- Email: [email protected]
Metastatic Mucous-Producing Adenocarcinoma of the Gingiva
CLINICAL
REPORTS
Metastatic mucous-producing adenocarcinoma of the gingiva Charles E. B arr, DDS H arry Dym, DDS Leonard A. W eingarten, MD
A n unusual metastasis o f adenocarcinom a o f the lung to the gingival m ucosa in a 75-year-old m an is reported. The case p resents an interesting differential clinical assessm ent as the gingival lesions seem to be o f local nature and involve a com bined endodontic-periodontic causation.
M
etastases of malignant tumors to the oral cavity, although they do occur, are infrequent; however, metastases confined to the oral soft tissues are a rare phenomenon. According to Meyer and Shklar,1 in their review of 2,400 cases of oral cancer, only 1% of tumors of hard tis sues (maxilla and mandible) were of metastatic origin, and only 0.1% of tumors were confined to the oral mu cosa and represented metastatic le sions. An unusual m etastatic gingival tumor arising from a pulmonary pri mary adenocarcinoma is described.
the patient did say that he had smoked two packages of cigarettes a day for 28 years. An X ray of the chest showed a rather large mass with irregular margins in the right lower lobe. The patient was admitted to the Beth Is rael Medical Center for extensive evalua tion of the condition. Shortly after admis sion, a bronchoscopy and a bronchial bi opsy was done; they proved to be negative. However, bronchial washings disclosed malignant cells compatible with a diag nosis of adenocarcinoma. A bone scan also was negative. Additionally, a liver and brain scan did not show any metastases. The patient was treated with irradiation in late April with 5,000 rads given for five weeks. In the middle of May, the patient was seen in the dental clinic. An enlarged,
smooth, red pedunculated mass, measuring 1.0 x 0.5 cm, was apparent. The lesion was soft and attached to the alveolar mucosa; it was buccal to the mandibular left lateral in cisor (Fig 1). A year and a half before admission, both the left canine and left lateral incisor had been treated endodontically and were re stored with veneer crowns by a general den tist (Fig 2). Radiographically, there ap peared to be generalized loss of bone and a periapical area at the apex of the mandibu lar left lateral incisor. Depth of the pocket was 3 mm around both the canine and lat eral incisor. Clinically, the lesion resem bled a pyogenic granuloma, periodontal abscess, or peripheral giant cell granuloma. An excisional biopsy of the peduncu lated mass was done with use of local anes thetic. Underlying bone was intact.
Fig 1 ■ Clinical pho tograph of gingival tumor before biopsy.
R e p o rt o f c a s e A 75-year-old white man was seen by a physician in April 1977 because of persis tent dry cough of ten weeks’ duration. The medical history was noncontributory, but JADA, Vol. 101, July 1980 ■53
CLINICAL
REPORTS
metastatic lesion can be palliative and may possibly effect a cure. In an extensive review of the litera ture, Hatziotis and others5 found only 48 cases of metastasis to oral soft tis sues. The tongue is the most frequent site of metastatic lesions; the buccal mucosa is second although the lung is the most common primary site and the kidney is next in frequency.5 The metastases probably spread from the lungs into a branch of one of the pul monary veins. From there, they spread into the systemic circulation via the left side of the heart.6 It is also impor tant to notice that, although swelling, pain, looseness of teeth, and pares th esia7 are signs associated with malignant lesions of the oral cavity, in many instances, the patient may not have any of these symptoms. Fig 2 ■ Radiograph of area near mandibular left canine. Notice periapical radiolucent area on lateral incisor, which suggests lesion of inflam matory origin.
T h e h is to p a th o lo g ic d ia g n o s is of mucous-producing adenocarcinoma (Fig 3) was consistent with the clinical diagnosis of primary pulmonary adenocarcinoma. Th e p a tie n t’s c o n d itio n w orsen ed rapidly and he died in September 1977.
D is c u s s io n
A review of the literature shows that only 22 cases2 of distant metastasis to gingiva without involvement of bone have been reported. This fact and the clinical observation that the gingival lesions resembled pyogenic granu lo m as or p e r ip h e r a l g ia n t c e ll granuloma make it imperative that metastatic carcinoma be included in the differential diagnosis of such gin gival masses. According to Bhaskar,3 approxi mately 33% of oral secondary tumors represent the initial indication of the existence of a primary tumor. Cash4 says that, if the primary site is recog nized at an early stage and treated, then surgery and irradiation of the oral
54 ■JADA, Vol. 101, July 1980
S u m m a ry
A rare example of metastasis to the gingival mucosa in a 75-year-old man has been reported. The oral lesion ap peared as a red, raised, painless lesion adjacent to the mandibular lateral in cisor that had been treated endodontically and had a periapical lesion that was seen during radiographic exami nation. C linically, the differential d ia g n o s is in c lu d e d p y o g e n ic granuloma, periapical periodontal abscess, and metastatic tumor. The gingival lesion may occasion ally be the first sign of a neoplasm in a distant organ. It is crucial then, that an adequate biopsy be done to arrive at an accurate diagnosis.
