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Seminoma metastatic to the maxilla
Oral pathology GENERAL SECTION
Seminoma metastatic to the maxilla Report
of a case
William C. Kranx, D.M.D.,* COLLEGE
OF DENTISTRY,
Lexington, Ky.
UNIVERSITY
OF
KEXTUCKY
T
esticular tumors comprise less than 1 per cent of all malignant tumors, and they usually occur between the second and fourt,h decades of 1ife.l Their greatest incidence is in patients between the ages of 29 and 34 ~-cars.~ Seminoma is a malignant tumor of the testis derived from the cells of the seminiferous tubules.” It is the most common of all testicular tumors, comprising 35 to 40 per cent of all testicular neoplasms.* The incidence of seminoma increases with age, being most frequent in the ages from -10 to 45 years”; 90 per cent are said to occur before the age of 50.” The tumor occurs rarely among Negroes6and has not been described in children.” Frequent extensive invasion of the body is possible through the lymphatics to the pelvic and abdominal nodes and to the lungs, liver, and other viscera by means of the bloodstream.7 Metastasis usually occurs within 6 months xfttrr the first symptoms appear but may not be evident for 2 or 3 years.‘. s Cut sections of the gross tumor resemble sarcoma in homogenous and fleshy consistency. Histologically, t,he appearance of t,hc tissue varies. The cellular arrangement may be tubular in the slow-growing tumors but diffuse in those which grow rapidly. They may closely rcsemblc sarcoma or enrcinoma. The tumor is generally recognized by its monocellularity, the cells being fairly large, round or cuboidal, and occasionally polyhedral, and usually uniform in size. The cell borders in most cases arc quite distinct. The cytoplasm is eithar clear or only lightly stained. The nucleoli may be present, hcin g slightly eosinophilic a.nd prominent. When arranged in irregular masses there is a. thin, fibrous tissue stroma dividing the tumor into lobules. Tn some tumors this stroma ma: be granulomatous or quite fibr0us.l. o The treatment of choice is excision of the tumor. The seminoma is the most QInstructor,
196
Department
of Oral
Surgery,
College
of Dentistry,
University
of Kentucky.
Volume Number
Xemin oma
21 2
radiosensitive of the testicular tumors, and potential metastatic areas of the pelvic and tional and will definitely improve the results The seminomas have the best prognosis prognosis generally remains good even when are present.l
197
postoperative roentgen therapy of abdominal lymph nodes is tradiof a simple orchidectomy.“’ of the testicular tumors, and the pelvic and abdominal metastases
CASE REPORT A 56.year-old white man was seen on Oct. 3, 1955, for diagnosis and treatment of a mass in the left maxilla. He had been treated by a dentist 2 weeks previously for moderate, diffuse teeth were removed at that time, but swelling of the upper left molar area. Roots of four the size of the mass had increased considerably in the interval. The patient was then referred for further treatment. Examination revealed a well-developed, well-nourished white man in no distress with a nontender maxillary mass extending from the midline to the left tuberosity and to the in&al third of the incisor teeth (Fig. 1). The left canine fossa and cheek showed fullness and induration, and there was moderate distortion of the lateral wall of the left nostril. The patient had chronic gingivitis, and many carious teeth were present. The oral hygiene was poor. There was no submaxillary or cervical lymphadenopathy.
A
B
Fig. I. a, A portion viewed in a mirror.
of
the
tumor
in
direct
front
view.
B, A portion
of
the
tumor
as
198
Kranx
O.S., O.M. February,
& 03. 1966
The patient’s previous medical history revealed that on July 27, 1955, he had undergone a right orchidectomy for a “growth” which had been present about one month. A mass in the lower abdomen was not explored. Hist.ologic diagnosis of the testicular growth was seminoma ; a clinical diagnosis of pelvic nodal metastasis was made and pelvic radiation was ordered. Radiation therapy was started on Aug. 5, 1955; this consisted of a 10 by 15 cm. port to the abdomen and posterior parts, 200 r daily, alternate sides on alternate days, for a total skin dose per area of 1,200 r. On Aug. 20, 1955, no masses were palpable. The patient was discharged on Aug. 21, 1955, and asked to return for further treatment as an outpatient. He did not return to his physician. He next presented with a dental probIcm. On the basis of the oral examination findings and the patient’s history, a clinical diagnosis of metastatie seminoma of the left maxilla was made. The patient was readmitted to the hospital on Oct. 4, 1955, for biopsy and treatment. Physical and laboratory examinations disclosed nothing remarkable except for a mass in the left maxilla and mild anemia. Roentgenograms of the chest and extraoral roentgenograms of the maxilla (Fig. 2) were reported as normal. However, periapical roentgcnograms made on Oct. 3, 1955, showed loss of normal trabeculation with mottling of the bone structure (Fig. 3). A. biopsy of the maxillary mass was performed on Oct. 5, 1955, under local anesthesia. The histologic diagnosis was anaplastie metastatic malignant tumor compatible with a diagnosis of seminoma.
