Metastatic transitional-cell carcinoma to the mandible: a case report

Non-Muscle Invasive Papillary Urothelial Carcinoma Metastatic to the Mandible

Urothelial carcinoma, the most common histologic subtype of bladder cancer in the United States, most frequently presents as non–muscle invasive disease. Initially, therapy involves transurethral endoscopic resection and subsequent intravesical therapies with extended surveillance for high-risk disease. Even with the best treatments, recurrence and progression can occur. However, metastasis of non–muscle invasive bladder cancer to distant sites without evidence of progression or regional metastasis is rare. In this article, we present the case of a patient with high-grade papillary urothelial carcinoma who developed an unusual metastasis to the mandible, confirmed by GATA-3 immunostaining, over 4 years after initial transurethral resection. Prior to the development of metastatic disease, this patient had no evidence of local recurrence during maintenance Bacillus Calmette-Guerin intravesical therapy and concurrent surveillance. Positron emission tomography-computed tomography taken after presentation with mandibular metastasis did not show any evidence of regional metastasis. This case highlights an unusual location for distant metastasis of urothelial carcinoma occurring in a patient without evidence of muscle invasive disease or regional metastasis. We additionally highlight the utility of GATA-3 immunostaining in identifying urothelial carcinoma histologically.

High-grade urothelial carcinoma with squamous differentiation metastasizing to the tongue

Tumors metastasizing to the head and neck region are uncommon. Metastasis of urothelial carcinoma to the maxillofacial region is exceedingly rare and mostly involves the jaw. We present a case of urothelial carcinoma metastasizing to the tongue. Immunohistochemistry in conjunction with fluorescent in situ hybridization was used to confirm the relation between the primary and metastatic lesions, making it the first such reported case employing the UroVysion (Catalogue number 02 J27-025, Abbott Molecular Inc., Des Plaines, IL, USA) fluorescent in situ hybridization probe in a metastatic lesion in the head and neck region.

Fine-needle aspiration cytology of metastatic transitional cell carcinoma

In this article we described the fine-needle aspiration cytology (FNAC) of five cases of metastatic transitional cell carcinoma (TCC). There were four cases of metastatic lymph nodes and one case of metastatic skin lesion. All of the TCC cases were primarily in the urinary bladder and were high grade on histopathology (grade 3). Three cases showed bladder muscle involvement and two cases showed superficial TCC at the time of primary diagnosis. FNAC smears showed abundant cellularity. The cells were present in discrete and small syncytial clusters. Nuclear position of the cell was central to eccentric. Many cells showed prominent nucleoli. Cercariform cells (CCs) were noted in four cases. These cells are malignant cells with a nucleated globular body and a unipolar nontapering cytoplasmic process. Two cases showed intranuclear inclusions. Prominent cytoplasmic vacuoles were noted in three cases. In addition, cell cannibalism and attempted pearl formations were noted in two cases.In conclusion, clinical history along with the certain cytological features such as the presence of CCs, cells with eccentric nuclei, and intranuclear inclusions are helpful to diagnose metastatic TCC on FNAC material.

Statistical analysis of cytologic features useful in separation of metastatic urothelial carcinoma from other metastatic epithelial malignancies

The identification of a site of origin and direction of differentiation for metastatic neoplasms is clinically important, but is often difficult purely by cytologic analysis of aspirated material. Cytologic separation of metastatic urothelial carcinoma (UC) from other moderate or poorly differentiated epithelial malignancies is difficult, with few cytologic criteria identified in the literature as valuable for this distinction. Several investigators have suggested that "cercariform cells" (CCs) are highly correlated with the presence of metastatic UC. We statistically analyzed the utility of 37 cytomorphologic features for the recognition of urothelial differentiation in a series of 26 metastatic UCs, 10 metastatic squamous cell carcinomas (SCCs), and 15 metastatic adenocarcinomas (ADCs). All specimens had been obtained from metastatic deposits in the lung, liver, lymph nodes, or soft tissues. Stepwise discriminate function analysis with all three diagnoses showed that the strongest discrimination could be made using the findings of waxy metaplastic cytoplasm, with significant increments in prediction added by analysis for (CCs) followed by spindle cells, multiple nucleoli, and columnar-shaped cells. The combination of these five variables accurately predicted 90% of all diagnoses, including 26 accurate diagnoses of UC, 9 accurate diagnoses of SCC, and 11 accurate diagnoses of ADC. CCs were present in highest numbers in UCs and present least frequently in cases of poorly differentiated ADC. While CCs were useful in the identification of UC, CCs occurred in a significant number of SCCs, limiting their diagnostic value as a single variable.

