Metastasis to the oral and maxillofacial region. A systematic review

OBJECTIVE

Metastasis to oral and maxillofacial region (MOMFR) is an unusual finding; representing between 1 and 1.5% of all malignancies in the maxillofacial region. A systematic review is presented to determine trends in presentation, diagnostic features, and patient outcome.

METHODS

Searches of databases were carried out for papers reporting MOMFR. The variables were demographics, patient symptoms, tumor location, tumor size, histopathology, origin of the tumor, immunohistochemical studies, follow-up and survival.

RESULTS

696 cases were identified; 391 males, and 305 females. The most common race was white. The most common primary tumor for females was from breast 31.1% (n = 95), for males from lung 20.5% (n = 143). The most common location was the mandible 44.9% (n = 313), followed by gingival soft tissue 16.8% (n = 117). A frequent clinical symptom was pain with 17.5% (n = 122). The most common clinical presentation was a mass or tumor 37.4% (n = 260). The mean age was 58.8 years. The average time before diagnosis was 10.3 months, the mean follow-up after diagnosis was 13.1 months, and the average survival was 9.8 months.

CONCLUSION

MOMFR shows a strong predilection for the posterior mandible, with a mass or tumor being the most common clinical presentation. They are frequently painful, and demonstrate a poor prognosis.

Fatal case of oral metastatic hepatocellular carcinoma in a patient unaware of his disease

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. Metastases to the soft tissues of the oral cavity are extremely uncommon. This report describes a rare case of an oral metastatic HCC, located completely within the oral mucosa overlying the alveolar ridge, in a patient who was unware of his primary disease. A 64-year-old man was referred for evaluation of a nodular mass on the edentulous mandibular ridge underneath an implant-supported overdenture. According to the patient, he was successfully treated for hepatitis C infection 7 years previously, and he reported that his α-fetoprotein levels were monitored at semiannual intervals. The results of his current blood tests were within the reference range. A biopsy was performed, and analysis of the specimen revealed a malignant neoplasm suggestive of metastatic HCC. Because the patient was unaware of any underlying disease, he was referred to an oncologist for further evaluation. However, signs of hepatic decompensation appeared immediately after the biopsy results were obtained, and the patient was hospitalized. The overall medical examination disclosed an HCC with metastases to the lungs and oral cavity, and the patient died 8 days after hospitalization. This case reinforces the important potential for dentists to identify neoplastic diseases that are unknown to their patients.

A challenging diagnosis: Case report of oral metastasis from gastric adenocarcinoma mimicking pyogenic granuloma

RATIONALE

Oral metastases occur more commonly in bone, but can also manifest in soft tissues and eventually resemble a reactive lesion. Few cases of oral metastases mimicking reactive lesions in soft tissues have been reported to date.

PATIENT CONCERNS

We report a metastasis of gastric carcinoma (GC) to the oral mucosa without bone involvement in a 43 yom clinically and microscopically mimicking a reactive lesion. The patient related that the lesion had 1 month of evolution, and the ulcerated area suggested the lesion was related to trauma.

DIAGNOSES

The histopathological examination of the lesion revealed an exuberant granulation tissue with few neoplastic cells, and the initial diagnosis of pyogenic granuloma was considered. In a second analysis, clusters of clear cells morphologically similar to degenerating mucous cells or macrophages, positive for Cytokeratin (CK)-20, and CDX2 were found. At the moment, it was confirmed the presence of a primary GC in the patient.

INTERVENTIONS

A palliative radiotherapy/chemotherapy was started.

OUTCOMES

However, the patient died 3 months after the diagnosis of oral metastasis.

LESSONS

This report highlights the importance of careful clinical and microscopic examinations in cases of oral metastasis that may mimic a reactive lesion.

Cytologic Features of Malignant Melanoma with Osteoclast-Like Giant Cells

BACKGROUND

Malignant melanoma showing numerous osteoclast-like giant cells (OGCs) is an uncommon morphologic phenomenon, rarely mentioned in the cytologic literature. The few reported cases seem to have an aggressive clinical behavior. Although most findings support monocyte/macrophage differentiation, the exact nature of OGCs is not clear.

CASE

A 57-year-old woman presented with an inguinal lymphadenopathy. Sixteen years before, cutaneous malignant melanoma of the lower limb had been excised. Needle aspiration revealed abundant neoplastic single cells as well as numerous multinucleated OGCs. Occasional neoplastic giant cells were also present. Nuclei of OGCs were monomorphic with oval morphology and were smaller than those of melanoma cells. The immunophenotype of OGCs (S100-, HMB45-, Melan-A-, SOX10-, Ki67-, CD163-, BRAF-, CD68+, MiTF+, p16+) was the expected for reactive OGCs of monocyte/macrophage origin. The tumor has shown an aggressive behavior with further metastases to the axillary lymph nodes and oral cavity.

CONCLUSION

Numerous OGCs are a rare and relevant finding in malignant melanoma. Their presence should not induce confusion with other tumors rich in osteoclastic cells. Since a relevant number of OGCs in melanoma may mean a more aggressive behavior, and patients may benefit from specific treatments, their presence should be mentioned in the pathologic report.

[Renal Cell Carcinoma metastases in the maxillofacial area: Case series.]

