Tumors metastatic to the mandible: Analysis of nine cases and review of the literature

J Oral Maxillofac 46246-251,

Surg

1990

Tumors Metastatic to the Mandible: Analysis of Nine Cases and Review of the Literature GREGORIO

SANCHEZ ANICETO, MD,* APOLINAR GARCiA PER/N, MD, DDS,t RAMIRO DE LA MATA PAGES, MD, DDS,$ AND JUAN JOSE MONTALVO MORENO, MD, DDS*

Metastases to the mandible are rare. In this article, nine cases of tumors metastatic to the mandible of various origins and locations, including metastasis to the condyle, are reported. The most common primary tumor was breast adenocarcinoma (three cases). The clinical features, diagnosis, and treatment of metastatic lesions, especially emphasizing clinical and radiologic aspects, are described, and a review of the literature is presented.

Mandibular bone involvement by malignant tumors occurs by several mechanisms during the course of the disease, but is usually due to direct extension of neoplasms originating in the oral cavity or the surrounding tissues.“’ Metastatic tumors to the mandible have been traditionally regarded as rare findings.‘.” Malignant tumors of the mouth and jaws constitute approximately 5% of all malignant neoplasms in the body,” and only 1% to 8% are considered to be metastatic.9’12’13 In 1963, Clausen and Poulsen14 defined the two conditions necessary to consider a mandibular tumor metastatic: histologic similarity between the primary tumor and the suspected metastasis, and a certain amount of intervening healthy tissue. Bone metastases are the most frequent metastatic tumors of the oral cavity and adjacent tissues (approximately 90%).‘*‘3,‘4 The main location is the mandibular bone, comprising more than 70% of all malignant metastatic tumors in the oral cavity. Metastatic carcinoma is the most prevalent malignant bone tumor in the body,15 as well as the most common mandibular metastatic tumor. Adenocarci-

noma of the breast, kidney, prostate, thyroid, colon, and stomach, as well as bronchial carcinoma are the main sites of origin of mandibular metastases in whites;‘,5,9,‘3,‘4.‘6-20 and of these breast carcinoma has the highest incidence.13 Mandibular and facial bone metastases are relatively rare, especially if one takes into account the high incidence of malignant metastatic tumors in the rest of the skeleton.2,9*15*2’ This has been hypothesized to be because of the paucity of red bone marrow in the mandibular bone, which is replaced by fat as age increases. In the vast majority of cases, bone metastases are hematogenous.2V2” The apparent increase in the incidence of mandibular metastases is due, at least in part, to a better awareness of the problem, the prolongation of life in patients with widespread tumors, and the use of the 99mT~ scintigraphy.2V3*7S8.18 In this article, nine cases of neoplasms metastatic to the mandible are presented with details of their clinical features, diagnosis, and treatment along with a review of the literature. Materials and Methods

Received from the Oral and Maxillofacial Surgery Unit, Hospital 12 de Octubre, Madrid, Spain. * Senior resident. t Staff surgeon. $ Chief. Address correspondence and reprint requests to Dr Petiin: Servicio de Cirugia Oral y Maxilofacial, Hospital 12 de Octubre, Crtra, Andalucia Km 5.4 Madrid, Spain. 0 1990 American

Association

of Oral and Maxillofacial

A total of 864 patients with malignant tumors of the head and neck region, excluding neoplasms of the pharynx, larynx, thyroid, and parathyroid glands, have been treated in our unit over 14 years (1974-1987). Two hundred nine tumors showed mandibular bone involvement by histologic examination. The distribution was as follows: 168 tumors (80.4%) affected the mandible by direct extension from their primary location or metastatic lymph

Sur-

geons 027%2391/90/4903-0004$3.00/0

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ANICETO ET AL

Table 1.