The authors thank Michael Grimaldi, Freida Dym, and Osmay Yalis for their help in prepara tion of the manuscript. Dr. Barr is director of dentistry and attending, Beth Israel Medical Center, 10 Nathan D. Perlman PI, New York, 10003. Dr. Dym is a second-year general dental resident, Beth Israel Medical Cen ter. Dr. Weingarten is associate attending, Beth Is rael Medical Center, and assistant clinical profes sor, department of medicine, Mount Sinai School of Medicine. Address requests for reprints to Dr. Barr.
Fig 3 ■ High-power photomicrograph of speci men shows presence of numerous mitotic figures and cellular pleomorphism. Nuclei are round, hyperchromatic, and enlarged. Cytoplasm was clear and reacted positively with mucin stain, indicative of adenocarcinoma (H & E, original magnification x280).
1. Meyer, I., and Shklar, G. Malignant tumors m etastatic to m outh and jaw s. O ral Surg 20(9):350-362, 1965. 2. Perlmutter, S.; Buchner, A.; and Smukler, H. Metastasis to the gingiva. Report of a case of metastasis from the breast and review of the litera ture. Oral Surg 38(5):749-754, 1974. 3. Bhaskar, S.N. Oral manifestations of metas tatic tumors. Postgrad Med 49(4):155-158,1971. 4. Cash, C.D.; Royer, R.Q.; and Dahlin, D.C. M etastatic tum ors of the jaw s. Oral Surg 14(8):897-905, 1961. 5. Hatziotis, J.C.; Constantinidou, H.; and Papanayotou, P.H. Metastatic tumors of the oral soft tissue. Review of the literature and report of a case. Oral Surg 36(10):544-550,1973. 6. Solomon, M.P., and others. Metastatic le sions to the oral soft tissues. J Oral Surg 33(1):5356, 1975. 7. Lund, B.A.; Moertel, C.G.; and Gibilisco, J.A. Metastasis of gastric adenocarcinoma to oral mu cosa. Oral Surg 25(6):805-809, 1968.
REPORTS
Metastatic mucous-producing adenocarcinoma of the gingiva Charles E. B arr, DDS H arry Dym, DDS Leonard A. W eingarten, MD
A n unusual metastasis o f adenocarcinom a o f the lung to the gingival m ucosa in a 75-year-old m an is reported. The case p resents an interesting differential clinical assessm ent as the gingival lesions seem to be o f local nature and involve a com bined endodontic-periodontic causation.
M
etastases of malignant tumors to the oral cavity, although they do occur, are infrequent; however, metastases confined to the oral soft tissues are a rare phenomenon. According to Meyer and Shklar,1 in their review of 2,400 cases of oral cancer, only 1% of tumors of hard tis sues (maxilla and mandible) were of metastatic origin, and only 0.1% of tumors were confined to the oral mu cosa and represented metastatic le sions. An unusual m etastatic gingival tumor arising from a pulmonary pri mary adenocarcinoma is described.
the patient did say that he had smoked two packages of cigarettes a day for 28 years. An X ray of the chest showed a rather large mass with irregular margins in the right lower lobe. The patient was admitted to the Beth Is rael Medical Center for extensive evalua tion of the condition. Shortly after admis sion, a bronchoscopy and a bronchial bi opsy was done; they proved to be negative. However, bronchial washings disclosed malignant cells compatible with a diag nosis of adenocarcinoma. A bone scan also was negative. Additionally, a liver and brain scan did not show any metastases. The patient was treated with irradiation in late April with 5,000 rads given for five weeks. In the middle of May, the patient was seen in the dental clinic. An enlarged,
smooth, red pedunculated mass, measuring 1.0 x 0.5 cm, was apparent. The lesion was soft and attached to the alveolar mucosa; it was buccal to the mandibular left lateral in cisor (Fig 1). A year and a half before admission, both the left canine and left lateral incisor had been treated endodontically and were re stored with veneer crowns by a general den tist (Fig 2). Radiographically, there ap peared to be generalized loss of bone and a periapical area at the apex of the mandibu lar left lateral incisor. Depth of the pocket was 3 mm around both the canine and lat eral incisor. Clinically, the lesion resem bled a pyogenic granuloma, periodontal abscess, or peripheral giant cell granuloma. An excisional biopsy of the peduncu lated mass was done with use of local anes thetic. Underlying bone was intact.
