be sepa.ratcil from tlw corlid bow over the vntirc awa :~ntl to Iwlom the lower border of the mandible. The bone surface was not porous. There was csu(latc~ was found. There were no wry little bleeding, and only a slight blood-stained granulations covering or adhering to tlrc surface of the mantiiblc, but under the surface of granulations the periosteum a mass of loosely attachctl clumps of pinkish gras, well-organized were found. These filled the suhprriostenl spave from the gingival margin to below t,he man(lible and from the cuspid to the angle of the mandible. Following curettage, 111~pwiostcum gauze lubriwtcvl witll felt unbroken and smooth. The wound was pwkecl wi tlr iotloform pctrolatum jelly. The c~sciscd tissue was sent for microscopic: diagnosis.

4

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0.1’. I!)ti;

Fig. 4. Photomicrograph of subperiosteal granulations removed from right mandiblr. TIuctlike structures lined with columnar epithelium are found in rather scant fibrous wnncctive tissue matrix. Even lowpower magnification gives impression of intestinal type of epithrlium. Epithelial ~~~11sare plcomorphic and h~pcrchromatic and revpal many niitot,i(* fipUW3.

grew progressively worse, and she died on April 3, 1965. An autopsy was performed, and the I’ostmortem diagnosis was carcinoma of the ascending colon, mctastatic to liver, lung, regional lymph nodes, and mandible.

CONCLUSION

The dkgnosis of this case was confused and orershaduwcd hy the history of ;I. recent fall, followed by swelling in the area,s of injury, dental pain in thcx arCa and sensitivity of the mandibular first molar, periodontal invol\-cment of the molars, s-ray evidence of bone dest,ruction and loss of the lamina dura ahout the root ends of t.he first molar, and the slight fluct.uat,ion demonstrahlc in the l~uccal swelling. It was thought that t,hc patient had s~ffrrd a suhperiostcal periodontal abscess with spontaneous drainage and a superimposed sul)periostral hematoma as the result of the injury sustained in the fall and that the hcmntoma had partly organized and partly liquefied. anSlllMt:ll~tiill .It n-as only after incision and drainage failed to prtdncr amount. of pus or infect.ed tissue aad the swellin, 07failed to subside that, furt hclr surgical investigation seemed to he indicated. There had heen not,hing in the pat.ient’s history to suggest tumor formation. The rapid development of the swellin, v following injury n,nd the relatively sliorl duration of t,he swelling seemed to negate such a prol)ahility. It was only a,f’tcxr wide incision and examination of the tissues removed during curettap that thaw was a strong suspicion of tumor growth. The rapid grow-th of this mass and the eoncurrent. growth of the mass in the frontal area d~iscount~ed such a tumors was not, weti diagnosis. The possibility of both masses bein, 07m&static c*onsidercd until aft.rr the pathologist’s report \vas rccci\-rd. It, is also significant that, the patient, gave no liist,or,v of a bowel ol)sti*u(~tion am1 that. there was no evidence of a pathologi(* cwndition of the colon. Adcnocarcinomas of the mandible, whc~thcr primary or mctasta.tic, aw USIIillly diffimlt to diagnose c~linically. 17 1.i Ihr>'id

Wh if n.cy Bldg.