Lung metastasis, an incidental finding in maxilla - A case report.

The aim of this article was to present an asymptomatic lesion with insignificant clinical findings which turned out to be metastatic lesion in the jaws with primary in lung. The most common site of lung metastasis in the orofacial region is the mandible, but in our case it was seen in the maxilla. Metastases to the jaw bones occur in later stages. Hence, a careful examination of patients with jaw bone lesions is strongly suggested. Metastasis to the jaw should be considered while doing oral examination as observed in the current case because such lesions usually develop at terminal stage of cancer.

Metastatic tumors in oral mucosa and jawbones: Unusual primary origins and unusual oral locations.

AIM: To perform clinico-pathological characterization of a large series of oral metastases, collected from 3 main medical centers in Israel and compare findings to data on frequency of primary cancer types in the population. MATERIALS: Pathology archives were searched for cases of metastatic tumors to the oral soft tissues and jawbones, 1990 - 2016. Metastases to the skin of face or to major salivary glands have been excluded. Demographic data and histopathological features were analyzed. RESULTS: Study population included 60 patients, 35 females and 25 males (ratio of 1.4:1). The age range was 17-87 years, mean 67.7 + 14.36 years. Only 3 (5%) patients were under 40 years, the remaining clustered predominantly in the 60-80 year age group. The mean age of females (59 + 13.84) was significantly lower than that of males (67.44 + 14) (p = 0.03). There was an almost equal distribution between the oral soft tissue and the jawbones (48.3% and 51.7%, respectively). The five most common organs from which metastases were distributed to the oral cavity and jawbones combined were kidney (20%), breast (15%), cutaneous (predominately melanoma, 13%), lung (11.7%) and soft tissue-sarcomas (8.3%). For comparison, Israel National Cancer Registry 2013 reported that the most frequent malignancies were breast (25.8%), colorectal cancer (16.3%), lung (12%) and prostate (10%). Malignant melanoma was 6th (5.4%), kidney malignancy was only 9th in frequency (4.2%). Although the gingiva and jawbones were the most frequent locations, some cases presented in unusual locations, (mandibular vestibule, lower lip, posterior dorsal tongue), without any specific clinical feature to suggest metastasis. CONCLUSIONS: The most frequent primary origins for oral metastasis do not correspond to the relative frequency of the primary tumors in the population, indicating that metastatic spread is not a random process. Although the majority of metastasis involves the gingiva and jawbones, any other oral mucosal location might be involved. Thus, in adult/older patients, metastasis from a distant site should be included in the differential diagnosis of oral masses at any oral location, whether the existence of a primary tumor is reported or not.

Malignant paraganglioma presenting as a mandibular metastasis.

BACKGROUND: Metastatic paragangliomas are rare neuroendocrine tumors. Bony metastases most commonly occur in the ribs, vertebrae, and pelvis. Few cases of mandibular metastases have been reported. METHODS: A 75-year-old female presented with a 6-month history of an enlarging mandibular mass. A biopsy was consistent with a paraganglioma. RESULTS: Staging workup with 18 F-fluorodeoxyglucose positron emission tomography demonstrated 2 hypermetabolic intra-abdominal lesions adjacent to the inferior vena cava. These were confirmed as paraganglioma by biopsy and presumed as the primary lesions. The patient underwent left segmental mandibulectomy and neck dissection with osteocutaneous fibula free tissue reconstruction. CONCLUSION: A rare case of malignant paraganglioma presenting as a mandibular metastasis is described. Nuclear medicine studies for paraganglioma are reviewed.

Solid malignant metastases in the jaw bones.