Fig. 8’. Lateral the tumor.
(a)
and
Water’s
(23)
views
showing
no abnormality
of
the
bone
from
Volume Number
21 2
Fig. 3. Molar area showing destruction by the tumor.
Semin oma
loss of
normal
trabcculation
with
mottling
indicative
199
of
The patient refused surgical or roentgen therapy and was discharged on Oct. 10, 1955. He consulted no one until he s&w his local physician for relief of pain in JdIluary, 1956. Narcotics were prescribed, and the oral lesion was reported as much worse. The patient’s brother reported that he consulted no one after this and that his general condition became steadily worst until his death in February, 1957.
SUMMARY
Although the over-all incidence of skeletal metastasis of malignant lesions is about 70 per cent” or more, metastasis to the jaws is extremely uncommon, being involved in less than 1 per cent of all cases of metastasis.l” The seminoma occurs rat.her infrequently, but there is metastasis in the majority of cases. The pelvic and abdominal lymph nodes are involved most frequently, and the lung and liver are involved less often. The present cast illustrates metastasis to the maxilla which is extremely rare. Less than I per cent of all metastatic malignant tumors of t.he jaws are seminomas.l”, I3 Extensive bone metastasis cannot be excluded merely on the basis of roentgenograms which may appear normal.‘l* I* It is obvious that an adequate history is essential in establishing a diagnosis and that metastatic tumors must always be considered in the differential diagnosis of any lesion of the mouth or jaws. REFERENCES
1. Ackerman, L. V., and Del Regato, J. A.: Cancer, ed. 3, St. Louis, 1962, The C. V. Mosby Company, pp. 867-885. 2. Dorn, H. F.: Illness From Cancer in the United States, Pub. Health Rep. 59: 33-48, 65. 77, 97.115, 1954. 3. Boyd, W.: Textbook of Pathology, ed. 7, Philadelphia, 1961, Lea & Febiger, pp. 883-886. 4. Robbins, Stanley L.: Textbook of Pathology With Clinical Applications, ed. 2, Philadelphia, 1962, W. B. Saunders Company! pp. 863-864. 5. Kaplan, G., and others: Malignant Testicular Tumors; Clinical and Therapeutic Evaluation of 153 Cases, Am. J. Roentgenol. 66: 405-419, 1951.
200
Kranz
6. Mostofi, 7. t5\$;60n,
03, O.M. !+lnTlary,
K.: W.
Infantile A. D.:
Testicular Pathology,
Tumors, Bull. New York Acad. Med. 28: ed. 4, St. Louis, 1961, The C. V. Mosby
684.687, Company,
& O.P. 1966 1952. pp.
8. Barringer, B. S., and Earl, D.: Teratoma Testis; Survey of Thirty-seven Autopsy Records, Surg. Gynec. & Obst. 72: 591-600, 1941. 9. Boyd, W.: Textbook of Pathology, ed. 5, Philadelphia, 19’47, Lea 65 Febiger, pp. 670-672. 10. Karsner, Howard T.: Human Pathology, ed. 7, Philadelphia, 1949, J. B. Lippincott Company, -. __ pp. 708-710. 11. Gaffe, Henry L.: Tumors and Tumorous Conditions of the Bones and Joints, Philadelphia, 1958: Lea & Febiger, pp. 598-600. 12. Castlgliano, S. G., and Rominger, C. J.: Metastatic Malignancy of the ,Taws, Am. J. Sure. 87: 496-507. 1954. 13. CashY, C. D., Roye< R. Q., and Dahlin, D. C.: Metastatic Tumors of the Jaws, ORAT, STJRG., ORAL MED. & ORAL PATH. 14: 897-905, 1961. 14. Shackman, R., and Harrison, C. V.: Occult Bone Metastasis, Brit. J. Surg. 35: 385, 1948. 1636
Nicholmville
Rd.