Metastatic transitional cell carcinoma of the urinary bladder presenting as a mandibular gingival swelling

Oral cavity metastases mostly originate from the breasts, lungs, or kidneys. Transitional cell carcinoma (TCC), the most frequent malignant tumor of the urinary bladder, rarely metastasizes to the jaws. To the best of our knowledge, only 8 cases of bladder carcinoma have been reported in the English literature to metastasize to the jawbones. A new case of mandibular metastasis of urinary bladder TCC with extension to the gingiva is presented in a 64-year-old white man. The patient was referred for a periodontal infection of the upper right first molar. The clinical examination also showed a gingival swelling located in the lower left premolar region with a hypoasthesia of the left side of the lower lip. The gingival mass was biopsied, and the microscopy showed a mandibular metastatic TCC of the urinary bladder extending to the gingiva. Periodontists should be aware that, although gingival metastases are rare, when they occur they may mimic other local benign pathological conditions.

Mandibular pain as the leading clinical symptom for metastatic disease: nine cases and review of the literature

BACKGROUND

Metastases to the jaws are a rare phenomenon. Nevertheless, the appearance of non-specific symptoms such as toothache can signal the onset of neoplastic disease in some patients.

PATIENTS

In this article, we present details of a 74-year-old patient with a history of breast cancer to illustrate this point. Retrospectively, covering a time span of one year, we could identify nine patients (1.2%) with metastatic disease to the mandible out of a total of 763 patients referred to our Maxillofacial Surgery department with non-specific jaw pain.

RESULTS

Four patients were subsequently diagnosed as having breast cancer, two had lung cancer, one prostate cancer, one renal cell carcinoma and one adenocarcinoma of unknown primary site. Only three of these patients had documented tumor spread to bones before the onset of jaw pain. In the other patients, the dental symptoms were either the first sign of a generalized neoplastic disease, or indicated relapse of disease after long term disease free interval. However, further work up disclosed generalized tumor spread with additional organ- or bone-lesions in all patients, and the median survival was only six months (range 3.5(-)+22) from diagnosis.

CONCLUSION

Pain of uncertain origin in the jaws should alert clinicians to the potential of metastatic disease in patients with a history of cancer and a bone scintigraphy should be done to rule out metastatic involvement. Although metastatic lesions in this area usually herald generalized neoplastic spread according to our experience, prompt diagnosis nevertheless can lead to useful palliation and an enhanced quality of life.

Metastatic tumors to the jawbones: analysis of 390 cases

A review of the English language literature revealed 390 well-documented cases of metastatic lesions to the jawbones. Most metastatic lesions were diagnosed in patients in their fifth to seventh decade. The primary site differed between the genders: for women, it was the breast followed by the adrenal, colo-rectum, female genital organs and thyroid; for men, it was the lung, followed by the prostate, kidney, bone and adrenal. The most common location of the metastatic tumors was the mandible, with the molar area the most frequent site involved. In about 30% of cases the oral lesion was the first sign of the malignant disease. The present data are compared with those of metastatic tumors to the oral mucosa and a view on the possible pathogenesis is presented.

Cytologic features of metastatic transitional cell carcinoma

Cytologic preparations containing metastatic transitional cell carcinoma (MTCC) from 18 sites in 16 patients were reviewed to determine characteristic morphologic features. The patient group included 13 males and 3 females with a mean age of 66 years. Primary TCC occurred in the bladder (14), kidney (1), and ureter (1); nearly all the primary tumors were poorly differentiated and most were invasive at the time of diagnosis. The cytologic specimens were derived from lymph nodes (6), liver (4), serous fluids (2), pelvic soft tissue (2), subcutaneous nodules (2), and lung (1). One patient presented with MTCC in Pap smears. Cytologically MTCC presented as loosely cohesive, moderate to markedly pleomorphic cells which occurred singly and in syncytial clusters. The malignant cells were usually large with abundant granular or fibrillar cytoplasm and the cell borders were generally distinct. Most nuclei were large and hyperchromatic with irregularly distributed granular chromatin and prominent nucleoli. The most distinctive features were the presence of spindled, pyramidal, and/or racquet-shaped malignant cells with eccentric nuclei and cytoplasmic features of both squamous and glandular differentiation including endoplasmic/ectoplasmic interfaces and intracytoplasmic vacuoles. Although clinical history is most useful in the diagnosis of MTCC, these morphologic features in cytologic preparations of malignant epithelial neoplasms may be helpful. In the absence of a known primary TCC, it is doubtful that a definite cytologic diagnosis could be made; however, the characteristic cell shapes and cytoplasmic features may be suggestive of MTCC.