Metastatic tumours to the jaw bones are rare, and usually develop during the final stages of cancer. Some, such as those of lung, breast, and kidney, are more likely to metastasise to the jaw. We have therefore analysed the clinical and epidemiological characteristics of patients with metastatic tumours. We retrieved the notes of 4 478 patients with metastatic tumours to the jawbones who were treated in the Clinical Hospital Centre Dubrava in Zagreb, Croatia, during the 15 years 2002-17 and made a retrospective analysis of patients' age, sex, site of primary tumour, site and clinical presentation of the metastases, time interval since diagnosis of the primary tumour and oral metastases, and time interval from diagnosis of oral metastases to death. Of the 10 who were diagnosed with metastases to the jaw, there were four male and six female patients (mean age 57 (range 51-84) years) and the most common primary tumours were kidney (n=5), lung (n=2), breast (n=1), colon (n=1) and unknown (n=1). The mandible was more often affected (n=7) than the maxilla (n=3), and the most common histological type was adenocarcinoma (n=6). The primary tumour in most of the patients (n=7) was diagnosed before the oral metastatic lesion. A metastasis in the jaw was the first sign of metastatic tumour in three patients, and in one case the metastasis and the primary tumour were diagnosed at the same time. Most of the patients had some oral problems. The time intervals from diagnosis of an oral metastasis to death varied from one month - five years. Because of the rarity of the presentation, the diagnosis of an oral metastatic lesion remains challenging, so metastases in the jaw should be suspected in every patient with such cancers and lesions in the jaw.

Maxillary metastasis from a hepatocellular carcinoma: Report of an uncommon presentation and literature review.

INTRODUCTION: Oral metastases from hepatocellular carcinoma (HCC) are very rare, and predominate in the mandible. We report an exceptional case of maxillary metastasis revealing HCC. CASE REPORT: A 56-year-old man with a previous medical history of alcohol abuse presented to our department with a 3-week evolving oral mass. Physical examination showed a left maxillary tumor. The biopsy revealed a HCC and a multi-metastatic HCC with portal thrombosis and a pulmonary embolism was discovered following a CT-scan. A state of advanced malnutrition contraindicated sorafenib chemotherapy. Thus, external irradiation was proposed, without success. The patient subsequently died 50 days later. DISCUSSION: Maxillary HCC metastases are extremely rare. The average age of HCC jaw metastases appearance in patients has been reported to be approximately 57 years, men are more affected than women are, and the mean life expectancy is 12 months following the diagnosis. These patients require palliative treatment. Local recurrences occur very early after possible surgery, and expose the patient to life-threatening bleeding.

Unusual jaw metastasis from squamous cell lung cancer in heavy smoker: Two case reports and review of the literature.

RATIONALE: Jaw metastasis is a very rare condition associated with lung cancer evolution. In this paper we present two cases of patients who underwent different approach.Lung cancer is the leading cause of cancer related death worldwide. Survival depends on the staging and biology of tumor. Smoking may affect the prognosis. PATIENT CONCERNS: There are herein reported the cases of two patients affected by squamous cell lung cancer with spread to mandibular bone. DIAGNOSES: In the first case a computed tomography (CT scan) showed a large mass located in upper right lung , then bronchoscopy was performed with biopsies and the histology revealed a squamous cell carcinoma P63+ and TTF-. In the second case upper right lung mass with metastases to mediastinal bilateral lymph nodes was found at CT scan. A bronchial biopsy revealed a squamous cell carcinoma p63 positive and TTF-1 negative. INTERVENTIONS: The first, a 65-years old man, current heavy smoker who quit and relapsed, at initial stage of IIa (T2aN1M0), after initial neo-adjuvant chemotherapy underwent lung lobectomy and lymph nodes resection. Three months later a metastasis located on mandibular bone was found out. The second case, a 68-years old female heavy smoker, at initial stage IIIb not available for surgery because of involvement of bilateral lymph nodes, underwent first line course chemotherapy with cisplatin and vinorelbine and second line with erlotinib. OUTCOMES: The first patient underwent hyperthermia and radiotherapy but a sepsis developed and patients died. In the second case, after two months from the beginning of II line the patient developed a jaw metastasis and underwent surgery with resection of hemi-mandible, but soon after she died because of pulmonary embolism. LESSONS: These cases highlight the poor prognosis of patients current smokers affected by squamous cell lung cancer. The jaw bone localization is very rare and different approach could be applied.

