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Metastatic Carcinoma of the Jaws
M etastatic carcinom a of the jaw s
H en ry M. C h e rric k , DDS, MSD, Los A ngeles D o nald D em kee, DDS, W ooster, O hio
M e tastatic carcin o m a of the jaw s is not fre q u e n tly seen by th e d e n tis t; but because it may be th e firs t clin ic a l sym ptom o f an undiscovered m a lig n a n cy at a d is ta n t site, it is im p o rta n t th a t the d e n tis t be aw are o f its sig n ifica n ce . A report of a case o f b i lateral m etastatic carcinom a o f the m a n d ib le il lu strates the s ym p to m a to lo g y of th is disease.
commonly affected sites. Radiographically, these lesions may appear as osteolytic (bone destructive) or osteoplastic (bone forming).
Report of case
Malignant neoplasms have the capacity to me tastasize to the bones or soft tissues of the jaws from any primary site in the body. These metas tatic carcinomas of the jaw do not occur fre quently; but because they may be the first clin ical symptom of an undiscovered malignancy at a distant site, their discovery is highly sig nificant. Malignancies from kidneys, breast, prostate, lung, thyroid, testes, and ovaries have a special predilection for metastasizing to the skeleton. The mandible is more commonly involved with metastatic lesions than is the maxilla, and the mandibular molar and premolar are the most
A 47-year-old white woman sought treatment for paresthesia of the right side of her lower lip; the paresthesia had been present for one day. A review of her medical history revealed a right radical mastectomy in July 1965 for carcinoma of the breast. She had received postoperative X-ray therapy and was asymptomatic until March 1970, when she developed lower back pain. A skull and long bone skeleton survey re vealed metastatic disease in the spine and skull. At this time, she received 4,000 Roentgens in ten treatments to the lumbar spine. In April 1971, she underwent a prophylactic hypophysectomy. The patient has been taking 50 mg of cortisone acetate per day since the hypophysectomy. Physical examination revealed mild buccal expansion in the region of the mandibular right first molar. The patient stated that she had had some pain and drainage from the right side of her lower lip the year before the examination; at this time, there was paresthesia of this area.
Fig 1 ■ Radiograph of mandibular right first molar area show ing external resorption and 1.5 cm radlolucent area surround ing the roots.
Fig 2 ■ Radiograph of mandibular left first molar area exhibit ing three nondistinct radiolucent areas below and distal to the first molar.
180 ■ JAD A, V o l. 87, Ju ly 1973
The left side of the mandible was asymptomatic. Intraoral radiographs revealed a 1.5 cm radiolucent lesion surrounding the distal root of the mandibular right first molar (Fig 1). In the re gion of the mandibular left first molar, there were indistinct 0.5 cm radiolucent areas just be low the mandibular first molar (Fig 2). A ten tative diagnosis of metastatic disease was made at this time. The patient was heavily sedated intravenous ly, and local anesthesia was administered; the mandibular first molars were extracted, and the sockets were curetted thoroughly. Examination of the teeth showed partial resorption of the apexes of the distal roots of both first molars. The teeth and soft tissue were submitted for pathologic examination (Fig 3). ■ Pathologic report: Diagnosis: Right and left mandible, metastatic adenocarcinoma. The submitted specimen is highly suggestive of me tastatic carcinoma from the breast. ■ Follow-up: The patient was referred to an oncologist and was immediately given 3,500 rads to the left and right sides of the mandible. The patient is currently receiving 6 mg of Leukeron and 2.5 gm of methotrexate daily. In July 1972, a small lump was observed on her fore head; it is probably a metastatic carcinoma.