Seminoma metastatic to the maxilla Report
of a case
William C. Kranx, D.M.D.,* COLLEGE
OF DENTISTRY,
Lexington, Ky.
UNIVERSITY
OF
KEXTUCKY
T
esticular tumors comprise less than 1 per cent of all malignant tumors, and they usually occur between the second and fourt,h decades of 1ife.l Their greatest incidence is in patients between the ages of 29 and 34 ~-cars.~ Seminoma is a malignant tumor of the testis derived from the cells of the seminiferous tubules.” It is the most common of all testicular tumors, comprising 35 to 40 per cent of all testicular neoplasms.* The incidence of seminoma increases with age, being most frequent in the ages from -10 to 45 years”; 90 per cent are said to occur before the age of 50.” The tumor occurs rarely among Negroes6and has not been described in children.” Frequent extensive invasion of the body is possible through the lymphatics to the pelvic and abdominal nodes and to the lungs, liver, and other viscera by means of the bloodstream.7 Metastasis usually occurs within 6 months xfttrr the first symptoms appear but may not be evident for 2 or 3 years.‘. s Cut sections of the gross tumor resemble sarcoma in homogenous and fleshy consistency. Histologically, t,he appearance of t,hc tissue varies. The cellular arrangement may be tubular in the slow-growing tumors but diffuse in those which grow rapidly. They may closely rcsemblc sarcoma or enrcinoma. The tumor is generally recognized by its monocellularity, the cells being fairly large, round or cuboidal, and occasionally polyhedral, and usually uniform in size. The cell borders in most cases arc quite distinct. The cytoplasm is eithar clear or only lightly stained. The nucleoli may be present, hcin g slightly eosinophilic a.nd prominent. When arranged in irregular masses there is a. thin, fibrous tissue stroma dividing the tumor into lobules. Tn some tumors this stroma ma: be granulomatous or quite fibr0us.l. o The treatment of choice is excision of the tumor. The seminoma is the most QInstructor,
196
Department
of Oral
Surgery,
College
of Dentistry,
University
of Kentucky.
Volume Number
Xemin oma
21 2
radiosensitive of the testicular tumors, and potential metastatic areas of the pelvic and tional and will definitely improve the results The seminomas have the best prognosis prognosis generally remains good even when are present.l
197
postoperative roentgen therapy of abdominal lymph nodes is tradiof a simple orchidectomy.“’ of the testicular tumors, and the pelvic and abdominal metastases
CASE REPORT A 56.year-old white man was seen on Oct. 3, 1955, for diagnosis and treatment of a mass in the left maxilla. He had been treated by a dentist 2 weeks previously for moderate, diffuse teeth were removed at that time, but swelling of the upper left molar area. Roots of four the size of the mass had increased considerably in the interval. The patient was then referred for further treatment. Examination revealed a well-developed, well-nourished white man in no distress with a nontender maxillary mass extending from the midline to the left tuberosity and to the in&al third of the incisor teeth (Fig. 1). The left canine fossa and cheek showed fullness and induration, and there was moderate distortion of the lateral wall of the left nostril. The patient had chronic gingivitis, and many carious teeth were present. The oral hygiene was poor. There was no submaxillary or cervical lymphadenopathy.
A
B
Fig. I. a, A portion viewed in a mirror.
of
the
tumor
in
direct
front
view.
B, A portion
of
the
tumor
as
198
Kranx
O.S., O.M. February,
& 03. 1966
The patient’s previous medical history revealed that on July 27, 1955, he had undergone a right orchidectomy for a “growth” which had been present about one month. A mass in the lower abdomen was not explored. Hist.ologic diagnosis of the testicular growth was seminoma ; a clinical diagnosis of pelvic nodal metastasis was made and pelvic radiation was ordered. Radiation therapy was started on Aug. 5, 1955; this consisted of a 10 by 15 cm. port to the abdomen and posterior parts, 200 r daily, alternate sides on alternate days, for a total skin dose per area of 1,200 r. On Aug. 20, 1955, no masses were palpable. The patient was discharged on Aug. 21, 1955, and asked to return for further treatment as an outpatient. He did not return to his physician. He next presented with a dental probIcm. On the basis of the oral examination findings and the patient’s history, a clinical diagnosis of metastatie seminoma of the left maxilla was made. The patient was readmitted to the hospital on Oct. 4, 1955, for biopsy and treatment. Physical and laboratory examinations disclosed nothing remarkable except for a mass in the left maxilla and mild anemia. Roentgenograms of the chest and extraoral roentgenograms of the maxilla (Fig. 2) were reported as normal. However, periapical roentgcnograms made on Oct. 3, 1955, showed loss of normal trabeculation with mottling of the bone structure (Fig. 3). A. biopsy of the maxillary mass was performed on Oct. 5, 1955, under local anesthesia. The histologic diagnosis was anaplastie metastatic malignant tumor compatible with a diagnosis of seminoma.
