|Year : 2013 | Volume
| Issue : 2 | Page : 143-146
Metastatic adenocarcinoma of mandible: A case report
Kiran Kumar Kattappagari1, Baddam Venkat Ramana Reddy1, Joshua Elizabeth2, Umadevi M Krishnamohan Rao2, Kannan Ranganathan2
1 Department of Oral Pathology, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
2 Department of Oral Pathology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||3-Jan-2014|
Kiran Kumar Kattappagari
Department of Oral Pathology, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Metastatic adenocarcinoma is a glandular tissue malignancy, which spreads to other regions of the body. Adenocarcinoma may develop anywhere in the body and commonly metastasizes to the jaw bone. We present a case of 83-year-old male, with a complaint of swelling on the lower left side of mandible. The clinical description of our case is supported by clinical, radiographic and pathological features.
Keywords: Adenocarcinoma, fine-needle aspiration, glandular cells, mandible
|How to cite this article:|
Kattappagari KK, Reddy BR, Elizabeth J, Krishnamohan Rao UM, Ranganathan K. Metastatic adenocarcinoma of mandible: A case report. J Orofac Sci 2013;5:143-6
|How to cite this URL:|
Kattappagari KK, Reddy BR, Elizabeth J, Krishnamohan Rao UM, Ranganathan K. Metastatic adenocarcinoma of mandible: A case report. J Orofac Sci [serial online] 2013 [cited 2020 Feb 23];5:143-6. Available from: http://www.jofs.in/text.asp?2013/5/2/143/124264
| Introduction|| |
"Metastasis connotes the development of secondary implants, discontinuous with the primary tumor possibly in remote tissue." The most common malignancy affecting skeletal bone is metastatic carcinoma. 
McMillan and Edwards are summarized manifold in metastasis to the oral cavity, in which approximately 80% of them are to the mandible, 15% to the maxilla and 5% in both the jaws.  Secondary deposits occur much more often in the mandible than in the maxilla and particularly in the molar region, but rarely have they appeared in the condyle.  Metastasis to the jaws most commonly originate from primary carcinomas of the breast in women and of the lung in men.  Other primary sites in decreasing order of frequency are the kidney, colon, rectum and thyroid gland. In children, neuroblastoma is the most common primary site in the first decade and bone malignancies in the second decade of life. 
Carcinomas of adjacent structures such as lip, gingiva and salivary gland often involve the jaws by direct extension, but carcinoma of the lower lip may also metastasize to the mandible by way of lymphatics, through the mental foramen.  Carcinoma of the parotid may give rise to hematogenous deposits in the mandible as well as involving it by direct extension. Carcinomas of the nasal mucosa and the tonsil have shown metastasis to the jaws. 
| Case Report|| |
Here we present a case report of an 83-year-old male patient who reported with a complaint of pain and swelling on the left side of the lower face since 1 month. History revealed that he underwent extraction 2 months back in the region of 37 and 38. Swelling developed after 1 month of extraction. Initially the swelling was small, which gradually increased in size. There is no significant medical history and general examination revealed the patient was co-operative, afebrile and thinly built. Pulse rate and respiratory rate were within the normal range.
Extra oral examination revealed a diffuse swelling on the left side of the face which was oval in shape and 10 cm × 9 cm in size. On palpation, the swelling was hard in consistency, associated with numbness of the lower lip (left side only and not crossed the midline). Extension of swelling was superiorly - 2 cm below the zygomatic arch, inferiorly - lower border of the mandible, anteriorly - 1 cm away from the angle of the mouth, posteriorly - up to angle of the mandible [Figure 1]. Sub-mandibular lymphadenopathy was evident on both the right and left sides.
|Figure 1: Clinical photograph showing swelling on the left side of the face|
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Intra oral examination revealed an ulcerated lesion distal to 36 regions, measuring about 5 cm × 4 cm, with expansion of buccal and lingual cortical plates [Figure 2]. Based on the extra oral and intra oral findings, provisional diagnosis was given as Intra osseous carcinoma, osteosarcoma and intra osseous mucoepidermoid carcinoma. An extra oral orthopantamograph revealed an ill-defined radiolucency in relation to 34, 35 and 36, associated with root resorption [Figure 3].
|Figure 2: Intra oral photograph showing ulcerative swelling with averted borders|
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|Figure 3: Orthopantamograph showing ill-defined borders (moth eaten) showing in relation with 33, 34, 35 and root resorption of 35and 36|
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The patient was sent for routine blood and biochemical investigations to the role out any systemic diseases and fine-needle aspiration cytology (FNAC) were done. Hematological reports revealed that he was anemic, with elevated erythrocyte sedimentation rate. Biochemical parameters were well within the normal limits.
To rule out the primary lesion, a chest radiograph was taken and ultra sound of abdomen (liver, prostate, kidney, thyroid, spleen, pancreases and gallbladder) was done. No primary lesion was detected. Expert consultation from gastroenterologist was advised, upon which, magnetic resonance imaging (MRI) of abdomen, colonoscopy and endoscopy were done for the patient. MRI findings were non-specific, but colonoscopy showed an intestinal mass of 2 mm × 3 mm, with surface projections. The gastroenterologist opined it to be an intestinal carcinoma. The patient was reluctant to go for a biopsy of the intestinal mass.
