Div of Oral and Maxillofacial Surgery, AFMC, Pune, IndiaDept of Dental Surgery, AFMC, Pune, IndiaDept of Pathology, AFMC, Pune, IndiaDiv of Oral and Maxillofacial Surgery, CH (SC), Pune, India
r t i c l e i n f o
rticle history:eceived 10 April 2012eceived in revised form 2 August 2012ccepted 20 August 2012vailable online 19 September 2012
eywords:rismusetastasis
nfiltrating ductal carcinoma
a b s t r a c t
The aim of this case report is to highlight the importance of clinical examination, the correct treatmentmodalities and effectiveness of multidisciplinary approach in managing a metastatic jaw tumour withpoor prognosis.
A 60 year old male patient reported with complaints of trismus and pain in the Lt side of the face forthe past eight months. Patient gave history of multiple teeth extraction. Case was initially diagnosed aschronic osteomyelitis mandible secondary to submasseteric infection. The lump in the left breast was asuspicious finding which was further investigated using US and FNAC. The cytomorphological picture wassuggestive of infiltrating ductal carcinoma. The 99mTc-MDP bone scan was done and showed multiplebony metastasis. The case was diagnosed as metastatic tumour of masticator space from carcinoma breast.
The patient was in his terminal stage of illness with widespread metastasis. Palliative treatment was theninstituted to reduce the pain. Patient’s condition became worse and finally he succumbed to his illness.
Metastatic tumours to the jaws and oral tissues are uncommon and represent less than 1% of all malig-nant tumours affecting the oral cavity. The breast being a primary site for metastasis to a jaw bone in a
Metastasis, the process by which a malignancy spreads from arimary to a distant site, is responsible for the majority of recordedancer-related deaths and metastatic tumours to the jaws and oralissues are uncommon and represent less than 1% of all malig-ant tumours affecting the mouth [1]. Certain malignancies exhibitsteotropism or an extraordinary affinity to target and proliferaten bone, of which breast carcinoma is the most researched example2]. The primary site of metastatic deposits to the jawbones in maless the lung, followed by the prostate, kidney, bone, and adrenals3]. The breast being a primary site for metastasis into a jaw bonen a male patient is a rare entity. This is a unique presentation of
cytopathologically proven case of infiltrating duct carcinoma in60-year-old male patient who showed multiple bony metasta-
is to vertebra, pelvis and masseter region, with a purpose to alert
� AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asianociety of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathol-gy; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japaneseociety of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants.∗ Corresponding author. Tel.: +91 2026444547.
d less documented.n AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd.
All rights reserved.
the clinician that swelling in the jaw bones in an elderly patientcould be metastatic. Though in this case the treatment modalityfrom there on was only palliative, correct diagnostic modalities hadalleviated the patient from further hardship of blind treatmentsand helped USG to learn that simplest clinical sign like trismus canhint such a serious underlying condition. Therefore general dentistor dental specialist should obtain the patient’s complete medicalhistory and carefully evaluate unusual clinical and radiographicfindings because these lesions are associated with a poor prognosishence early detection is of extreme importance.
2. Case report
A 60-year-old male patient reported to Dept of Oral and Max-illofacial Surgery of this college with chief complaints of pain andlimitation of mouth opening for the past eight months. The patientunderwent extraction of lower anterior teeth four months back andleft side lower molar teeth two months back following increasedmobility. The socket healing was uneventful but his mouth openingprogressively decreased with gradual increase in pain and stiff-ness in the left pre-auricular region. There was no history of fever,
dysphagia, and hoarseness of voice, colic pain or haemoptysis. Onexamination diffuse swelling on the left side of the face was notedwhich was hard and tender on palpation (Fig. 1). Skin overlyingwas not fixed with any change in colour or laxity. There was no
I. Published by Elsevier Ltd. All rights reserved.
N.K. Sahoo et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 160–163 161
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cells of similar morphology to that of breast lump (Fig. 7). Theoverall cytomorphology showed features of an infiltrating duct car-cinoma of left breast with metastasis to skin ipsilateral axillarynodes and masseter muscle region. Now the attempt was made to
Fig. 1. Diffuse swelling Lt side of face.
