Metastasis to the oral and maxillofacial region. A systematic review

Metastatic neuroendocrine carcinoma of the small intestine presenting as temporomandibular disorder

BACKGROUND

Neuroendocrine carcinomas (NECs) are rare tumors from hormone-secreting neuroendocrine cells, often within the gastrointestinal tract. The authors report what is, to their best knowledge, the first case of a small intestine NEC metastasizing to the temporomandibular joint (TMJ).

CASE DESCRIPTION

A 60-year-old man came to the oral medicine, oncology, and orofacial pain clinic with a chief concern of left-sided jaw pain. Clinical examination revealed left TMJ arthralgia and deep masseter myalgia, and results of imaging showed both osteoblastic and osteolytic changes in the left TMJ. A comprehensive diagnostic approach, including detailed history, clinical evaluation, and advanced imaging techniques, such as positron emission tomography computed tomography, was used to establish an accurate diagnosis.

PRACTICAL IMPLICATIONS

This case highlights the importance of considering metastasis in differential diagnosis of TMJ pain in patients with NEC, underscoring collaboration between oncology and orofacial pain specialists for accurate diagnosis and effective management.

TMJ Metastasis: Evaluation of 3 Patients

Metastases of the articular process, temporomandibular joint (TMJ), are rare findings. Their frequency is around 5% of patients with metastatic involvement of the mandible. The most common primary tumor is adenocarcinoma of the lung in women and adenocarcinoma of the prostate in men. The authors present 3 patients with TMJ metastasis. These were metastasis of breast adenocarcinoma, prostate adenocarcinoma, and lung adenocarcinoma. TMJ metastases are rare but complicated to diagnose because their presence may be accompanied by symptoms typical of other TMJ diseases (discopathy, arthritis, osteoarthritis). However, the authors recommend the unequivocal exclusion of a metastatic process in cases where the patient has a positive cancer history and their complaints do not respond to usual therapy.

Pattern and Outcome of Metastatic Malignant Lesions to the Jaws: A Systematic Review of 594 Cases

The jaws are affected secondarily by metastasis from a distant site. Metastatic lesions of jaws are very rare and constitute about 1% of all the malignancies occurring in the jaw, and the pattern of metastasis differs by age and sex. The objective of this review was to analyze the pattern of metastatic jaw lesions and its outcome. This was a systematic review of cases of metastatic jaw lesions published between 1950 and 2022. An electronic search of PubMed, Scopus, Web of Science, African Journals Online, and Google Scholar was performed. Only case reports or case series with histopathological results demonstrating metastasis to the jaws were included. The main outcomes included demographics, primary site, metastatic site, clinical manifestations, and patient survival. Descriptive and multivariate analysis and a Kaplan-Meier survival curve were performed. A total of 450 articles were selected with a total of 594 cases. The mean age of the patients was 54.31 (SD = 19.49) years with a median age of 58 (IQR = 47-68) years. There were slightly more females (N = 299, 50.3%) with a male-to-female ratio of 1:1.01. The most common malignant lesion to metastasize to the jaws was adenocarcinoma (N = 230, 38.7%). In females, the frequent sites of the primary lesion were the breast (N = 99, 33.1%), thyroid (N = 52, 17.4%), and lungs (N = 27, 9.0%), whereas in males they were the lung (N = 57, 19.3%) the prostate (N = 41, 13.9%), liver (N = 36, 12.2%), and kidney (N = 28, 9.5%). The frequently reported clinical symptoms include jaw swelling (N = 460, 77.4%), pain (N = 250, 42.1%), paresthesia (N = 117, 29.8%), and trismus (N = 72, 12.1%). Regarding the outcome, 65.3% had succumbed to the disease at the time of publication of their cases. The survival of patients with metastatic jaw lesions did not depend on the demographics of the patient, the primary site, and the treatment of the primary lesion. Metastasis to the jaw bone is very rare and its prognosis is poor. Females and the elderly are more affected. The most common primary malignant lesion is adenocarcinoma. Most of the clinicians misdiagnosed the metastatic jaw lesion on initial presentation. Factors determining the survival of patients with metastatic jaw lesions could not be ascertained.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-05120-w.

Mandibular metastasis of pulmonary adenocarcinoma: How unexpected could it be?

OBJECTIVE

Metastatic tumours of bone must be considered in all patients with unexplained bone pain and particularly in patients who present with a known cancer, localised pain at multiple sites, and radiographic findings suggestive of metastasis. The purpose of this report was to present a case of a pathological fracture of the mandible as a consequence of metastatic pulmonary adenocarcinoma.

MATERIALS AND METHODS

In July 2018 a 68-year-old male patient was hospitalised because of pulmonary adenocarcinoma and attended our department for an oral maxillo-facial evaluation. He complained of pain and swelling in the right temporomandibular region resulting in a reported functional limitation. An Orthopantomogram (OPG) demonstrated a right intracapsular condylar compound fracture associated with an osteolytic lesion at the condyle base with jagged margins. Subsequently, a CT scan with contrast of the maxillo-facial complex and a fine-needle aspiration of the lesion was performed.

RESULTS

CT images showed the presence of a right mandibular condyle fracture associated with a large osteolytic lesion which confirmed the pathological nature of the fracture. Fine-needle aspiration of the lesion confirmed its metastatic nature. It was not possible to proceed with a mandibular resection due to the critical clinical condition of the patient who died in September 2018.