Discussion Secondary involvement of the jaws by meta static disease is certainly not common. Costigliono and Rominger1 found only 176 reported instances in the world literature from 1902 to 1953. Cash and co-workers2 have found an addi tional 37 cases up to 1961. Because most post mortem examinations do not include thorough oral examinations, these figures are probably misleading; metastasis to the jaws is probably much more common than it appears to be. Past statistics reveal that these organs, in or der of frequency, are the most common sites of origin of secondary jaw tumors: breast, lung, large intestine, prostate and kidney, thyroid gland, and testes. With the great increase in the incidence of carcinoma of the lungs, new sta tistics will probably reveal that carcinoma of the lungs is the most common tumor to metastasize to the jaws. Metastasis from the lower portions of the
Fig 3 ■ Mandibular right first molar exhibiting resorption, and associated soft tissue specimens.
body to the jaws without filtration by the lungs has been difficult to explain. In 1959, Stockdale3 discussed the importance of the vertebral ve nous plexus in this mechanism of metastasis. The mandibular posterior body of the man dible is the most common site of metastasis to the jaws. It has been suggested that metastatic emboli need a favorable environment in which to propagate; the high incidence of metastasis in the posterior body of the mandible is prob ably due to the large amounts of hematopoietic bone marrow in that area. Clinical signs and symptoms of secondary tu mors vary and may even be missing. The most common symptoms are slight discomfort or pain followed by paresthesia or anesthesia of the lip or chin secondary to mandibular nerve involve ment. Teeth in the affected area may become extruded, or roots may become resorbed. Cash2 reported that definite swelling or expansion is almost always found. The prognosis in secondary tumor involve ment of the jaws is extremely poor. Usually other sites are involved, or the primary carci noma is found to be inoperable.
Dr. Cherrick is chairman, department of oral pathology, Uni versity of California at Los Angeles School of Dentistry, Los Angeles, 90024. Dr. Demkee is a private practitioner, 250 E Ohio Bldg, Wooster, Ohio 44691. 1. Castigliono, S.G., and Rominger, C.J. Metastatic malig nancy of the Jaws. Am J Surg 87:496 April 1954. 2. Cash, C.D.; Royer, R.Q.: and Dahlin, D.C. Tumors of the jaws. Oral Surg 14:897 Aug 1961. 3. Stockdale, C.R. Metastatic carcinoma of the jaws second ary to primary carcinoma of the breast. Oral Surg 12:1095 Sept 1959. C h e rric k — D em kee: M E TA S T A TIC C AR C IN O M A OF TH E JA W S ■ 181
H en ry M. C h e rric k , DDS, MSD, Los A ngeles D o nald D em kee, DDS, W ooster, O hio
M e tastatic carcin o m a of the jaw s is not fre q u e n tly seen by th e d e n tis t; but because it may be th e firs t clin ic a l sym ptom o f an undiscovered m a lig n a n cy at a d is ta n t site, it is im p o rta n t th a t the d e n tis t be aw are o f its sig n ifica n ce . A report of a case o f b i lateral m etastatic carcinom a o f the m a n d ib le il lu strates the s ym p to m a to lo g y of th is disease.
commonly affected sites. Radiographically, these lesions may appear as osteolytic (bone destructive) or osteoplastic (bone forming).
Report of case
Malignant neoplasms have the capacity to me tastasize to the bones or soft tissues of the jaws from any primary site in the body. These metas tatic carcinomas of the jaw do not occur fre quently; but because they may be the first clin ical symptom of an undiscovered malignancy at a distant site, their discovery is highly sig nificant. Malignancies from kidneys, breast, prostate, lung, thyroid, testes, and ovaries have a special predilection for metastasizing to the skeleton. The mandible is more commonly involved with metastatic lesions than is the maxilla, and the mandibular molar and premolar are the most
A 47-year-old white woman sought treatment for paresthesia of the right side of her lower lip; the paresthesia had been present for one day. A review of her medical history revealed a right radical mastectomy in July 1965 for carcinoma of the breast. She had received postoperative X-ray therapy and was asymptomatic until March 1970, when she developed lower back pain. A skull and long bone skeleton survey re vealed metastatic disease in the spine and skull. At this time, she received 4,000 Roentgens in ten treatments to the lumbar spine. In April 1971, she underwent a prophylactic hypophysectomy. The patient has been taking 50 mg of cortisone acetate per day since the hypophysectomy. Physical examination revealed mild buccal expansion in the region of the mandibular right first molar. The patient stated that she had had some pain and drainage from the right side of her lower lip the year before the examination; at this time, there was paresthesia of this area.