Renal cell carcinoma is an unpredictable malignancy. Sometimes, metastases are the disease debut. On the other hand, metastases could present years after treatment of the primary tumor. Four clinical cases of atypical metastases in the head and neck location are presented: parotid gland, mandibular bone, attached molar gingiva and masticator space. Physiopathology, clinics, histology and management of metastatic renal cell carcinoma at those anatomical regions are reviewed.

Metastatic solid tumors to the jaw and oral soft tissue: A retrospective clinical analysis of 44 patients from a single institution

PURPOSE

Metastatic solid tumors to the oral cavity are rare, frequently indicative of an end-stage disease process, and associated with poor survival rates. We performed a 20-year retrospective clinical analysis of our institution's cases of solid metastases to the oral cavity, and investigated these patients' clinical outcomes.

MATERIAL AND METHODS

A retrospective study of patients with metastatic solid tumors to the oral cavity over a 20-year period (October 1996 to September 2015) was conducted at Memorial Sloan Kettering Cancer Center. Patients were selected if they had a histopathologically confirmed diagnosis. Demographic, pathologic, and clinical information were reviewed to identify patient outcomes.

RESULTS

A total of 44 patients with metastatic non-melanocytic non-hematopoietic tumor to the oral cavity were identified: 24 males and 20 females (39 adults and 5 children) with a mean age of 54.3 years. In all, 24 cases involved the jaw and 20 cases involved the oral soft tissue. Eight patients (18.2%) had oral cavity metastases as the first indication of an occult malignancy. In adult patients, the common primary sites were the lungs (n = 9, 20%), kidney (n = 7, 16%), breast (n = 5, 11%), and colon (n = 4, 9%); and in pediatric patients the adrenal gland (3/5) was the most common site. Of the adult patients, 33 (84.6%) died of disease. From the time of metastasis diagnosis, patients with jaw metastases had a median and mean survival of 12 months and 27.7 months, respectively. In comparison, patients with oral soft tissue metastases had a median survival time of 5 months, and mean of 8 months. One pediatric patient (20%) died of disease 8 months after metastasis diagnosis.

CONCLUSION

Metastatic solid tumors to the oral cavity can be the first sign of a malignancy. Pediatric patients with oral cavity metastases have a better prognosis compared to adult patients. In this series, adults with oral soft tissue involvement had shorter survival times compared to patients with jaw involvement.

The value of (18) F-FDG-PET/CT imaging in oral cavity cancer patients following surgical reconstruction

OBJECTIVE

Follow-up of patients with oral cavity squamous cell carcinoma (OCSCC) after tumor resection and reconstruction with tissue transfer is challenging. We compared contrast-enhanced computed tomography (ceCT), (18) F-fluorodeoxyglucose-positron emission tomography combined with noncontrast enhanced CT ((18) F-FDG-PET/CT), and (18) F-FDG-PET combined with ceCT ((18) F-FDG-PET/ceCT) to determine the accuracy for detection of residual/recurrent disease after flap reconstruction for OCSCC.

STUDY DESIGN AND METHODS

Two readers (R1, R2) retrospectively reviewed a total of 27 (18) F-FDG-PET/ceCT scans in patients after resection of stage II to IV OCSCC. They recorded the presence of local persistence/recurrence (LR), lymph node metastasis, or distant metastasis independently for ceCT, (18) F-FDG-PET/CT, and (18) F-FDG-PET/ceCT. Histological workup, imaging follow-up, or clinical follow-up served as the standard of reference. Maximum standardized uptake value (SUVmax) was evaluated to discriminate between physiological uptake and LR.

RESULTS

The highest accuracy to detect LR was achieved with (18) F-FDG-PET/ceCT, with a sensitivity/specificity of 88%/89% and 88%/79% for R1 and R2, respectively, as compared to ceCT with 75%/79% for R1 and 88%/68% for R2 and (18) F-FDG-PET/CT with 88%/58% for both R1 and R2. Receiver-operating-characteristic analysis determined a cutoff value for SUVmax of 7.2, yielding a sensitivity and specificity of 75% and 94%, respectively, to distinguish LR from physiological (18) F-FDG uptake.

CONCLUSION

(18) F-FDG-PET/ceCT seems to be the most reliable tool for locoregional surveillance of OCSCC patients after resection and reconstruction.

LEVEL OF EVIDENCE

4.

Metastatic tumors to the jaws and mouth

Metastatic dissemination to the oral cavity is rare and is usually the evidence of a wide spread disease with an average survival rate of 7 months. In almost a quarter of the cases, oral metastasis was found to be the first indication of an occult malignancy at a distant site. Metastatic lesions can be found anywhere in the oral cavity, however, the jaw bones with the molar area is the most frequently involved site. In the oral soft tissues, the gingiva is the most common site, suggesting the possible role of inflammation in the attraction of metastatic deposits. The most common primary malignancies presenting oral metastases were the lung, kidney, liver, and prostate for men, and breast, female genital organs, kidney, and colo-rectum for women. Most patients with jawbone metastasis complain of swelling, pain, and paresthesia. An exophytic lesion is the most common clinical presentation of metastatic lesions in the oral soft tissues. Early lesions, mainly those located in the gingiva, may resemble a hyperplastic or reactive lesion. Once a lesion is recognized as metastasis, the primary tumor site should be identified following clinical, radiological and histopathological investigations. If standardized diagnostic workup fails to detect the site of origin, then the term carcinoma of unknown primary is applied. Personalized medicine tools such as tissue-of-origin assays should be applied, either by immunohistochemical testing or by molecular-profiling methods as these may lead to a more favorable outcome.

