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CASE REPORT  
Year : 2020  |  Volume : 63  |  Issue : 2  |  Page : 273-275
Lung metastasis, an incidental finding in maxilla – A case report


Department of Oral and Maxillofacial Pathology and Microbiology, D. Y Patil Deemed to be University, School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India

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Date of Web Publication18-Apr-2020
 

   Abstract 


The aim of this article was to present an asymptomatic lesion with insignificant clinical findings which turned out to be metastatic lesion in the jaws with primary in lung. The most common site of lung metastasis in the orofacial region is the mandible, but in our case it was seen in the maxilla. Metastases to the jaw bones occur in later stages. Hence, a careful examination of patients with jaw bone lesions is strongly suggested. Metastasis to the jaw should be considered while doing oral examination as observed in the current case because such lesions usually develop at terminal stage of cancer.

Keywords: Asymptomatic lung adenocarcinoma, jaw, maxilla, metastasis

How to cite this article:
Tamgadge S, Pereira T, Kale S, Shetty S, Tamgadge A. Lung metastasis, an incidental finding in maxilla – A case report. Indian J Pathol Microbiol 2020;63:273-5

How to cite this URL:
Tamgadge S, Pereira T, Kale S, Shetty S, Tamgadge A. Lung metastasis, an incidental finding in maxilla – A case report. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 May 27];63:273-5. Available from: http://www.ijpmonline.org/text.asp?2020/63/2/273/264517





   Introduction Top


Metastatic tumors to the oral region are extremely rare, comprising only upto 3% of all malignant oral neoplasms. They may present in oral soft tissues or hard tissues or in both, which was evident in the current case.[1]

The predominant sites of origin of jaw metastasis are the breast, lung, and kidney. The mandible is the most common location for metastases, with the molar area being the most often involved site as it contains hemopoietic marrow. Such lesions are nonaggressive clinically and mimic a reactive or benign lesion or even simple oral infections.[2]

These tumors with insignificant findings should be dealt with great caution, as their appearance may be the first indication of an undiscovered malignancy at a distant primary site, or the first evidence of dissemination of a known tumor from its primary site.[3]

This article presents a unique case with asymptomatic lesion in the maxilla which turned out to be metastatic lesion with primary in the lung and could have been easily missed out by oral surgeon.


   Case Report Top


A 41-year-old male patient, watchman by profession, reported with chief complaint of mobile front teeth with dull pain and insignificant swelling in the upper front region of the gums for 4 months.

Systemic history was not contributory with no history of routine medications. There was history of trauma 20 years back, to the left eye while walking when he was hit by a branch of a tree. After that, he partially lost his vision for which he took treatment at Calcutta. The patient was gutkha chewer for 20 years consuming two to four times a day. As there was no significant history pertaining to the chief complaint, the patient was referred for oral prophylaxis followed by root canal treatment. He was advised intraoral periapical (IOPA) radiograph with 11, 12.

Intraoral examination revealed inflamed gingiva in 11 and 12 with bleeding on provocation.

There was diffuse mild insignificant swelling extending from 12 to 21 region which was nontender on palpation initially. Gingival recession was observed in 11–21, associated with mild cortical plate expansion. Due to significant tooth mobility, the patient was finally advised tooth extraction of 12 [Figure 1].
Figure 1: (a and b) Intraoral photograph showing lesion in upper left gingiva. (c) IOPA showing the osteolytic lesion. (d) OPG showing the osteolytic lesion

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After extraction, curetted periapical granulation tissue and little gingival tissue were submitted for histopathological examination.

Histopathological examination of both the tissues revealed connective tissue stroma composed of proliferating columnar to polygonal tumor cells atypically arranged in ductal pattern showing malignant features with moderate amount of chronic inflammatory cell infiltration [Figure 2].
Figure 2: (a) Malignant cells in connective tissue in gingival biopsy (H and E stain). (b) Malignant cells in connective tissue in gingival biopsy showing negative S-100 staining (IHC). (c) Malignant cells in connective tissue in gingival biopsy showing positive CD34 staining (IHC). (d) Malignant cells in periapical tissue (H and E stain). (e) Malignant cells in periapical tissue showing negative S-100 staining (IHC). (f) Malignant cells in periapical tissue showing positive CD34 staining (IHC)

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It was suggestive of adenocarcinoma which was also confirmed by a second opinion from an eminent general pathologist.

Immunohistochemistry was positive for CD34 and negative for S-100 marker. The patient was advised positron emission tomography scan to rule out primary in lung. As the patient was from low socioeconomic background, he could not afford and therefore never reported back in spite of our repeated attempts.

Ultrafast computed tomography scan of neck and thorax revealed lung mass lesion noted in the posterobasal segment of the left lower lobe of size 33 × 31 mm with cut-off of the subsegmental bronchiole, perilesional interlobular septal thickening, and abutting the adjacent posterior mediastinal and costal pleura with minimal loculated pleural effusion.

There were two other smaller lung nodules noted, one in the apicoposterior segment of the left upper lobe (2 mm) and the other in the medial basal segment of the right lower lobe (7.1 mm). The posterolateral segment of the left lower lobe also had 33 × 31 mm nodule.