FNAC was done for the intra-oral mass and prepared smears were stained with Hematoxylin and Eosin (H and E) and Papanicoulau (PAP) stains. H and E smear revealed epithelial cells in clusters, mostly columnar cells with basally placed nuclei. These cells were in different size and shape, some of them being spindle shaped and tadpole like cells, showing nuclear hyperchromatism. Some cells showed altered nuclear-cytoplasmic ratio [Figure 4].
|Figure 4: Cytological smear shows columnar cells with basally placed hyper chromatic nuclei. Cells shows in different size and shape (spindle shaped, tad pole like cells) (×10)|
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PAP stain revealed the appearance similar to H and E stained smear. Columnar cells showed green colored cytoplasm with basally placed nucleus, suggestive of glandular cell origin.
Upon repeated counseling, the patient agreed to go for a biopsy of the intraoral mass. Histopathological examination (×4) revealed stratified squamous epithelium with fibro vascular connective tissue stroma. Deeper areas show highly vascular dilated capillaries and areas of extravasated red blood cells. Focal areas show ruptured blood vessels with invading tumor cells into them. Under ×10 magnification, small clumps of malignant epithelial cells arranged in glandular pattern are seen with vascular spaces and also showing papillary configuration. Large aggregates of clear cells are also evident. Irregular bone trabeculae and immature bone is seen within the lesion [Figure 5]. ×40 view shows clusters of non-columnar hyper chromatic cells with pleomorphism, admixed with few clear cells [Figure 6].
|Figure 5: Photomicrograph showing numerous blood vessels with irregular bony trabaculae. Focal area showing papillary configuration with in the blood vessels (×40)|
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|Figure 6: Photomicrograph showing sheets of tumor cells with large clear cells (×40)|
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Special staining technique with periodic acid Schiff's stain was done to rule out mucin and showed mild positivity. All the above findings were suggestive of metastatic adenocarcinoma.
| Discussion|| |
Metastatic tumors to the oral region are uncommon and may occur in the oral soft-tissues or jaw bones.  Metastatic carcinoma is the most common form of cancer involving the bones, both the long bones and jaw bones. Metastatic tumors account for about 1% of malignant tumors of the oral cavity.  Most commonly, the breast in case for women and lungs in men are the potential sources for metastatic lesions to the oral mucosa. Though such lesions may be observed in any bone, vertebrae, ribs, pelvis and skull are the most frequent sites for metastasis. 
The pathogenesis of the metastatic process in the jaw bones is not clear. In the skeleton, bones with red bone marrow are the preferred site for metastatic deposits. Jaw bones have little active marrow especially in elderly persons.  Remnants of hematopoietic active marrow can be detected in the posterior area of the mandible. Since the mode of spread is usually hematogenous, tumor cells tend to be deposited in thin vascular medullary tissue. 
A primary carcinoma from any anatomic site may metastasize to the jaw bone. Most of the carcinomas arising from the breast, lung, thyroid and kidney may give rise to a metastatic carcinoma in the jaw bone. A metastatic tumor spreads through lymphatic, blood - vessel permeation, transcoelomic permeation, local infiltration or a combination of these.  Blood - borne metastatases to the oral cavity are far more common than those spread by the lymphatic route.  Tumor cells in the primary site must enter the vascular condition and survive in their travel through the blood stream. Batson proposed the valve-less vertebral venous plexus as a mechanism for bypassing filtration through the lungs.  Secondary deposits occur more often in the mandible than in the maxilla because the deposits are usually transmitted through hematogenous route. According to Castigliano and Rominger, mandible is more commonly affected. Secondary deposits in the jaws may give rise to symptoms while the primary growth may still remain silent. 
In our case, clinically, a hard swelling with radiographically diffused poorly outlined radiolucency was seen on the body of the mandible. Histopathologically, both osteoblastic and osteoclastic features were noticed and in some areas, small papillary-like projections were also seen.
Metastatic lesions resemble the primary tumor, but these are more anaplastic. Intra osseous metastases usually proliferate in the medullary portion.  Metastatic tumors arising from Prostate usually show osteoblastic activity, whereas those arising from Breast show both osteoclastic and osteoblastic activity.  Clausen and Poulsen described a case of metastatic adenocarcinoma of the mandible, where the oral metastasis was manifested before the primary tumor was diagnosed. 
| Conclusion|| |
Metastatic tumors in the jaws are an important clinical consideration as they pose a significant challenge in diagnosis. Metastasis from a distant site to the jaw bones may indicate an already wide-spread disease with poor prognosis. In many such cases, the primary site may go undiagnosed by the time a metastatic lesion has been identified. A series of tests are essential for confirming the diagnosis of such metastatic tumors. Sequential investigations such as radiographs, complete blood picture, biochemical investigations, computed tomography/MRI scan, FNAC and other confirmative tests like biopsy, all of them, when properly correlated, will confirm the diagnosis. Diagnosis should always be made on histologic grounds, which is the gold standard.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]