High-risk human papillomavirus and lymph node size in patients with single node metastasis of oral and oropharyngeal cancer

CONCLUSION

High-risk human papillomavirus (HPV) infection was significantly related to lymph node size in patients with single node metastasis of oral and oropharyngeal cancer.

OBJECTIVE

The purpose of this study was to examine the relationship between high-risk HPV infection and lymph node size in patients with single node metastasis of oral and oropharyngeal carcinoma.

METHODS

This study included 48 patients with oral and oropharyngeal carcinoma. Pathologic lymph node stages comprised 36 N1 and 12 N2a.

RESULTS

High-risk HPV in situ hybridization was positive in 29% of patients (14/48). Of those patients with high-risk HPV, there was a significant difference (p = 0.008) between oral (9.5%) and oropharyngeal (44.4%) cancers. Average lymph node diameter was 20.7 ± 12.6 mm (range 5-54 mm). We found a positive correlation between high-risk HPV status and lymph node size (p = 0.018). Mean lymph node diameter in high-risk HPV-positive cases was 27.3 ± 13.1 mm and 18.0 ± 11.5 mm in high-risk HPV-negative cases. Extracapsular spread (p = 0.030) and cystic nodal metastases (p = 0.019) were also significantly related to lymph node size. High-risk HPV negative status (p = 0.043), advanced tumor stage (p = 0.009), and extracapsular spread (p = 0.038) all had significant adverse effects on 5-year disease-specific survival.

Oral cancer chemotherapy adherence and adherence assessment tools: a report from North Central Cancer Group Trial N0747 and a systematic review of the literature

Oncologists are now prescribing more oral chemotherapy than ever before, thus placing the onus for taking the right dose at the right time under the right circumstances directly on the patient. This study was undertaken to understand emerging adherence issues and to explore available adherence assessment tools. This two-part study (1) examined N0747, a randomized phase II trial that tested the oral agents, sunitinib and capecitabine, in patients with metastatic esophageal cancer from an adherence standpoint, and (2) conducted a systematic review to compile and assess adherence tools that can be used in future clinical trials. First, in N0747, patients were assigned to sunitinib and capecitabine versus capecitabine; 53 chemotherapy cycles were prescribed to this 12-patient cohort. Nearly all patients denoted that they "always or almost always" took their pills as prescribed, and two patients who reported lack of full adherence suffered from grade 3+ adverse events. Surprisingly, however, over 14 cycles, 9 patients reported grade 3+ toxicity but checked "always or almost always" to describe their adherence. No relationships were observed between adherence and cancer outcomes. Secondly, 21 articles identified the following adherence tools: (1) healthcare providers' interviews, (2) patient-reported adherence with diaries/calendars, (3) patient-completed adherence scales, (4) medication event monitoring, (5) automated voice response, (6) drug/metabolite assays, and (7) prescription databases. Of note, only the automated voice response seems capable of real-time detection of over-adherence, as observed in N0747. Oral chemotherapy adherence should be further studied, particularly from the standpoint of over-adherence.

Endometrial carcinoma metastatic to the retromolar pad

Metastatic carcinoma from the female genitalia to the oral mucosa is exceptionally rare, with only 11 such cases having been previously reported in the English-language literature. We describe a new case in a 65-year-old woman with a history of endometrial carcinoma who presented with swelling of the retromolar pad. Radiographic examination showed slight opacities and irregular trabecular bone in the left posterior mandible. Following an incisional biopsy, histologic examination and immunohistochemical studies revealed glandular adenocarcinoma with positivity for progesterone receptor, estrogen receptor, and cytokeratin 7. The patient was referred to her primary care physician for comprehensive treatment. This case illustrates the value of considering cancer metastasis in the differential diagnosis of an oral swelling, particularly in a patient with a history of cancer.

Tongue and cheek metastases as the first clinical sign of a primary cancer

Metastases to the oral cavity are rare and are most frequently seen in the jawbones. Soft tissue metastases as the first clinical sign of a metastatic cancer are quite exceptional. In this case report, we describe the history of a 67-year old patient presenting with painless oral lesions for 4 weeks. Biopsies showed metastases of an adenocarcinoma that was not yet identified. This case report highlights that an ENT physician should consider metastases to the oral cavity as part of the differential diagnosis in every patient with an uncommon, persistent oral lesion with unclear origin.

Oral metastasis: a report of 23 cases

The authors describe a pooled analysis of 23 French patients presenting with oral metastasis between 1981 and 2008. The reviewed cases were collected from the medical records of two cancer institutes. The inclusion criteria were: the histology of the metastases must be known; the primary location must be known; metastasis and primary location must be physically separated; and oral primary locations were excluded. This sample represent 0.48% of all oral malignancies treated during the period. The sex-ratio was 2.3:1 in favour of men, the mean age was 64.5 years (±13.2). Lungs and kidneys represent 52.2% of the primary cancer locations. In most cases, the primary cancer was a carcinoma or an adenocarcinoma (82.6%). The most affected oral regions were the gingiva and alveolar mucosa (60.7%), followed by the tongue (17.9%). The mean survival was 16.6 months. This sample is characterized by the relative absence of specific symptoms and quite different distribution in primary sites. Even if oral metastases are rare, their semiological value necessitates the histopathological examination of any oral tumour, and a systematic search in all patients with cancer history.