Analysis of Nine Cases of Metastatic Mandibular Tumors Primary Site

Mandibular Location

Case

Age/Sex

1

62/F

Breast

Adenocarcinoma

Body, left side

2

67/M

Prostate

Adenocarcinoma

Left angle and ramus

Histology

3

54/M

Kidney

Adenocarcinoma

Right angle and ramus

4

48/M

Unknown

Adenocarcinoma

Symphyseal region

5

48/F

Skin (back)

Melanoma

Left molar, angle, and ramus regions

6

30/M

Unknown

Adenocarcinoma

Left condyle

7

64/F

Breast

Adenocarcinoma

Left body and angle

Clinical Features

Radiology, Scintigraphy

History

Radical surgery 1 v previously: radiotherapy and chemotherapy for primary tumor Osteoblastic Hormone Swelling, therapy for pain, trislesion (chondralmus (1 mo) I yr. Other like calcifibone mecations) tastasis Gammagraphy (iliac) (6 mo previ(+) ously) Radiolucency Primary tuLip numbmor disness. (8 covered mo) swellafter the ing (2 mo), mandibular pain, trismetastases mus Radiolucency Study after Swelling, the intratooth loos- Gammagraphy oral biopsy (+I ening did not (2 mo) reveal the primary site Radiolucency Excision of Swelling. lip the skin numbness, Gammagraphy tumor 16 tooth loos(+) mo previening ously; axil(4 mo) lary lymphadenectomy 3 mo previously Radiolucency Diagnosed TMJ syn(FNA bidrome (I S Gammagraphy opsy) 1.5 yr), preau(+) yr after the ricular onset of mass symptoms (I mo) and refused treatment; surgical treatment 8 mo later

Swelling, pain, trismus, lip numbness. mucosal ulceration (5 mo)

Diffuse radiolucency Gammagraphy (+)

Swelling, lip numbness, tooth loosening (4 mo)

(Continued

on following

Radiolucency Gammagraphy (+)

page)

Mastectomy 4 yr previously; radiotherapy and chemotherapy

Treatment

Prognosis

Radiotherspy; chemotherapy

Died 2 yr later

Radiotherapy; chemotherapy

Alive after

Hemimandibulectomy; radiotherapy and chemotherapy Chemotherapy

Died I yr later

Immunotherapy

Died 5 mo later

Total radical parotidectomy: neck dissection; partial mandibulectomy including masseter and pterygoid muscles; chemotherapy Chemotherapy

Died 5 mo later

1 yr

Died 2 yr lafer

Died 6 mo later

TUMORS METASTATIC TO THE MANDIBLE

248 Table 1.

Analysis of Nine Cases of Metastatic Mandibular Tumors (Cont’d) Primary Site

Histology

Mandibular Location

Clinical Features

Radiology, Scintigraphy

Case

Age/Sex

8

56/F

Breast

Adenocarcinoma

Right body

Swelling, pain (3 mo)

Radiolucency Gammagraphy (+)

9

15/M

Femur

Osteogenic sarcoma

Symphyseal region

Swelling (1 mo)

Radiolucency (sunray form) Gammagraphy (+)

Abbreviation:

History

Treatment

Prognosis

Mastectomy 11 mo previously; radiotherapy and chemotherapy Surgery of the primary tumor 6 mo previously; radiotherapy and chemotherapy

Radiotherapy and chemotherapy

Alive 6 mo later

Radiotherapy and chemotherapy

Died 6 mo later

FNA, fine-needle aspiration.

nodes, 32 tumors (15.3%) were primary mandibular neoplasms, and 9 tumors were classified as metastatic mandibular tumors (4.3%). Metastatic adenocarcinoma was found in 7 cases, metastatic osteosarcoma in 1 case, and metastatic melanoma in the remaining case. The analysis of the cases appears in the Table 1. All of them fulfilled the criteria established by Clausen and Poulsen,‘4 except cases 4 and 6, which were classified as metastatic adenocarcinoma of unknown origin according to the histologic findings and clinical course. Six patients had a previously known malignant disease: 4 females, 3 with breast carcinoma and 1 with malignant melanoma; and 2 males, one with prostate carcinoma and the other with osteosarcoma. Three patients had occult malignant disease, whose primary manifestation was a mandibular metastatic tumor: 3 males, one of them with kidney carcinoma, the others with adenocarcinoma from unknown origin. All patients with suspected metastases underwent a detailed clinical evaluation, mandibular and chest radiographs, bone scintigraphy, and intraoral biopsy of the tumor. Other studies, such as head and body computerized tomography (CT) (Fig l), abdominal echography, urography, thyroid scintigraphy, etc, were used to search for other metastases and/or the primary tumors in those cases in which mandibular metastases were the first signs of the malignant disease.