Fig. 8’. Lateral the tumor.
(a)
and
Water’s
(23)
views
showing
no abnormality
of
the
bone
from
Volume Number
21 2
Fig. 3. Molar area showing destruction by the tumor.
Semin oma
loss of
normal
trabcculation
with
mottling
indicative
199
of
The patient refused surgical or roentgen therapy and was discharged on Oct. 10, 1955. He consulted no one until he s&w his local physician for relief of pain in JdIluary, 1956. Narcotics were prescribed, and the oral lesion was reported as much worse. The patient’s brother reported that he consulted no one after this and that his general condition became steadily worst until his death in February, 1957.
SUMMARY
Although the over-all incidence of skeletal metastasis of malignant lesions is about 70 per cent” or more, metastasis to the jaws is extremely uncommon, being involved in less than 1 per cent of all cases of metastasis.l” The seminoma occurs rat.her infrequently, but there is metastasis in the majority of cases. The pelvic and abdominal lymph nodes are involved most frequently, and the lung and liver are involved less often. The present cast illustrates metastasis to the maxilla which is extremely rare. Less than I per cent of all metastatic malignant tumors of t.he jaws are seminomas.l”, I3 Extensive bone metastasis cannot be excluded merely on the basis of roentgenograms which may appear normal.‘l* I* It is obvious that an adequate history is essential in establishing a diagnosis and that metastatic tumors must always be considered in the differential diagnosis of any lesion of the mouth or jaws. REFERENCES
1. Ackerman, L. V., and Del Regato, J. A.: Cancer, ed. 3, St. Louis, 1962, The C. V. Mosby Company, pp. 867-885. 2. Dorn, H. F.: Illness From Cancer in the United States, Pub. Health Rep. 59: 33-48, 65. 77, 97.115, 1954. 3. Boyd, W.: Textbook of Pathology, ed. 7, Philadelphia, 1961, Lea & Febiger, pp. 883-886. 4. Robbins, Stanley L.: Textbook of Pathology With Clinical Applications, ed. 2, Philadelphia, 1962, W. B. Saunders Company! pp. 863-864. 5. Kaplan, G., and others: Malignant Testicular Tumors; Clinical and Therapeutic Evaluation of 153 Cases, Am. J. Roentgenol. 66: 405-419, 1951.
200
Kranz
6. Mostofi, 7. t5\$;60n,
03, O.M. !+lnTlary,
K.: W.
Infantile A. D.:
Testicular Pathology,
Tumors, Bull. New York Acad. Med. 28: ed. 4, St. Louis, 1961, The C. V. Mosby
684.687, Company,
& O.P. 1966 1952. pp.
8. Barringer, B. S., and Earl, D.: Teratoma Testis; Survey of Thirty-seven Autopsy Records, Surg. Gynec. & Obst. 72: 591-600, 1941. 9. Boyd, W.: Textbook of Pathology, ed. 5, Philadelphia, 19’47, Lea 65 Febiger, pp. 670-672. 10. Karsner, Howard T.: Human Pathology, ed. 7, Philadelphia, 1949, J. B. Lippincott Company, -. __ pp. 708-710. 11. Gaffe, Henry L.: Tumors and Tumorous Conditions of the Bones and Joints, Philadelphia, 1958: Lea & Febiger, pp. 598-600. 12. Castlgliano, S. G., and Rominger, C. J.: Metastatic Malignancy of the ,Taws, Am. J. Sure. 87: 496-507. 1954. 13. CashY, C. D., Roye< R. Q., and Dahlin, D. C.: Metastatic Tumors of the Jaws, ORAT, STJRG., ORAL MED. & ORAL PATH. 14: 897-905, 1961. 14. Shackman, R., and Harrison, C. V.: Occult Bone Metastasis, Brit. J. Surg. 35: 385, 1948. 1636
Nicholmville
Rd.