Metastases to the oral cavity

Metastatic spread to the oral cavity of a malignant neoplasm is a rare yet important sign of advanced systemic malignant disease. This manuscript briefly describes the metastatic process and highlights the most common neoplasms that metastasise to the oral cavity as well as their clinical and radiological presentations. The role of the patients' history in suspecting metastatic disease and the importance of a microscopic diagnosis is emphasised.

Delayed lymph node metastases after elective neck dissection in patients with oral and oropharyngeal cancer and pN0 neck

PURPOSE

Patients with surgically treated head and neck cancer and clinical N0 neck with high risk of occult lymph node metastasis undergo elective neck dissection (ND). Late lymph node metastasis may appear in those patients with pN0 neck. The aim of the present study was to analyze the incidence and clinical relevance of late lymph node metastasis in patients with head and neck cancer.

MATERIALS AND METHODS

The clinical data of 61 patients with head and neck cancer who had undergone elective ND with pN0 neck were retrospectively analyzed. Only patients without local failure, second primary, or radiochemotherapy were included in the study.

RESULTS

Late lymph node metastasis could be observed in 4 (6.5%) cases at the margin or outside the initially dissected lymph node levels. In those patients, the primary tumor was localized in the oral cavity (n = 3) or oropharynx (n = 1) and was classified in all cases as T1 or T2. Lymph node metastasis could be found in levels I (n = 2), II (n = 1), and IV (n = 1), respectively.

CONCLUSION

Even in the case of pN0 neck after an elective ND, the appearance of late lymph node metastases must be expected. The low proportion of patients with late lymph node metastases after a selective ND in clinical and histologic N0 does not justify an extended form of neck surgery.

The role of elective supraomohyoidal neck dissection in the treatment of early, node-negative oral squamous cell carcinoma (OSCC): a retrospective analysis of 122 cases

The adequate treatment of the neck in early, clinically node-negative oral squamous cell carcinoma (OSCC) remains controversial. To assess whether elective supraomohyoid neck dissection is reasonable and efficient in early, locally circumscribed OSCC, the outcomes of treatment of 122 patients with an OSCC of clinical UICC stage I or II were retrospectively analysed in this study. Occult lymph node metastases were detected in 13.9% (17/122) of cases. They were more frequently found in T2 compared to T1 tumours (19.7% (14/71) vs. 5.9% (3/51), p=0.03), age, gender and grading had no influence on the prevalence of occult lymph node metastases (all p-values>0.05) in a multivariate logistic regression model. Subsequent multivariate survival analysis found that the presence of occult metastases was an independent predictor of reduced disease-free survival after 5 years (82.2% vs. 62.5%, p=0.004, and 61.9% vs. 17.8%, p<0.001, respectively). Elective supraomohyoid neck dissection detects occult metastases in early, node-negative OSCC, and patients with early OSCC exhibiting occult metastases should be considered as high risk patients, warranting additional therapeutic regimes.

Impact of neck dissection in early tongue and buccal cancer without neck extension

PROBLEM

The role of elective neck dissection in early stage tongue and buccal squamous cell carcinoma with negative neck lymph nodes is still controversial.

METHODS

We retrospectively reviewed patients with T1-2N0M0 buccal and tongue cancer who underwent primary tumour excision with or without elective neck dissection between January 1997 and December 2006.

RESULTS

Elective neck dissection specifically improved disease-free survival of T2N0M0 buccal cancer and overall survival of T2N0M0 tongue cancer.

CONCLUSION

Elective neck dissection seems to improve the disease-free survival rate of T2N0M0 buccal cancer and the overall survival rate of T2N0M0 tongue cancer but has no beneficial effect on the survival rate of T1N0M0 buccal and tongue cancer.

Metastases to the mouth and jaws: a contemporary Canadian experience

BACKGROUND AND OBJECTIVE

The types of cancers that most frequently metastasize to the mouth and jaws reflect, for the most part, the relative incidence of cancers in a given population at a given time. We report a retrospective, but relatively contemporary study of 38 cases of metastatic oral tumours in a Canadian population to compare the Canadian experience with that of nearby and distant countries.

METHODS

Thirty-eight cases of metastatic disease to the mouth and jaws in a Canadian population were analyzed. Data about patients' age, sex, site of metastatic deposits, clinical history, including the presence of a known primary cancer, and radiographic features were collected from the files (1992-2010) of the oral pathology diagnostic service at the University of Western Ontario, and the hospital archives (2002-2010) of the department of pathology, London Health Sciences Centre, London, Ontario.

RESULTS

Most metastases were to the mandible, although oral soft tissues were also involved, most frequently, the gingiva and mucosa of the alveolar ridge. Prostate, lung and breast cancers were the most common primary sites, but a variety of cancer types were found.