Fig 1 ■ Clinical pho tograph of gingival tumor before biopsy.
R e p o rt o f c a s e A 75-year-old white man was seen by a physician in April 1977 because of persis tent dry cough of ten weeks’ duration. The medical history was noncontributory, but JADA, Vol. 101, July 1980 ■53
CLINICAL
REPORTS
metastatic lesion can be palliative and may possibly effect a cure. In an extensive review of the litera ture, Hatziotis and others5 found only 48 cases of metastasis to oral soft tis sues. The tongue is the most frequent site of metastatic lesions; the buccal mucosa is second although the lung is the most common primary site and the kidney is next in frequency.5 The metastases probably spread from the lungs into a branch of one of the pul monary veins. From there, they spread into the systemic circulation via the left side of the heart.6 It is also impor tant to notice that, although swelling, pain, looseness of teeth, and pares th esia7 are signs associated with malignant lesions of the oral cavity, in many instances, the patient may not have any of these symptoms. Fig 2 ■ Radiograph of area near mandibular left canine. Notice periapical radiolucent area on lateral incisor, which suggests lesion of inflam matory origin.
T h e h is to p a th o lo g ic d ia g n o s is of mucous-producing adenocarcinoma (Fig 3) was consistent with the clinical diagnosis of primary pulmonary adenocarcinoma. Th e p a tie n t’s c o n d itio n w orsen ed rapidly and he died in September 1977.
D is c u s s io n
A review of the literature shows that only 22 cases2 of distant metastasis to gingiva without involvement of bone have been reported. This fact and the clinical observation that the gingival lesions resembled pyogenic granu lo m as or p e r ip h e r a l g ia n t c e ll granuloma make it imperative that metastatic carcinoma be included in the differential diagnosis of such gin gival masses. According to Bhaskar,3 approxi mately 33% of oral secondary tumors represent the initial indication of the existence of a primary tumor. Cash4 says that, if the primary site is recog nized at an early stage and treated, then surgery and irradiation of the oral
54 ■JADA, Vol. 101, July 1980
S u m m a ry
A rare example of metastasis to the gingival mucosa in a 75-year-old man has been reported. The oral lesion ap peared as a red, raised, painless lesion adjacent to the mandibular lateral in cisor that had been treated endodontically and had a periapical lesion that was seen during radiographic exami nation. C linically, the differential d ia g n o s is in c lu d e d p y o g e n ic granuloma, periapical periodontal abscess, and metastatic tumor. The gingival lesion may occasion ally be the first sign of a neoplasm in a distant organ. It is crucial then, that an adequate biopsy be done to arrive at an accurate diagnosis.
The authors thank Michael Grimaldi, Freida Dym, and Osmay Yalis for their help in prepara tion of the manuscript. Dr. Barr is director of dentistry and attending, Beth Israel Medical Center, 10 Nathan D. Perlman PI, New York, 10003. Dr. Dym is a second-year general dental resident, Beth Israel Medical Cen ter. Dr. Weingarten is associate attending, Beth Is rael Medical Center, and assistant clinical profes sor, department of medicine, Mount Sinai School of Medicine. Address requests for reprints to Dr. Barr.
Fig 3 ■ High-power photomicrograph of speci men shows presence of numerous mitotic figures and cellular pleomorphism. Nuclei are round, hyperchromatic, and enlarged. Cytoplasm was clear and reacted positively with mucin stain, indicative of adenocarcinoma (H & E, original magnification x280).
1. Meyer, I., and Shklar, G. Malignant tumors m etastatic to m outh and jaw s. O ral Surg 20(9):350-362, 1965. 2. Perlmutter, S.; Buchner, A.; and Smukler, H. Metastasis to the gingiva. Report of a case of metastasis from the breast and review of the litera ture. Oral Surg 38(5):749-754, 1974. 3. Bhaskar, S.N. Oral manifestations of metas tatic tumors. Postgrad Med 49(4):155-158,1971. 4. Cash, C.D.; Royer, R.Q.; and Dahlin, D.C. M etastatic tum ors of the jaw s. Oral Surg 14(8):897-905, 1961. 5. Hatziotis, J.C.; Constantinidou, H.; and Papanayotou, P.H. Metastatic tumors of the oral soft tissue. Review of the literature and report of a case. Oral Surg 36(10):544-550,1973. 6. Solomon, M.P., and others. Metastatic le sions to the oral soft tissues. J Oral Surg 33(1):5356, 1975. 7. Lund, B.A.; Moertel, C.G.; and Gibilisco, J.A. Metastasis of gastric adenocarcinoma to oral mu cosa. Oral Surg 25(6):805-809, 1968.