primary tumors more frequently metastasizing to the oral region’4,23 and to the mandible.‘~5*14*‘7*19*24 Bronchial carcinoma, 14,‘7-‘9*23*25*26neuroblastoma ‘,27,28 choriocarcinoma,*‘29 retinoblastoma,29 hepa;oma3’ and, more rarely, melanoma5*‘8~‘9~31are also tumors described as metastasizing to the mandibular bone. Seven of our nine cases were adenocarcinomas: three from the breast, one from the kidney, one from the prostate, and two adenocarci-

Discussion

PRIMARYTUMORS Adenocarcinoma from the breast, prostate, thyroid gland, kidney, uterus, colon and stomach are

FIGURE 1. CT scan showing osteolysis and enlargement of the ramus due to a metastatic melanoma (case 5).

ANICETO ET AL

249

nomas of unknown origin. The remainder were cases of metastatic melanoma and osteosarcoma.

AGEANDSEX Most of the authors report a female to male ratio of approximately 3:2,‘*i4 and others find a similar incidence in both sexes.13 The mean age reported is between the fourth and seventh decades of life.‘*6*‘3*‘4,32In our series, the female-to-male ratio was 45, and the mean age of the patients was 49.3 years (range 15 to 67 years).

LOCATION The most common locations for metastases are the molar and premolar regions (Fig 2), perhaps due to the larger amount of red bone marrow and peculiar vascularization at these sites.1*5*8**0,18,23,33*34 The mandibular gonion and ramus are also frequent sites of metastases. 3,‘8*33Metastatic tumors are rare in the condyle, possibly due in part to the small amount of red marrow and vascularization.35 There are fewer than 30 cases of condylar metastases described in the literature, some without histologic or cytologic confirmation.36 Carcinoma is also the most common primary neoplasm involving the condyle.5.6,37‘39 Multiple mandibular metastases are rare.14*40 Three of our cases were located in the mandibular body, two in the angle and ramus, one affected the body, angle and ramus, two lesions were located in the symphyseal region (Fig 3), and one was in the condyle (Figs 4 and 5; Table 1).

FIGURE 3. Radiolucency in the symphyseal region in a patient with metastatic adenocarcinoma of unknown origin.

Other often-reported ing and pain. i.iO*i3~14,i7~23*26 symptoms are loosening of affected teeth, and hypoesthesia or anesthesia of the lower lip. ‘*2,4S7*23*41*42 Approximately 50% of condylar metastases begin as a temporomandibular joint (TMJ) syndrome, and the remainder are diagnosed because of a previously known disseminated neoplastic disease.5V35,37 A mandibular tumor was the first symptom of the malignant disease in 25% to 30% of cases in the literature.“” Only three of our nine cases presented had mandibular metastases as the first symptom of the malignant disease: hypernephroma and two

CLINICALSIGNSAND SYMPTOMS Metastatic tumors of the mandibular body and angle most frequently manifest symptoms of swell-

FIGURE 2. Radiograph showing typical osteolytic appearance in the premolar-molar region in a metastatic adenocarcinoma of the breast (case X).

FIGURE 4. Radiograph showing ill-defined margins of the lesion in case 6. a metastatic adenocarcinoma to the condyle of unknown origin.

250

TUMORS METASTATIC TO THE MANDIBLE

FIGURE 5. Technetium Tc 99m scintigraphy of the same case as Fig 4, showing increased uptake in the condylar region.

cases of adenocarcinoma of unknown origin. Hypoesthesia of the lower lip and swelling were the most frequent symptoms (Table 1). Other symptoms were pain, tooth loosening, trismus and, more rarely, mucosal ulceration and facial palsy. DIAGNOSIS