CONCLUSIONS

The relative frequency of types of metastatic cancer to the oral region is similar in Canada, the United States and Northern Europe, but differs significantly from those reported in South East Asia and Japan. The relative frequency of types of cancer that metastasize to the mouth and jaws reflects the relative incidence of cancers in the population.

Late metastasis of gastrointestinal stromal tumour to the oral cavity

This report describes the diagnosis and treatment of a metastasis of a gastrointestinal stromal tumour (GIST) to the oral cavity in a 64-year-old female, 14 years after treatment for a gastric primary and 11 years after partial hepatectomy for regional recurrence. The metastasis grew slowly in the buccal soft tissues and became symptomatic by intraoral extension. Positron-emission tomography combined with computed tomography depicted a solitary space-occupying lesion in the right buccal region with high standardized uptake values. Surgical exploration revealed a ball-shaped firm tumour mass adhering to the adjacent tissues that was completely resected. Subsequent healing was uneventful. Six months following ablative surgery the patient was in good general condition. There were neither signs of local tumour recurrence nor further distant spread. However, the patient is now under continuous medication with imatinib. GIST metastases to the head and neck region are very rare. Two recent case reports about head and neck metastases of GIST showed a predilection for bone. This metastasis was solely located in the oral soft tissues.

[Distant metastases of malignant tumors of head and neck]

The charts of 176 previously untreated patients with head and neck squamous cell carcinoma who completed treatment during 2006 in Oro-Maxillo-Facial Clinic, UMF "Carol Davila" Bucharest were reviewed. These patients had no evidence of distant metastases when initially evaluated. The overall incidence of distant metastases was 27.84%, varying from 10.52% for buccal mucosa to 63.63% for tongue and floor of the mouth (p < 0.05). 80% of the metastases were detected within two years after treatment. The rate also increased with the T and N classification; however, the N stage had greater influence on the rate of metastases than the T stage.

Multiple distant metastases of hepatocellular carcinoma to the oral cavity

We describe the palliative therapy for multiple metachronous oral metastases of hepatocellular carcinoma in a 72-year-old patient with emphasis on maintaining oral functions by local debulking procedures in due consideration of the dissemination of the neoplasm to multiple organs. The first oral metastasis was the first evidence of multiple tumor spread after partial hepatectomy. Palliative chemotherapy with sorafenib was cancelled after three weeks due to tumor progression and hemiplegia following brain metastasis and stroke. Periodical screening of the patient for oral findings allowed the non-mutilating excision of further oral metastases at an early stage with no signs of local recurrence during the follow-up period. Oral metastases from hepatocellular carcinoma appear to occur more frequently than formerly supposed.

A case of neonatal mature teratoma transformed to malignancy in the neck extending to the mouth floor

A case with neonatal teratoma originating from the cervicofacial region which transformed to be malignant during treatment is reported. The case is a full-term baby girl with swallowing difficulty and has a mass at the floor of her mouth with the right neck swelling. The mass was revealed to be multi-cystic and extending deep into the sublingual space and protruding outside. Puncture and marsupialisation of the cyst could not relieve her symptom and the tumor was resected in three occasions and was diagnosed as mature teratoma without malignant component. However, three months after the last resection, the solid right neck mass enlarged rapidly and the serum alpha-fetoprotein level was elevated. Biopsied specimen demonstrated the mass to be germ cell tumor with embryonal carcinoma and yolk sac tumor component. Eight courses of JEB regimen with recurrent mass resection successfully lead to complete regression without compromising patient growth as well as cosmetics. Head and neck teratomas in children are mostly benign amenable to curative excision but its rarity and site and size of the tumor make its treatment challenging. It is important to have multi-disciplinary management for the disease from neonatal period until growth has finished. There exists a relationship between the age at diagnosis and outcome of a patient with teratoma and head and neck teratomas in neonate are mostly benign but should be removed completely as soon as the patient condition is stabilized to reduce the risk of malignant change.

Metastatic tumors to the oral and maxillofacial region: a retrospective study of 19 cases in West China and review of the Chinese and English literature

PURPOSE

The aim of this article was to obtain an overview of metastatic tumors to the oral and maxillofacial (OMF) region, especially the differences in the constituent ratios of primary cancers between the United States and China.

PATIENTS AND METHODS

Clinical findings of 19 cases encountered in West China Hospital of Stomatology were summarized and the English and Chinese literature were reviewed and analyzed. The main clinical features of OMF metastases were summarized, with an emphasis on primary cancers' constituents.

RESULTS

The lung, breast, kidney, liver, and prostate were the top 5 common primary sites of cancer. However, there was a significant difference in the primary cancers' constituents between United States and China (P < .001). The breast, kidney, prostate cancers, and melanoma of skin were more frequent primary cancers in United States than in China, whereas that of the lung, thyroid, liver, esophagus, and the stomach were more common in China than in United States. The proportions of the OMF metastatic lesions originating in the lung, kidney, liver, thyroid, and esophagus in all OMF metastatic tumors were higher than the corresponding primary cancers' prevalent proportions.

CONCLUSIONS

The frequency of developing OMF metastasis is not always consistent with primary cancers' prevalence, which suggests that different cancers have different potentiality to develop OMF metastasis. Cancers of the kidney, liver, lung, thyroid, and esophagus were more likely to spread to the OMF region. In general screening of primary cancer, it would be helpful to take into account the metastatic potentiality of different cancers and primary cancers' prevalence in different countries in the case of occult primary.