Fig 1 ■ Radiograph of mandibular right first molar area show ing external resorption and 1.5 cm radlolucent area surround ing the roots.
Fig 2 ■ Radiograph of mandibular left first molar area exhibit ing three nondistinct radiolucent areas below and distal to the first molar.
180 ■ JAD A, V o l. 87, Ju ly 1973
The left side of the mandible was asymptomatic. Intraoral radiographs revealed a 1.5 cm radiolucent lesion surrounding the distal root of the mandibular right first molar (Fig 1). In the re gion of the mandibular left first molar, there were indistinct 0.5 cm radiolucent areas just be low the mandibular first molar (Fig 2). A ten tative diagnosis of metastatic disease was made at this time. The patient was heavily sedated intravenous ly, and local anesthesia was administered; the mandibular first molars were extracted, and the sockets were curetted thoroughly. Examination of the teeth showed partial resorption of the apexes of the distal roots of both first molars. The teeth and soft tissue were submitted for pathologic examination (Fig 3). ■ Pathologic report: Diagnosis: Right and left mandible, metastatic adenocarcinoma. The submitted specimen is highly suggestive of me tastatic carcinoma from the breast. ■ Follow-up: The patient was referred to an oncologist and was immediately given 3,500 rads to the left and right sides of the mandible. The patient is currently receiving 6 mg of Leukeron and 2.5 gm of methotrexate daily. In July 1972, a small lump was observed on her fore head; it is probably a metastatic carcinoma.
Discussion Secondary involvement of the jaws by meta static disease is certainly not common. Costigliono and Rominger1 found only 176 reported instances in the world literature from 1902 to 1953. Cash and co-workers2 have found an addi tional 37 cases up to 1961. Because most post mortem examinations do not include thorough oral examinations, these figures are probably misleading; metastasis to the jaws is probably much more common than it appears to be. Past statistics reveal that these organs, in or der of frequency, are the most common sites of origin of secondary jaw tumors: breast, lung, large intestine, prostate and kidney, thyroid gland, and testes. With the great increase in the incidence of carcinoma of the lungs, new sta tistics will probably reveal that carcinoma of the lungs is the most common tumor to metastasize to the jaws. Metastasis from the lower portions of the
Fig 3 ■ Mandibular right first molar exhibiting resorption, and associated soft tissue specimens.
body to the jaws without filtration by the lungs has been difficult to explain. In 1959, Stockdale3 discussed the importance of the vertebral ve nous plexus in this mechanism of metastasis. The mandibular posterior body of the man dible is the most common site of metastasis to the jaws. It has been suggested that metastatic emboli need a favorable environment in which to propagate; the high incidence of metastasis in the posterior body of the mandible is prob ably due to the large amounts of hematopoietic bone marrow in that area. Clinical signs and symptoms of secondary tu mors vary and may even be missing. The most common symptoms are slight discomfort or pain followed by paresthesia or anesthesia of the lip or chin secondary to mandibular nerve involve ment. Teeth in the affected area may become extruded, or roots may become resorbed. Cash2 reported that definite swelling or expansion is almost always found. The prognosis in secondary tumor involve ment of the jaws is extremely poor. Usually other sites are involved, or the primary carci noma is found to be inoperable.
Dr. Cherrick is chairman, department of oral pathology, Uni versity of California at Los Angeles School of Dentistry, Los Angeles, 90024. Dr. Demkee is a private practitioner, 250 E Ohio Bldg, Wooster, Ohio 44691. 1. Castigliono, S.G., and Rominger, C.J. Metastatic malig nancy of the Jaws. Am J Surg 87:496 April 1954. 2. Cash, C.D.; Royer, R.Q.: and Dahlin, D.C. Tumors of the jaws. Oral Surg 14:897 Aug 1961. 3. Stockdale, C.R. Metastatic carcinoma of the jaws second ary to primary carcinoma of the breast. Oral Surg 12:1095 Sept 1959. C h e rric k — D em kee: M E TA S T A TIC C AR C IN O M A OF TH E JA W S ■ 181