There is no pathognomonic radiographic appearance for mandibular metastasis. Radiolucency is the most common feature.‘,3*8V’0*‘8The margins of the lesion are ill defined and irregular in the majority of cases.’ Radiopaque lesions are rare, and often associated with prostate, breast, and lung neoplasms .3,8 There are some reported cases with clinical and radiologic patterns mimicking periodontal disease43 and ameloblastomata.‘0,20 The size of the lesion usually depends on the rapidity of growth and the diagnosis. We found an osteolytic appearance in eight cases, and an osteoblastic pattern in only one (case 2). The typical sunray pattern of osteosarcoma was found in case 9, a metastatic osteosarcoma. Scintigraphy of the facial skeleton usually shows an abnormally high accumulation of the isotope in the affected area, demonstrating the lesion better and earlier than radiography3,10*18 (Fig 6). In our series, when used, 99mT~ scintigrap h y of the facial bones always showed increased uptake at the involved site (8 cases). The definitive means to diagnose mandibular metastases is by biopsy and microscopic examination of the lesion, comparing it with the histologic features of the primary tumor, if known.2,3*9,14,16,‘7Intraoral biopsy and microscopic examination were carried out in all our cases, often showing some features of metastatic origin. Inmunohistochemistry failed to reveal the primary site of the tumors in cases 4 and 6. TREATMENT

AND PROGNOSIS

The treatment and prognosis are varied, chiefly depending on the site of the primary lesion and the

FIGURE 6. Technetium Tc 99m scintigraphy showing increased uptake of the isotope in the left mandibular body and ramus (case 7).

degree of metastatic spread. If the patient is in a terminal stage of disease, and there is widespread metastasis, relief of symptoms can often be obtained with radiation, chemotherapy, and hormone therapy.‘,’ Surgical treatment is used only in selected patients, depending on the type of tumor and, in most cases, where no other metastases are demonstrated.‘*2*8,26 In our series, treatment was palliative in seven cases. Radical surgical treatment was attempted in two cases (3 and 6), but both patients died of disseminated disease in the first year after surgery. There was no local recurrence of the mandibular tumors. References 1. Nishimura Y, Yakata H, Kawasaki T, et al: Metastatic tumours of the mouth and jaws: A review of the Japanese literature. J Maxillofac Surg 10:253, 1982 2. Van der Kwast WAM, Van der Waal I: Jaw metastases. Oral Surg 37:850, 1974 3. Bergstedt HF, Haverling M: Facial bone scintigraphy. I. Metastatic lesions in the mandible. Acta Radio1 Diagn 19: 859, 1978 4. Ciola B: Oral radiographic manifestations of a metastatic prostatic carcinoma. Oral Surg 52:105, 1981 5. Gerlach Kl, Horch HH, De Lacroix WF: Condylar metasta-

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6.

I. 8. 9.

10.

11. 12. 13. 14. 15.

16. 17. 18.

19. 20.

21. 22.

23.

sis from bronchial carcinoma. Case report. J Maxillofac Surg 10:250, 1982 Hecker R, Noon W, Elliot M: Adenocarcinoma metastatic to the temporomandibular joint. J Oral Maxillofac Surg 43: 629, 1985 Levy B, King Smith W: A jaw metastasis from the colon. Oral Surg 38:769, 1974 Linkous CM, Welch JT: Metastatic malignant tumors of the jaws: Report of a case. Oral Surg 38:703, 1974 Stypulkowska J, Bartkowski S, Pana’s M, et al: Metastatic tumors to the jaws and oral cavity. J Oral Surg 37:805, 1979 Yagan R, Bellon EM, Radivoyevitch M: Breast carcinoma metastatic to the mandible mimicking ameloblastoma. Oral Surg 57: 189, 1984 Samat BG, Schour I: Oral and Facial Cancer, Chicago, IL, Year Book Medical, 1957 Bhaskar SN: Synopsis of Oral Pathology. St Louis, MO, Mosby, 1973, p 304 Meyer I, Shklar G: Malignant tumors metastatic to the mouth and jaws. Oral Surg 20:350, 1965 Clausen F, Poulsen H: Metastatic carcinoma to the jaws. Acta Path01 Microbial Stand 57:361, 1963 Spjut HJ, Dorfman HD, Fechner RE, et al: Tumors of Bone and Cartilage, Atlas of Tumor Pathology, Fascicle 5. Washington, DC Armed Forces Institute of Pathology, 1971, p 367 Brabant H, Demoulin J: J. Przerzuty rak6w w okolice twarzowoszczekowa. Czas Stomatol 22:495, 1969 Castigliano SG, Rominger CJ: Metastatic malignancy to the jaws. Am J Surg 87:496, 1954 Grinspan D: Blastomas y pseudoblastomas de 10s maxilares: Tumores no genuinos de 10s maxilares, in Grinspan D (ed): Enfermedades de la Boca. Semiologia, Clinica y Terapetltica de la Mucosa Bucal, tomo v. Buenos Aires, Argentina 1983, pp 4103-4105 McDaniel RK, Luna MA, Stimson PG: Metastatic tumors in the jaws. Oral Surg 31:380, 1971 Parichatikanond P, Parichatikanond P, Damrongvadmap, et al: Jaw metastasis from follicular carcinoma of thyroid gland simulating ameloblastoma. J Med Assoc Thai 671362, 1984 Spott RJ: Metastatic breast carcinoma disguised as periapical disease in the maxilla. Oral Surg 60:327, 1985 Cramer SF. Fried L, Carter KJ: The Cellular basis of metastatic bone disease in patients with lung cancer. Cancer 48:2649, 1981 Grinspan D: Canceres secundarios de la mucosa bucal, in Grinspan D (ed): Enfermedades de la Boca: Semiologia,