Oral metastasis of renal cell carcinoma, presentation of a case

The oral cavity constitutes a site of low prevalence for metastasis of malignant tumors. Nevertheless, it has a high prevalence for metastasis of renal origin. Besides the kidneys, there are other primary sites with high prevalence of metastasis to the oral mucosa, such as the lungs, skin and breasts. Metastasis is common in patients with a background of treated renal tumors, thereby, it is proper to determine the possibility of oral metastasis as part of the protocol of attention. However, it constitutes a diagnostic challenge when it presents in patients with no renal antecedents. It is in this type of patients that the diagnosis of carcinoma is achieved by means of a metastasis. Survival rate in these patients is short because at the time of the metastasis diagnosis, the general compromise is high. The following report describes a case referred from the Rheumatology Unit with an intraoral tumor, that was finally diagnosed as a Metastasic Renal Cell Carcinoma with multiple metastasis.

E-cadherin loss and Delta Np73L expression in oral squamous cell carcinomas showing aggressive behavior

BACKGROUND

This article sought to investigate the existence of parameters useful for predicting lymph node metastases in cases of surgically resected oral squamous cell carcinomas (OSCCs).

METHODS

Fifty-eight cases were studied for E-cadherin and the truncated dominant-negative isoform of p63 (Delta Np63) with immunohistochemistry. In addition, the p63 gene expression profile was evaluated by reverse transcriptase-polymerase chain reaction (RT-PCR) to disclose the presence of the truncated variant Delta Np73L.

RESULTS

E-cadherin expression was the most powerful parameter related to the presence of lymph node metastases at presentation. Twenty-four of 38 (63%) cases showing low E-cadherin expression had lymph node metastases at presentation compared with 5 of 20 (25%) (p <.01) cases showing high E-cadherin expression. The high predictive value was also maintained when a low expression of E-cadherin was associated with immunohistochemical high expression of DeltaNp63. The association between low E-cadherin expression and Delta Np73L (as seen with reverse transcriptase-polymerase chain reaction) was highly predictive for developing lymph node metastases, especially in small tumors (T1\T2). When this association occurred, metastases developed in 62.5% of cases during the follow-up compared with 16.1% in those which did not show low E-cadherin expression and presence of Delta Np73L.

CONCLUSION

This study shows that low E-cadherin expression is useful for predicting lymph node metastases in cases of OSCC. The predictive value is enhanced when low E-cadherin positivity is associated with DeltaNp63 and Delta Np73L expression.

Large oral soft tissue metastasis from anaplastic carcinoma of the lung mimicking a primitive malignancy: case report and brief review of the literature

Metastatic tumours to the oral region are rare, and those reported in the buccal soft tissues are even less frequent. We describe a case of anaplastic carcinoma of the lung in a 60-year-old man, presenting a huge oral metastasis as the first sign of his primitive lung malignancy. Clinically, the oral lesion mimicked a high-grade primitive carcinoma of the oral cavity. The biopsy established the gingival metastasis from lung cancer which was confirmed by a fine-needle aspiration cytology examination. We report an uncommon case of metastatic lung carcinoma to the gingiva emphasizing the differential diagnosis between primary and metastatic tumours; a short discussion on the pathways of metastatization to oral cavity soft tissues, as well as brief review of the literature are also presented.

UCN-01 (7-hydroxystaurosporine) induces apoptosis and G1 arrest of both primary and metastatic oral cancer cell lines in vitro

OBJECTIVE

Our aim was to clarify the in vitro antiproliferative effects of UCN-01 on human oral squamous cell carcinoma (OSCC) cell lines.

STUDY DESIGN

Cell growth was measured by MTT assay, and cell cycling was assessed by flow cytometry. Changes in the levels of protein and protein phosphorylation were analyzed by Western blotting. In addition, tumor cell apoptosis was assessed by propidium iodide (PI) and annexin double-staining.

RESULTS

UCN-01 significantly inhibited the proliferation of all the OSCC cell lines, with a 50% inhibition concentration of about 300 nmol/L, and induced G1 arrest in these cell lines in a dose-dependent manner. Primary and metastatic oral cancer cell lines had different sensitivities to UCN-01. Our results showed that HSC-3 cells (primary-type OSCC) are less sensitive than LMF4 cells (metastatic-type OSCC) to UCN-01. In addition, the induction of p21 in OSCCs was found to be important for the suppression of tumor growth.

CONCLUSION

The results of this study suggest that UCN-01 induces apoptosis and G1 arrest in OSCCs, albeit with different sensitivity of the primary and metastatic cell lines to UCN-01.

Correlation of proliferative markers (Ki-67 and PCNA) with survival and lymph node metastasis in oral squamous cell carcinoma: a clinical and histopathological analysis of 113 patients

The purposes of this study were to examine the correlations between proliferation markers and survival rate in oral squamous cell carcinoma (OSCC) patients, and to evaluate the efficacy of proliferation markers in predicting lymph node metastasis. The patients' age, gender, T score, clinical stage, PCNA and Ki-67 index were analysed. Univariate analysis showed that T score had a significant influence on survival, and stage 4 group had a significantly lower survival rate. Lymph node metastasis was also a significant predictor of survival. Using a cut-off point of 25%, those patients with lower Ki-67 scores had survival advantage over those with higher Ki-67 scores. PCNA did not show any differences in survival with a cut-off point of 50%. Ki-67 and PCNA were significantly higher in the primary tumours associated with lymph node metastasis (pN+) than in those without lymph node metastasis (pN0). Multivariate analysis showed that clinical stage and Ki-67 were independent prognostic factors for survival in OSCC patients. From this result, it can be postulated that the cancer staging based on the TNM stage was a powerful prognostic variable and Ki-67 had a significant effect on the cumulative survival rate.

