Introduction:
Oral region is an uncommon site for metastatic tumor cell colonization and usually evidence of wide spread disease.
It accounts for only 1% of all oral malignant neoplasms. They mainly involve the bony structures, particularly the mandible, whereas primary
metastases to soft tissues are extraordinarily rare, accounts only 0.1% of oral malignancies. The most common sites of soft tissue involvement
are the gingiva, tongue, lips, and the buccal and palatal mucosa.The breast is the most common primary site for tumors that metastasize to the
jawbones, whereas the lung is the most common source for cancers that metastasize to the oral soft tissues. Primary tumors are mainly from lung,
breast, kidney and colon which accounts for 70% of all cases, while stomach accounts for only for 2.5% of all cases.[1]
Oral metastatic lesions (in soft tissues) commonly manifest as progressive discomfort, pain, bleeding,
superadded infection, dysphagia, interference with mastication, and disfigurement. Rarely do they also present with swelling, paresthesia,
numb chin syndrome or even being asymptomatic with an accidental discovery.[2]
Oral metastasis carries a grave prognosis for the patient because it represents advanced disease.
Affected patients usually die within a year.[3]
Case Report:
A 50 years old male patient, known alcoholic & smoker, was referred from a dental college with history of
swelling in the anterior alveolar ridge. It had been clinically diagnosed as pyogenic granuloma and the incisional biopsy had been reported as
metastatic adenocarcinoma, following which the patient was subjected to oral gastroduodenoscopy (OGD) that revealed proliferative growth
at cardia extending into lesser curvature (Figure 1). In our institution, slide and block review showed that biopsy
from stomach had moderately differentiated adenocarcinoma, and biopsy from anterior alveolar ridge growth had metastatic adenocarcinoma
with extensive necrosis.
Patient presented to us with history of swelling in the oral cavity of 5 months duration, associated with pain
abdomen and vomiting of 3 months duration and haemetemesis of 1 week duration. Clinical examination showed Ulceroproliferative growth 4x4 cms in
anterior aspect of the upper alveolus extending to involve the upper labial mucosa extending upto the premolars on the right side involving the
palate not crossing the midline, involving the gingivo buccal sulcus & gingivo labial sulcus (Figure 2). Routine blood investigations were within
normal limits. Echocardiogram showed ischemic heart disease with left ventricular segmental hypokinesia with ejection fraction of 45% for
which he was started on medication under a cardiologist care.
OGD showed proliferative growth at the cardia, extending into lesser curvature. CT Scan abdomen showed malignant
wall thickening of the gastro esophageal junction, cardia and lesser curvature with perigastric & peripancreatic lymphadenopathy with multiple
liver metastasis. CT scan oral cavity (Figure 3) showed growth at anterior aspect of upper alveolus extending into gingivo buccal sulcus & gingivo
labial sulcus, eroding the lateral nasal wall, thickening of the nasal wall mucosa seen, not involving the palate.
Biopsy of the stomach showed moderately differentiated adenocarcinoma (Figure 4), biopsy of the oral growth and FNAC
liver showed metastatic adenocarcinoma. Immunohistochemistry (IHC) showed focal positivity for CK7 and CK20 which confirmed the gastric primary
(Figure 5).
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 Figure 2: Ulceroproliferative growth 4x4 cms on anterior aspect of the upper alveolus extending into gingivo buccal sulcus and gingivo labial sulcus. |
Figure 1: OGD showing proliferative growth at cardia |
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Figure 3: CT scan of oral cavity showing the growth at anterior aspect of upper alveolus extending into gingivo buccal sulcus & gingivo labial sulcus, eroding the lateral nasal wall, thickening of the nasal wall mucosa seen, not involving the palate. |
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Figure 4: Fragments of gastric mucosa with intestinal metaplasia, with few fragments showing tumour cells arranged in sheets; cells are round to oval with hyperchromatic nuclei, nucleoli & moderate amount of amphophilic cytoplasm – suggestive of moderately differentiated adenocarcinoma |
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Figure 5: IHC showing focal positive for CK7 and CK 20 |
As the patient had metastatic disease, he received single agent palliative chemotherapy. However patient expired 3
weeks later after 1st cycle of chemotherapy due to a cardiac event.
Discussion:
The oral region is an uncommon site for metastatic lesions.[4] This is because the jawbones have little red marrow
hence are not preferred site for bony metastasis, however active marrow may rarely be found in posterior area of mandible. In dentulous patients,
80% of metastasis involves the gingiva; probably due to rich capillary network of the chronically inflamed gingiva that entraps malignant cells.
In edentulous patients metastatic lesions commonly involve the tongue and the alveolar mucosa.[5]
The diagnosis is always based on histological examination and immunohistochemical testing from the biopsy specimen of both primary and metastasis.
This helps in ruling out several primary intraoral tumors especially those originating from salivary glands like the primary ductal carcinoma
of salivary gland, and also in differentiating from other metastatic primary arising from lung, colorectal, hepatocellular and genitourinary
system.[6,7]
Oral metastasis indicates widespread disease and poor prognosis.[8] Treatment modalities are limited to palliation
to improve the patient’s quality of life.
The discovery of an oral metastasis sometimes leads to the detection of an occult malignancy in other body sites,
and so it is extremely important to identify it correctly, first clinically and then pathologically for better patient care.
References:
- Devesa SS, Blot WJ, Fraumeni JF Jr. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer. 1998;83:2049-2053.
- Colombo P, Tondulli L, Masci G, Muzza A, Rimassa L, Petrella D, et al. Oral ulcer as an exclusive sign of gastric cancer: report of a rare case. BMC Cancer 2005;5:117.
- Clausen F, Poulsen H. Metastatic carcinoma of the jaws. Acta Pathol Microbiol Scand. 1963;57:361-374.
- Zachariades N. Neoplasms metastatic to the mouth, jaws and surrounding tissues. J Craniomaxillofac Surg. 1989;17:283-290.
- Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic tumours to the oral cavity - pathogenesis and analysis of 673 cases. Oral Oncol. 2008;44:743-752.
- Krishna M. Diagnosis of metastatic neoplasms: an immunohistochemical approach. Arch Pathol Lab Med. 2010;134:207-215.
- Natoli C, Ramazzotti V, Nappi O, Giacomini P, Palmeri S, Salvatore M, et al. Unknown primary tumors. Biochem Biophys Acta. 2011;1816:13-24.
- Seoane J, Van der Waal I, Van der Waal RI, Cameselle-Teijeiro J, Antón I, Tardio A, et al. Metastatic tumours to the oral cavity: a survival study with a special focus on gingival metastases. J Clin Periodontol. 2009;36:488-492.
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