24. 25.

26. 27. 28.

29. 30.

31.

32. 33. 34. 35. 36. 37. 38.

39.

40. 41. 42.

43.

Patologia, ClInica y Terapetltica de la Mucosa Bucal, tomo V. Buenos Aires, Argentina, 1983, pp 3845-3855 Freilich RE: Adenocarcinoma of the pancreas metastatic to the mandible. J Oral Maxillofac Sum 44:735. 1986 Donoff RB, Albert T, Olson DJ, et 2: Me&static bronchogenic carcinoma to the mandible. J Oral Surg 34: 1007, 1976 Kaugars GE, Svirsky JA: Lung malignancies metastatic to the oral cavity. Oral Surg 51: 179, 1981 Newland JR, McClendon JL, Lynch DP: Metastatic neuroblastoma of the jaws. J Oral Maxillofac Surg 43:549, 1985 Wilcox PB, Wright JM, Byrd RL: Metastatic neuroblastoma to the jaws: Report of two cases. ASDC J Dent Child 51:211, 1984 Sesenna E, Gazzotti A: Choriocarcinoma metastatic to the maxillofacial region. J Oral Maxillofac Surg 43:543, 1985 Goveia G, Bahn S: Asymptomatic hepatocellular carcinoma metastatic to the mandible: Report of a case. Oral Surg 45~424, 1978 McNelis FL, Barone AJ: Metastatic malignant melanoma in the mandible: Site is a rare one for the spread of this tumor. RI Med J 68:403, 1985 Cash CD, Royer RQ, Dahlin DC: Metastatic tumours of the jaws. Oral Surg 14:897, 1961 Batsakis JG: Tumors of the Head and Neck (ed 2). Baltimore, MD, Williams & Wilkins, 1979, pp 240-241 Pindborg JJ: Atlas de enfermedades de la mucosa oral (ed 4). Barcelona, Spain, Salvat, 1986, pp 86-88 Blackwood HJJ: Metastatic carcinoma of the mandibular condyle. Oral Surg 9: 1318, 1956 Webster K: Adenocarcinoma metastatic to the mandibular condyle. J Craniomaxillofac Surg 16:230, 1988 Owen DG, Stelling CB: Condylar metastasis with initial presentation as TMJ syndrome. J Oral Med 40:198, 1985 Thatcher SL, Dye CG, Grau MJ, et al: Carcinoma of the prostate metastatic to the mandibular condyle mimicking a parotid tumor. J Oral Maxillofac Surg 44:394, 1986 DeBoom GW, Jensen JL, Siegel W, et al: Metastatic tumors of the mandibular condyle: Review of the literature and report of a case. Oral Surg 60:512, 1985 McMillan MD, Edwards JL: Bilateral metastases. Oral Surg 39:959, 1975 Perriman AO, Figures KH: Metastatic retinoblastoma of the mandible. Oral Surg 45:741, 1978 Rohrer MD, Colyer J: Mental nerve paresthesia: Symptom for a widespread skeletal metastatic adenocarcinoma. J Oral Surg 39442, 1981 Block RM, Mark HI, Bushel A: Metastatic carcinoma of the breast mimicking periapical disease in the mandible. J Endodont 3:197, 1977