Soft-tissue metastasis of osteosarcoma to the submental vestibule

A case of metastatic osteosarcoma in the submental vestibule of the oral cavity and the lung is described in an 18-year-old male with primary osteosarcoma occurring in the sacrum. Dissemination of osteosarcoma to other organs, especially early to the lung, is common, but its metastasis to the oral mucosa has been rarely reported. The patient presented 6 years after initial diagnosis, suggesting the need for careful long-term follow-up of patients with osteosarcoma. This case also illustrates that immunohistochemical staining of osteocalcin is useful to confirm the histological diagnosis of oral soft-tissue metastasis.

Array-comparative genomic hybridization to detect genomewide changes in microdissected primary and metastatic oral squamous cell carcinomas

Oral squamous cell carcinoma (OSCC) is a common worldwide malignancy. However, it is unclear what, if any, genomic alterations occur as the disease progresses to invasive and metastatic OSCC. This study used genomewide array-CGH in microdissected specimens to map genetic alterations found in primary OSCC and neck lymph node metastases. We used array-based comparative genomic hybridization (array-CGH) to screen genomewide alterations in eight pairs of microdissected tissue samples from primary and metastatic OSCC. In addition, 25 primary and metastatic OSCC tissue pairs were examined with immunohistochemistry for protein expression of the most frequently altered genes. The highest frequencies of gains were detected in LMYC, REL, TERC, PIK3CA, MYB, MDR1, HRAS, GARP, CCND2, FES, HER2, SIS, and SRY. The highest frequencies of losses were detected in p44S10, TIF1, LPL, MTAP, BMI1, EGR2, and MAP2K5. Genomic alterations in TGFbeta2, cellular retinoid-binding protein 1 gene (CRBP1), PIK3CA, HTR1B, HRAS, ERBB3, and STK6 differed significantly between primary OSCC and their metastatic counterparts. Genomic alterations in PRKCZ, ABL1, and FGF4 were significantly different in patients who died compared with those who survived. Immunohistochemistry confirmed high PIK3CA immunoreactivity in primary and metastatic OSCC. Higher FGF4 immunoreactivity in primary OSCC is associated with a worse prognosis. Loss of CRBP1 immunoreactivity is evident in primary and metastatic OSCC. Our study suggests that precise genomic profiling can be useful in determining gene number changes in OSCC. As our understanding of these changes grow, this profiling may become a practical tool for clinical evaluation.

[Malignant melanoma metastasis in the oral cavity]

Malignant melanoma occurs only rarely as a primary tumour in the oral cavity, with an incidence of 1-2 percent. Oral melanomas are predominantly to be found in the hard and soft palate, and less often in the gingiva and mandible. Mucosal malignant melanomas are much more aggressive than those situated in the skin. In two-thirds of the cases the route of formation of the metastases is lymphogenic, and haematogenic in the remainder. The typical sites of the distant metastases are the skin, the lungs, the brain, the liver, and the bones. Metastatic malignant melanoma in the oral cavity, a rarity in the literature, is associated with a very poor prognosis. This paper reports on two cases in which an isolated distant metastasis developed in the oral cavity.

Oral metastasis of ciliary body melanoma. A case report

Metastases of melanoma rarely occur in the oral cavity, and very few reports have been published. They are chiefly localized in the tonsil, tongue and lip, regardless of the primary site of the neoplasm. A 76-year-old woman presented a brownish berry-shaped floating neoformation at the upper lip, for which she was hospitalized at the Maxillofacial Surgery Unit, Italian Stomatologic Institute, Milan. Medical history revealed that 6 years previously, in 1998, she underwent enucleation of the right eye due to the presence of a melanoma of the ciliary body. The labial neoplasm was removed and at histological examination it was found to be a spindle cell melanoma with numerous melanophages containing granules of melanin. Both the spindle cells and the melanophages were strongly positive for HMB-45 and for S-100. Thus, the presence of melanic neoplasia at an unusual site together with the medical history of melanoma at the ciliary body, removed 6 years previously, indicated a diagnosis of labial metastasis of melanoma of the ciliary body and the patient was therefore transferred to the Oncology Unit for appropriate treatment.

A metastatic haemangiopericytoma of the floor of the mouth

A case of metastatic haemangiopericytoma in the floor of the mouth is described. Haemangiopericytoma is a relatively rare slow-growing vascular tumour with variable malignant potential. This tumour has been identified in almost every region of the body, but its occurrence in the oral cavity has been rarely reported. The rate of regional and distant metastasis of the tumour is low. This case, presented 12 years after initial surgery suggested the need for careful long-term follow-ups of patients with haemangiopericytoma.