egional neurosensory deficit or alopecia. Left side peri-areolaregion showed single, sessile, lobulated and hyper-pigmented lumpf approximately 5 cm × 4 cm in dimension (Fig. 2). The lump wasard, fixed and tender. There were multiple nodules in the left
nfra-mammary and infra-axillary region. Levels I, II and left axil-ary lymph nodes were palpable. Intraorally there were multiple
issing teeth with poor oral hygiene. The inter-incisal opening wasmm. The mucosa was non-inflamed with no draining sinus. The
ocket healing was satisfactory. Routine blood and urine examina-ion including liver and renal function test and blood sugar levelere within normal range. Chest radiograph showed no abnormal-
ties. Radiograph of jaw bone, PA view mandible showed ill-definedortical plate and cotton-wool marrow space of the left gonial andamus region. The case was provisionally diagnosed as osteomyeli-is mandible following submasseteric space infection. CT, MRI andltrasonography (USG) of middle third of the face were done tond the hard and soft tissue pathological changes. CT imaginghowed irregular thickening of the cortical margin in left ramusegion. The density, volume and configuration of left masseter mus-le were also altered (Fig. 3). USG of the masseter region revealedhickened disorganised muscle fibres of left masseter that showedntermingling heteroechoic infiltration and oedema, suggestive of
nfiltrative pathology of masseter muscle. T1 and T2 weighed MRIf temporomandibular region showed loss in normal intensity ofarrow space in the ramus with focal areas of cortical breach
nd periosteal reaction, with pterygoid and masseter muscles
Fig. 2. Hyper pigmented nodules peri-areolar and sub-auxillary region.
Fig. 3. Axial CT image showing infiltrative pathology of left masseter muscle.
showing pockets of necrosis and the antral lining was thickened, allsuggestive of infective and infiltrative pathology of ramus extend-ing into left masseteric space (Fig. 4). USG left mammary regionand abdomen was done to detect the nature of the lump. Theleft retroareolar region on USG showed well defined lobulatedsolid hypoechoic mass of 11 mm × 28 mm in size. USG abdomenrevealed normal liver, spleen, gall bladder, pancreas and prostatewith no evidence of ascitis and no mesenteric or retroperitoneallymph node enlargement. FNAC was done from left breast includ-ing periareolar nodules, nodes of left axilla and masseter region. Themicroscopic picture of the smear from breast lump showed ovalto polygonal cells having scanty cytoplasm, large irregular pleo-morphic nuclei, coarse chromatin and prominent nucleoli (Fig. 5).The smears from axillary nodes showed cells with lymphoglandu-lar bodies (Fig. 6) and the smears from masseter muscle showed
Fig. 4. MRI, axial section, showing focal areas of necrotic patches.
162 N.K. Sahoo et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 160–163
Fig. 5. Oval to polygonal cells having scanty cytoplasm, large irregular pleomorphicnuclei, coarse chromatin and prominent nucleoli.
fiti(e(pcmt
Fs
Fig. 6. Axillary nodes showing cells with lymphoglandular bodies.
nd other regions where the tumour has thrown its metastasis ando ascertain its prognosis. 99mTc-MDP bone scan was done and thencreased radio-tracer uptake was seen in bilateral frontal regionRt > Lt), Lt maxilla, Lt mandible, both scapula (Lt > Rt), proximalnd of both humeri, manubrium sterni, multiple ribs and vertebraecervical, dorsal, lumbar, sacral), pelvic bone (B/L ilium, ischium,
ubic bone) and proximal end of both femori (Fig. 8). This finding isonsistent with multiple skeletal ‘hot spots’ suggestive of skeletaletastasis. The case was discussed with the patient, his rela-
ives, oncophysician and the counsellor. The complications of the
ig. 7. Smears from masseter showing cells of similar morphology to that of breastwelling.
Fig. 8. Bone scan showing multiple ‘hot spots’.
treatment and poor prognosis of the condition were explained.NCCT brain was carried out to rule out brain metastasis. Chemothe-raphy was planned in the hospital day care centre. Patient waspremedicated and paclitaxel administered intravenously over 3 hat a dose of 175 mg/m2 followed by cisplatin at a dose of 75 mg/m2.The next dose was planned three weeks later. Meanwhile thepatients general condition started deteriorating. The palliativetreatment was then instituted in the following days mainly toreduce the suffering. Patient’s condition became worse and finallyhe succumbed to his illness.