   Discussion Top


Metastatic tumor spreads through lymphatic, blood vessel permeation, transcoelomic permeation, local infiltration, or a combination of these. Metastasis to jaw is more common through blood stream when compared to lymphatic route. The most common primary sites are carcinomas of the breast in women and of the lung in men similar to our case.[4]

Metastatic spread is more common to the mandible due to the presence of active red marrow in the mandible than maxilla. But in our case, it was seen in the maxilla which is a unique feature reported in the literature.[5]

Oral metastasis carries a grave prognosis for the patient because it represents advanced disease. The gingival or alveolar mucosa is the most common soft-tissue site, as seen in our case, but our case also had intraosseous deposits along with gingival involvement.[2]

Metastasis to the jaw may be the first indication of an undiscovered malignancy at a distant primary site, or the first evidence of dissemination of a known tumor from its primary site. Similar findings were observed in our case as the patient was unaware of the lesion because of insignificant clinical findings and history.[6]

The diagnosis of a metastatic oral lesion is challenging. The clinician must recognize the possibility of metastasis and treat such deceptive lesions with great caution. Therefore, after extraction, the gingival and periapical tissues were submitted for histopathological examination and it turned out to be lung metastasis which could have been easily missed out. Most of the metastatic lesions to the jaw bones are osteolytic which was also seen in our case.[7],[8]

In 2008, Hirshberg et al. presented a review of 673 cases of oral metastasis. The mean age of occurrence was 54 years (range: 9–88 years) with slight male predilection, but this case report presents a slightly younger patient with age of 41 years.[9]

Primary tumors have been detected in most of the patients before the metastatic spread to the oral cavity. In our case, it was detected before.

Pathogenesis of oral metastasis is unclear. In oral soft tissues, passage of tumor cells in the gingival tissue can be facilitated by the greatest permeability of vessels with rich capillary network and the presence of adhesive molecules.[8]

This article emphasizes on detailed dentoalveolar examination and early diagnosis of metastatic tumor, which will help in better prognosis of patients.

Oral cavity metastasis is also a therapeutic challenge for clinicians. The dentists have an important role in the diagnosis and management of patients with cancer, especially in those with undiscovered malignancy.[9],[10] On radiographic examination, metastatic lesions mostly appear as a radiolucent area with ill-defined borders.[11]

In conclusion, metastases to the oral cavity are not rare. They usually present with insignificant clinical findings, causing a delayed diagnosis and treatment. Careful examination and a multidisciplinary team approach is suggested. Dentists and general physicians should take into consideration the possible presence of jaw metastases in cases that present atypical symptoms, especially in patients with unknown malignant disease.

The diagnosis of metastatic lesion may be difficult owing to their rarity and clinical presentation. There is the potential for misdiagnosis as a benign lesion or odontogenic pathology. Therefore, a biopsy is essential especially in patients with a previous known history of malignancy. Health professionals should be aware of the possible presence of jaw metastasis in patients with atypical presenting symptom.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bhaskar SN. Synopsis of Oral Pathology. Vol. 6. St Louis: The CV Mosby Company; 1981. p. 330-3.  Back to cited text no. 1
    
2.
Daley T, Darling MR. Metastases to the mouth and jaws: A contemporary Canadian experience. J Can Dent Assoc 2011;77:b67.  Back to cited text no. 2
    
3.
Cotran RS, Kumar V, Robbins SL. Robbins Pathology Basis of Diseases. 5th ed. Philadelphia, PA: W.B. Saunders Company; 1994. p. 276-8.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
  [Full text]  
5.
Tamiolakis D, Samis T, Thomaidis V, Lambropoloulou M, Alexiadis G, Venizelos I, et al. Papadapoulos jaw bone metastasis: Four cases. Acta Dermatoven Alp Pannonica Adriat 2007;16:21-5.  Back to cited text no. 5
    
6.
Aoe K, Hiraki A, Kohara H, Maeda T, Murakami T, Yoshimura T, et al. Gingival metastasis as initial presentation of small cell carcinoma of the lung. Anticancer Res 2003;23:4187-9.  Back to cited text no. 6
    
7.
Muttagi SS, Chaturvedi P, D'Cruz A, Kane S, Chaukar D, Pai P, et al. Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center. Indian J Cancer 2011;48:234-9.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
RajiniKanth M, Ravi Prakash A, Raghavendra Reddy Y, Sonia Bai JK, Ravindra Babu M. Metastasis of lung adenocarcinoma to the gingiva: A rare case report. Iran J Med Sci 2015;40:287-91.  Back to cited text no. 8
    
9.
Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic tumours to the oral cavity – Pathogenesis and analysis of 673 cases. Oral Oncol 2008;44:743-52.  Back to cited text no. 9
    
10.
Rajinikanth M, Prakash AR, Swathi TR, Reddy S. Metastasis of lung adenocarcinoma to the jaw bone. J Oral Maxillofac Pathol 2015;19:385-8.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Irani S. Metastasis to the oral soft tissues: A review of 412 cases. J Int Soc Prev Community Dent 2016;6:393-401.  Back to cited text no. 11
    

Top
Correspondence Address:
Sandhya Tamgadge
Department of Oral and Maxillofacial Pathology and Microbiology, D. Y Patil Deemed to be University, School of Dentistry, Sector 7, Nerul, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_325_19

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