Metastatic tumours to the jaws and oral soft tissues: a retrospective analysis of 41 Korean patients

This article describes a pooled analysis of 41 Korean patients with metastatic oral tumours. The data reviewed are from Korean dental and medical case reports published between 1983 and 2004. The mean age was 55.2 years, and the male-to-female ratio was 1.9:1. There were more metastases in the jawbone than in oral soft tissues. The lung was the most common primary site for jawbone metastases, whereas the liver was for those of oral soft tissues. In contrast to reports in Western literature of the breast being the most common primary site, the liver was the most common primary site, followed by the lung and thyroid. These differences may be caused by a relatively high incidence rate of hepatocellular carcinoma in Korea.

Metastatic uterine leiomyosarcoma masquerading as a primary lesion of the masseter muscle

Leiomyosarcomas are malignant tumours of smooth muscle origin. These tumours are very rare in the head and neck region. We report a case of metastatic uterine leiomyosarcoma masquerading as a primary sarcoma of the masseter muscle. We highlight the importance of considering the possibility of an unrecognised primary abdominal or uterine tumour.

Oral ulcer as an exclusive sign of gastric cancer: report of a rare case

BACKGROUND

The oral cavity is a rare but occasional target for metastases, which may masquerade as various benign and inflammatory lesions, and sometimes also be asymptomatic. Oral metastatic lesions have been described in various cancers, particularly lung, breast and kidney carcinoma.

CASE PRESENTATION

We here describe an uncommon case of a hard palate mucosa and gingival metastasis from gastric carcinoma that was originally diagnosed as a periodontal disease. Histopathological examination of a biopsy of the lesion revealed a signet-ring cell carcinoma, and a subsequent biopsy of an ulcerated stomach lesion showed a poorly differentiated gastric carcinoma. The patient underwent gastric resection but died of heart failure on the tenth postoperative day; a post-mortem examination revealed a residual bilateral ovarian infiltration by gastric carcinoma (Krukenberg's tumor).

CONCLUSION

An occult carcinoma of the stomach may rarely metastasise to the oral cavity even as a first and exclusive manifestation; it is important to bear this possibility in mind because such conditions may mimic a benign disease.

Metastatic breast cancer of the oral cavity

OBJECTIVE

To present a rare case of breast carcinoma initially presenting as an oral cavity mass.

STUDY DESIGN

Case report with review of the literature.

RESULTS

A case is presented of a postmenopausal woman with a remote history of treated breast carcinoma who was declared disease-free 2 years before presentation. She presented with an enlarging vestibule mass consistent with metastatic breast carcinoma. Subsequent investigations revealed widely metastatic disease for which the patient was referred for palliative chemotherapy.

CONCLUSIONS

Metastatic disease to the oral cavity represents only 1% of all oral cavity malignancies. A high index of clinical suspicion is necessary when evaluating patients with a history of non-head and neck carcinoma.

Long-term follow-up of secondary malignancies in adults after allogeneic bone marrow transplantation

The purpose of this study was to evaluate the estimated incidence of secondary malignancies post-allogeneic bone marrow transplantation (BMT) in a cohort of adult patients previously reported now with an additional 8.5 years of follow-up. A cohort of 557 patients older than age 16 years underwent allogeneic BMT between June 1970 and November 1993. Histologic reports confirmed the diagnosis of a secondary malignancy. Multivariate Cox proportional hazards method was utilized to investigate predictors for the development of secondary malignancies. In all, 31 patients in this cohort developed a secondary malignancy a median of 6.79 years after their transplant. The estimated cumulative incidence rate of secondary malignancy was 4.2% at 10 years post transplant. When compared to the general population, the estimated observed/expected ratio of new cancer diagnoses was 5.13. On multivariate analysis, older age at the time of transplant was the only significant predictor for development of secondary cancer (P=0.01). The most common malignancies observed were nonmelanomatous skin cancers and squamous cell cancers of the buccal cavity. The risk of developing a secondary malignancy after allogeneic BMT is significant, particularly in older patients. Long-term survivors of transplant require regular monitoring for early signs of cancer, particularly of the skin and oral cavity.

ORAL PRESENTATION OF EPITHELIOID ANGIOSARCOMA WITH FIRST SIGN IN THE SCAPULA: REPORT OF A CASE AND REVIEW OF THE LITERATURE

Occurrence of a primary or metastatic angiosarcoma in the oral cavity is extremely rare. The term "epithelioid angiosarcoma" (EA) has been used to designate a morphological variant of angiosarcoma characterized by poorly differentiated epithelial-like cells arranged in carcinoma-like fashion, but which still forms identifiable vascular channels. To our knowledge, EA in the oral region is extremely rare. Only two previous instances of EA in the maxilla have been reported. We present an additional oral case of EA in a 71-year-old man. Histology of the initial oral biopsy revealed suspicion of un-differentiated carcinoma. In order to confirm the diagnosis, immunohistochemical examinations were performed. The final diagnosis was EA. The patient died of multiple metastases shortly after the final diagnosis, implying an aggressive clinical course. This case showed that it was essential to use the vascular markers, such as FVIII-Rag and CD34, for a correct histological diagnosis of EA. The oral EA described here almost certainly represents a metastatic focus, rather than the primary site of tumor origin. This is because clinical history of EAs appears to arise in deep, rather than in more superficial tissues.