CONCLUSION

Lung cancer frequently produces lytic-type metastasis, sometimes even in the jaw. In patients with an established diagnosis of lung cancer, any radiolucent lesion of the jaw or an unexplained painful symptomatology to the oro-maxillo facial complex should be placed in differential diagnosis with metastasis of the primary tumour.

Challenging Differential Diagnosis of Mandible Angle Metastasis from Breast Cancer

Breast cancer is the most common cancer in women and the second leading cause of cancer-related death. Breast cancer manifestations in the head and neck are relatively rare, and they are mostly bony metastasis to the mandible and maxilla. In this paper, we present a case report of a metastatic tumor in the mandibular angle originating from breast carcinoma. A 32-year-old female patient with a paresthesia/anesthesia in the left mandibular area was referred to us to aid in the differential diagnosis between osteonecrosis and metastasis. Her medical history revealed a radical bimastectomy 3 years ago for invasive lobular carcinoma of the breasts. Additionally, she received chemotherapy and radiotherapy 3 years ago, and intravenous zoledronic acid was administered every 3 weeks. Intraoral examination did not reveal any mucosal ulcer or fistula, and there was no radiological evidence of cyst. The patient demonstrated good oral hygiene. Palpable regional left submandibular lymph nodes and a few swellings on the lateral angular mandibular surface were observed. Cone-beam computed tomography (CBCT) and positron emission tomography (PET) were performed. CBCT showed small poorly diffused radiopacity in proximity to the mandibular angle on both medial and lateral surfaces. PET showed fluoro-2-deoxy-D-glucose uptake in the mandible in the left angle surface area. Based on the patient's clinical history, signs, symptoms, and tomographic evidence, we were able to diagnose mandibular metastasis. This case also highlights the importance of proficiency in reading tomographic examinations, which can be carried out in dental clinics for various purposes. In the absence of symptoms, misdiagnosis can occur, underscoring the significance of accurate interpretation and diagnosis.

Impact of Early Diagnosis of Maxillofacial Metastases on Treatment and Patient Outcomes - A Retrospective Study

Introduction

Maxillofacial metastases from distant primary sites account for less than 1% of cancer in the head-and-neck region and are often misdiagnosed as benign or inflammatory conditions. The purpose of this study was to describe the clinical characteristics of patients with maxillofacial metastases, treatment and outcomes.

Materials and Methods

Subjects with head-and-neck cancer were identified from the institutional database. Descriptive statistics were employed.

Results

Of 532 patients with head-and-neck cancer between 2008 and 2020, 15 (2.8%) had histologically verified metastatic lesions, of which 53.33% males with a mean age of 69 years. The median time from symptom onset to diagnosis was 17 days (range: 7-60). The mandible was the most common location (40%), followed by the parotid gland (33.33%) and maxilla (13.33%). Adenocarcinoma was the most frequent histology (60%), and half of the patients had extraoral manifestations. Tumour origin was gastrointestinal, lung (33.33% each), prostate (20%) and breast (13.3%). No predilection for tumour type or histology and location were seen. Radiographic features were non-specific, with computed tomography (CT) demonstrating periosteal reaction, bone expansion and lytic lesions and high variability in Positron Emission Tomography (PET) standardised uptake value (minimum: 2.0, maximum: 10.93 and mean: 4.14). Diagnosis led to altered treatment in 60%, more in extraoral than intraoral manifestations (71% vs. 37.5%); 40% received radiotherapy, 20% systemic treatment and none underwent surgery. Over half of the patients passed away within 6 months, median survival was 5 months, shorter in patients with intraoral than extraoral disease (3 vs. 13.2 months, P < 0.05).

Discussion

Maxillofacial metastases have elusive manifestations and often warrant specific treatment. Prospective data should evaluate associations between timely diagnosis and symptomatic improvement and survival.

Breast Ductal Infiltrative Adenocarcinoma Metastasis to the Mandible

Metastatic lesions to the jaws are rare. The oral sites to which metastasis most commonly occur are the jaws, the gingiva, and the tongue. Lower jaw is a more frequent site of metastasis compared to the upper jaw with posterior areas (ramus, body) that are more prone to the deposition of cancerous cells due to presence of hematopoietic bone marrow, subdivision of local blood vessels and reduced velocity of blood flow. In fact, the formation of secondary foci of tumor colonization occurs by hematogenous dissemination of tumor emboli, that accumulate in regions with larger amounts of bone marrow and low circulatory velocity. In females, commonly seen metastatic lesions arise from primary neoplasms in breasts, colon, genitals and thyroid glands, whereas in males arise from lungs, prostate and colon region. Patients with metastatic jaw disease may be asymptomatic or may show various clinical signs and symptoms that include pain, swelling, paresthesia, foul smell, tooth mobility, exophytic growths of the soft tissues, reduced mouth opening and, infrequently, pathological fractures. In particular, metastasis in breast cancer is commonly seen in the lungs, liver, bones, pleura, brain, and kidneys, whereas breast cancer metastasis to the oral cavity is not common and is seen in only around 1% of the cases. Breast cancer can also be latent where the metastases appear years after treatment of the primary tumor. The presence of metastasis is highly important in determining the patient's prognosis and mode of treatment. The aim of the present article is to present and discuss the diagnosis of a breast cancer metastasis in the mandibular angle.