Numb chin syndrome: A harbinger of tumor progression or relapse.

Numb chin syndrome (NCS) is a rare yet potentially ominous sensory neuropathy in the distribution of the mental or inferior alveolar nerve characterized by unilateral hypoesthesia over the lower lip, chin and occasionally gingival mucosa. Recognizing NCS is clinically important as this may be a subtle sign of occult malignancy progression or heralding the relapses. It may also occur in benign disease, both systemic and dental in origin. Current expert opinion is that patients with NCS without apparent cause should be assumed to have a malignant etiology until proven otherwise Lossos and Siegal (1992) [1]. Here we report a relapse of Non-Hodgkin lymphoma with NCS with no evidence of metastasis.

Metastatic solid tumors to the jaw and oral soft tissue: A retrospective clinical analysis of 44 patients from a single institution.

PURPOSE: Metastatic solid tumors to the oral cavity are rare, frequently indicative of an end-stage disease process, and associated with poor survival rates. We performed a 20-year retrospective clinical analysis of our institution's cases of solid metastases to the oral cavity, and investigated these patients' clinical outcomes. MATERIAL AND METHODS: A retrospective study of patients with metastatic solid tumors to the oral cavity over a 20-year period (October 1996 to September 2015) was conducted at Memorial Sloan Kettering Cancer Center. Patients were selected if they had a histopathologically confirmed diagnosis. Demographic, pathologic, and clinical information were reviewed to identify patient outcomes. RESULTS: A total of 44 patients with metastatic non-melanocytic non-hematopoietic tumor to the oral cavity were identified: 24 males and 20 females (39 adults and 5 children) with a mean age of 54.3 years. In all, 24 cases involved the jaw and 20 cases involved the oral soft tissue. Eight patients (18.2%) had oral cavity metastases as the first indication of an occult malignancy. In adult patients, the common primary sites were the lungs (n = 9, 20%), kidney (n = 7, 16%), breast (n = 5, 11%), and colon (n = 4, 9%); and in pediatric patients the adrenal gland (3/5) was the most common site. Of the adult patients, 33 (84.6%) died of disease. From the time of metastasis diagnosis, patients with jaw metastases had a median and mean survival of 12 months and 27.7 months, respectively. In comparison, patients with oral soft tissue metastases had a median survival time of 5 months, and mean of 8 months. One pediatric patient (20%) died of disease 8 months after metastasis diagnosis. CONCLUSION: Metastatic solid tumors to the oral cavity can be the first sign of a malignancy. Pediatric patients with oral cavity metastases have a better prognosis compared to adult patients. In this series, adults with oral soft tissue involvement had shorter survival times compared to patients with jaw involvement.

Staging significance of bone invasion in small-sized (4cm or less) oral squamous cell carcinoma as defined by the American Joint Committee on Cancer.

OBJECTIVES: The staging significance of bone invasion is controversial in oral squamous cell carcinoma (OSCC) cases with tumors measuring 4cm or less according to the American Joint Committee on Cancer (AJCC). Our aim was to retrospectively examine a large group of patients with OSCC to determine the staging significance of bone invasion. MATERIALS AND METHODS: Three hundred and twenty-three patients with primary OSCC were classified based on tumor size. Bone invasion was categorized as absent, one side bone, and both buccal and lingual bones, and analyzed for association with disease progression. Regional lymph node metastasis (N), perineural invasion, vascular invasion, surgical margin involvement, and adjuvant treatment were also analyzed. RESULTS: In all OSCC cases, bone invasion (p=0.007) with stage N, perineural invasion, and surgical margin involvement were significant independent prognostic factors of disease progression. However, in OSCC cases with tumors measuring 4cm or less, bone invasion was not significantly associated with disease progression. Nevertheless, invasion of both buccal and lingual bones was significantly associated with disease progression (p=0.03). In multivariate analysis, both buccal and lingual bone invasion (p=0.04; hazard ratio=3.4; 95% confidence interval, 1.0-11.0), stage N2, and perineural invasion were also independent prognostic factors. CONCLUSION: Although OSCC bone invasion was an independent prognostic factor, bone invasion in small OSCC was not. However, small OSCC with both buccal and lingual bone invasion had a significantly worse prognosis. The AJCC T system is of limited prognostic value for small OSCC with bone invasion. But other elements should be examined before a modification can be accepted.

