LETTER TO EDITOR
Year : 2009 | Volume
: 52 | Issue : 3 | Page : 446--447
Metastatic hepatocellular carcinoma presenting as a gingival mass
Sharada Rai, Ramadas Naik, Muktha R Pai, Astha Gupta
Department of Pathology, Kasturba Medical College, Mangalore, India
Department of Pathology, Kasturba Medical College, Light House Hill Road, Mangalore, Karnataka - 575 001
|How to cite this article:|
Rai S, Naik R, Pai MR, Gupta A. Metastatic hepatocellular carcinoma presenting as a gingival mass.Indian J Pathol Microbiol 2009;52:446-447
|How to cite this URL:|
Rai S, Naik R, Pai MR, Gupta A. Metastatic hepatocellular carcinoma presenting as a gingival mass. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Nov 14 ];52:446-447
Available from: http://www.ijpmonline.org/text.asp?2009/52/3/446/55027
Oral metastatic tumors are uncommon and account for approximately 1% of oral malignant neoplasms. The common primary tumors which can metastasize to the oral cavity occur in the breast, lung, kidney, bone and colon. , Here we report a case of hepatocellular carcinoma (HCC) metastatic to the gingiva.
An 82-year-old man presented with a nodular gingival growth measuring 3 ´ 2 cm on the left side of the oral cavity, posterior to the second molar tooth and extending up to the tonsillar pillar. Computerized tomography scan revealed a soft tissue mass measuring 3 ´ 3 cm adjacent to the angle of the mandible and eroding the alveolar process of the maxilla. A diagnosis of carcinoma alveolus was considered based on the radiological findings and biopsy was performed from the growth. The biopsy comprised three hemorrhagic tissue bits each measuring about 1 cm in length. Histopathologic examination showed intact surface stratified squamous epithelium overlying a tumor [Figure 1]. The tumor tissue comprised large cells arranged in a trabecular pattern. The cells had abundant eosinophilic granular cytoplasm, moderately pleomorphic nuclei and prominent nucleoli. Few sinusoidal spaces filled with blood were also seen between the tumor cells. Since the surface epithelium was intact a diagnosis of metastatic tumor was considered.
On further investigation, ultrasound revealed a mass lesion in the liver [Figure 2] which on needle core biopsy proved to be an HCC. In correlation with these findings a final diagnosis of metastatic HCC to the oral cavity was rendered.
The oral sites of metastatic HCC include the jaw with a predilection for the mandible and the gingiva.  Clinically, gingival metastasis resembles hyperplastic or reactive lesions such as pyogenic granuloma, peripheral giant cell granuloma or fibrous epulis. The malignant gingival tumors differ from the non-malignant gingival tumors in that rapid and extensive growth is usually present in the former. 
The precise mechanism of metastasis of HCC to the oral region is poorly understood. It is believed that the portal hematogenous route is the preferred mode for oral metastasis. Another route consists of a pathway of rich anastomoses of paravertebral veins that lack valves and may be capable of bypassing other venous systems such as the pulmonary, caval and portal systems. ,
On radiographs, HCC metastatic to the jaw or to the gingiva with intraosseous extension, typically has a destructive radiolucent appearance with ill-defined borders as seen in our case. ,, A definite diagnosis of metastatic HCC to the jaw requires histological verification. Immunohistochemistry with alphafetoprotein, Hep-Par-1, α-1-antichymotrypsin and cytokeratin may aid in distinguishing metastatic HCC from other oral metastatic tumors in case of an unknown primary. 
The prognosis for patients with oral metastatic HCC is very poor, with palliative treatment often indicated to improve local function. , In conclusion, oral metastatic HCC though rare should be considered in the differential diagnosis of rapidly growing oral lesions.
|1||Ramón Ramirez J, Seoane J, Montero J, Gomez GCE and Cerero R. Isolated gingival metastasis from hepatocellular carcinoma mimicking pyogenic granuloma. J Clin Periodontol 2003;30:926-9.|
|2||Llanes F, Sanz- Ortega J, Suarez B and Sanz- Esponera J. Hepatocellular carcinomas diagnosed following metastasis to the oral cavity: Report of 2 cases. J Periodontol 1996;67:717-9.|
|3||Pires FR, Sagarra R, Correa MEP, Pereira CM, Vargas PA and Lopes MA. Oral metastasis from a hepatocellular carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:359-68 .|
|4|| Marker P, Clausen PP. Metastases to the mouth and jaws from hepatocellular carcinomas. Int J Oral Maxillofac Surg 1991;20:371-4.|
|5||Yoshimura Y, Matsuda S, Naitoh S. Hepatocellular carcinoma metastatic to the mandibular ramus and condyle: Report of a case and review of the literature. J Oral Maxillofac Surg 1997;55:297-306.|