3. Discussion
Metastatic lesions to the head and neck are rare entities. Theselesions are often the first sign of systemic disease, but are gener-ally a sign of widespread systemic disease and poor outcome. Theoral malignancies can be a primary one or a metastatic tumour.A metastatic can spread through direct extension (permeation),through lymphatics or blood vessels (embolic spread) or by trans-plantation [4]. In this case involvement of axillary nodes and levelsI and II cervical nodes was suggestive of lymphatic spread.
Mandibular and facial bone metastasis is rare probably becauseof the paucity of the red bone marrow, which is replaced byfat as age progresses. The most common locations for metasta-sis are gonial and ramus region [5]. Patients will often presentwith delayed healing of an extraction socket, pathologic frac-ture, trismus, masticatory difficulties, and symptoms mimickingtemporomandibular joint dysfunction. Sensory deficit in areasinnervated by the mental nerve, a condition called mental neu-ropathy or numb chin syndrome is of clinical importance because
that represents progression of malignant disease with very poorprognosis [6]. Surprisingly what could disguise any clinician is thatpatient presented with only trismus and dysphagia. Though therewas a recent history of multiple teeth extraction, socket healing was
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N.K. Sahoo et al. / Journal of Oral and Maxillofacia
atisfactory. The only finding that was suspicious was the breastump that was hard and fixed.
Breast cancer in men has a less favourable outcome than breastancer in women. In men the disease is usually more advanced andhigher incidence of lymph node metastasis (60% in men versus8% in women) has been linked to the poorer prognosis [7]. Breastancer in men occurs in 5th or 6th decade of life, even T1 tumourhowing axillary lymph node involvement, and pure infiltratinguctal carcinoma is the commonest. In our case the tumour wason-ulcerated and T2 in size with axillary nodal involvement.
The term metastasis can only be used if there is histologicaldentity between the primary tumour and the growth suspected ofeing a metastasis. FNAC was performed from three sites, the breast
ump, the masseter muscle and the axillary nodes. The smears fromasseter muscle showed cells of similar cellular morphology to
hat of breast lump. This confirmed the lesion to be a metastaticnfiltration from left breast. The primary tumour was histologicallyroven as infiltrating ductal carcinoma.
Mammography has been shown to be an accurate method foristinguishing between benign gynecomastia and breast carcinoma8]. Ultrasound (USG) is just as effective for evaluating the maleatient as it is for evaluating female patients. The small breast sizeacilitates penetration with a high-frequency transducer, allowingssessment of deeper regions not accessible on mammograms. Inhis case we performed USG that showed a well defined lobulatedolid hypoechoic mass on the left retroareolar region.
Bone is the most common site of distant metastasis from breastancer and is the first affected site in a substantial proportion ofomen with an advanced breast cancer [2]. A case of male car-
inoma breast metastasising to jaw bone is rarely documentedondition. When a tumour has metastasised in to a bone, it hasropensity to invade multiple bones. The detection of the same
s mandatory to understand the severity of the tumour as well aso ascertain the prognosis. Various diagnostic aids are available toetect the bony metastasis. Conventional radiographs (PA chest andA mandible), CT of the maxillofacial region and brain, MRI to deter-ine the soft tissue infiltration were done but the 99mTc-MDP bone
can proved most vital aid in detecting the multiple bony metastasisn the case.
The prognosis for patient with neoplasm metastatis to oral andaxillofacial region is poor [9]. The presence multiple metastatic
nfiltration and acutely deteriorating general condition of theatient were indications for a poor outcome. The surgeon’s role in [
ery, Medicine, and Pathology 25 (2013) 160–163 163
treating these lesions is to improve or maintain the patient’s qualityof life, taking into consideration the overall prognosis. The patientwas in his terminal stage of illness with widespread metastasis.The relief of symptoms can now be obtained by chemotherapy orpalliative therapy.
The key principle of palliating most distressing symptoms interminal cancer is to relieve the symptom without adding newproblems by way of side effects, interactive effects, social or finan-cial burdens [10]. The case was well counselled and referred toonco-physician. First phase of chemotherapy was started but thepatient did not respond hence he was put on palliative therapy,mainly to control the pain.
4. Conclusion
This case presentation emphasises on three important aspectsfirstly the importance of through general examination by the physi-cian and patient himself to detect any suspicious finding that couldbe a tip of iceberg for an underlying serious condition. Secondlythe right modalities of diagnosing the condition in order to allevi-ate further suffering to the patient and finally the importance ofmultidisciplinary approach for conservative and palliative therapyin managing the tumour metastatic to oral and maxillofacial region.
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