Colorectal Adenocarcinoma Metastasizing to the Oral Mucosa of the Upper Jaw.

INTRODUCTION: Metastases to the oral cavity are uncommon, accounting for only 1% of all oral malignant tumors. When they occur they mostly originate from primary tumors of the lungs, kidney, breast and prostate. Oral metastases from the primary colorectal carcinoma are much more infrequent. CASE OUTLINE: We present an unusual case of a 78-year-old man with a soft tissue oral metastasis originating from the primary colorectal carcinoma.The patient was referred to the Department of Otorhinolaryngology, Head and Neck Surgery with an intraoral mass on the right side of the maxilla. The diagnosis was confirmed by histopathologic examination and immunohistochemical analysis. CONCLUSION: Oral metastases occur rarely and often can mimic much more common benign lesions, therefore they should be considered as a possibility in a differential diagnosis.

Metastases to oro-maxillo-facial region from distant sites: are they so rare? A single centre 8-years experience.

AIM: The goal of our study is investigate the frequency of metastasis to oro-maxillo-facial region to understand if they are really so rare. MATERIAL OF STUDY: In this eight year's retrospective study (2004-2012) we collected 15 cases of metastasis localized in the maxilla-facial region from distant primary tumor. RESULTS: Our results show breast and kidney as the most frequent primary site (40% and 20% respectively), adenocarcinoma as most common histological type (60%). Bone involvement has found to be much frequent than the soft tissue one (53.3%). The mandible (5/15 cases) is more affected than the maxilla, and most common interested subsites are molar and retromolar region. In our study we found only one case of unknown primary tumor, it was a mandibular bone metastasis from a renal clear cell carcinoma. CONCLUSION: Finally, according to our results and considering the increase of survival in cancer disease, even if metastases to oro- maxilla- facial region from distant sites are not frequent, it is important to suspect secondary lesions both in patients that was referred a tumor in their medical history and in those that present a head and neck lesion.

Metastatic tumors to the jaws and mouth.

Metastatic dissemination to the oral cavity is rare and is usually the evidence of a wide spread disease with an average survival rate of 7 months. In almost a quarter of the cases, oral metastasis was found to be the first indication of an occult malignancy at a distant site. Metastatic lesions can be found anywhere in the oral cavity, however, the jaw bones with the molar area is the most frequently involved site. In the oral soft tissues, the gingiva is the most common site, suggesting the possible role of inflammation in the attraction of metastatic deposits. The most common primary malignancies presenting oral metastases were the lung, kidney, liver, and prostate for men, and breast, female genital organs, kidney, and colo-rectum for women. Most patients with jawbone metastasis complain of swelling, pain, and paresthesia. An exophytic lesion is the most common clinical presentation of metastatic lesions in the oral soft tissues. Early lesions, mainly those located in the gingiva, may resemble a hyperplastic or reactive lesion. Once a lesion is recognized as metastasis, the primary tumor site should be identified following clinical, radiological and histopathological investigations. If standardized diagnostic workup fails to detect the site of origin, then the term carcinoma of unknown primary is applied. Personalized medicine tools such as tissue-of-origin assays should be applied, either by immunohistochemical testing or by molecular-profiling methods as these may lead to a more favorable outcome.

Metastatic tumors of the oral cavity.

The pivotal reason for morbidity and mortality of any type of cancer is due to metastasis that occurs as a result of adaptation of genetically unstable cancer cells, in an ectopic conducive environment. Oral metastasis in spite of being unusual or rare represents around 25% of the first signs of metastatic spread. Literature says there are more number of cases of jaw bone metastasis reported than in the oral soft tissues. The most common primary organs metastasizing to the jaw bones and the oral soft tissues are the breast and the lungs respectively. The issue in diagnosing a metastatic tumor arises either when the patient does not reveal the history of the primary illness he or she may be suffering from or when he or she is unaware of it. Diagnosis in such situations is a challenge to the clinician or pathologist. Diagnosing any lymph node or distant metastasis from oral cancer is very important for the prognosis of the patient. In this review we have made an attempt, to explain some recent concepts of pathophysiology of the metastatic process, the clinical manifestations of metastatic tumors to the oral region and to discuss their diagnostic workup.

Malignancy mimicking bisphosphonate-associated osteonecrosis of the jaw: a case series and literature review.

OBJECTIVE: Bisphosphonate-related osteonecrosis of the jaw (BONJ) is a common complication of bisphosphonate treatment that has been well documented over the past decade. Nevertheless, its pathogenesis is poorly understood, and treatment guidelines are based mostly on expert recommendations. Clinicians must be aware of malignancy mimicking BONJ, of which a few cases have been documented in the literature. STUDY DESIGN: Three patients undergoing long-term treatment with intravenous bisphosphonates for malignant disease demonstrated the distinct diagnostic signs of BONJ. Surgical treatment was performed by resecting the affected bone. In all cases, histologic specimens were taken for analysis. RESULTS: Histologic analysis of the bone specimen with surrounding soft tissue revealed necrotic bone with signs of inflammation, but also with cells of the underlying malignant disease. CONCLUSIONS: Clinical and radiographic diagnosis of BONJ should be confirmed by histologic analysis in patients with underlying malignant disease.

Metastatic cancer identified in osteonecrosis specimens of the jaws in patients receiving intravenous bisphosphonate medications.

PURPOSE: The aim of the present study was to investigate the microscopic presence of metastatic cancer in jaw specimens clinically and histologically diagnosed as having osteonecrosis in patients receiving intravenous bisphosphonate medications. PATIENTS AND METHODS: A retrospective cohort multicenter study was designed. Patients from the University of Tennessee Medical Center, New York University Medical Center, and New York Center for Orthognathic and Maxillofacial Surgery were enrolled who had been treated with intravenous bisphosphonate medications for an underlying diagnosis of cancer and who had been clinically diagnosed with bisphosphonate-related osteonecrosis of the jaws (BRONJ). The institutional review boards approved the present study. The primary predictor variable was the clinical presence of BRONJ. The primary outcome variable was the microscopic presence of metastatic cancer in the osteonecrotic jaw specimens. RESULTS: A total of 744 sites of BRONJ were clinically diagnosed. Of these sites, 552 (74%) were diagnosed in patients who had received intravenous bisphosphonate medications. Of these 552 sites, 357 (65%) underwent microscopic evaluation through biopsy, sequestrectomy, or resection with curative intent. Of the 357 sites of BRONJ subjected to microscopic analysis, 19 (5.3%) sites were diagnosed with 20 cancers in 16 patients. CONCLUSIONS: Albeit rare, the presence of cancer in a BRONJ specimen represents 1 explanation for the development of osteonecrosis in patients exposed to intravenous bisphosphonate medications in whom a clinical diagnosis of BRONJ has been applied. Additional molecular information is needed to provide an explanation for this observation.

[A case of brain abscess secondary to bisphosphonate-related osteonecrosis of the jaws in metastatic bone lesions from breast carcinoma].

Bisphosphonates have been used clinically as highly effective drugs in the treatment of hypercalcemia of malignancy, and bone metastasis of solid cancers. Despite these benefits, however, the emergence of bisphosphonate-related osteonecrosis of the jaws has become a growing and significant problem in a subset of patients receiving these drugs. We report a rare case of brain abscess secondary to BRONJ in metastatic bone lesions from breast carcinoma.