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| CASE REPORT |
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| Year : 2019 | Volume
: 7
| Issue : 1 | Page : 18-20 |
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Prostatic adenocarcinoma with mandibular metastasis
Kritika Saxena
Department of Medical Health and Family Welfare, Government of Uttarakhand, Dehradun, Uttarakhand, India
| Date of Web Publication | 11-Jun-2019 |
Correspondence Address:
Kritika Saxena
G-12 Nehru Colony, Dehradun - 248 001, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jomr.jomr_3_19
Metastatic lesions of primary tumors comprise almost 1% of different types of oral cancers. These lesions can affect either bones or soft tissues in the maxillofacial region. Whenever the maxillofacial area is affected, the most common location is in the molar region of the mandible. A 70-year-old male patient, presented with swelling in the jaw region, of acute onset. Clinical, radiological, and histological examinations were carried out. Finally, it was diagnosed to be a metastatic lesion in the jaw, with the primary lesion being in the prostate gland. The clinical presentation of mandibular metastasis follows a pattern characterized by irradiated dental pain in the third molar region. Differential diagnosis and treatment of these patients can be extremely difficult because there are several pathologic conditions with similar symptoms.
Keywords: Cone-beam computed tomography, maxillofacial osseous metastasis, numb chin syndrome, prostatic adenocarcinoma
How to cite this article:
Saxena K. Prostatic adenocarcinoma with mandibular metastasis. J Oral Maxillofac Radiol 2019;7:18-20 |
| Introduction | |  |
Secondary malignancy of the jaws is uncommon. When encountered, such cases may be diagnostically challenging. About 1% of oral cancers, which are located in the soft tissues and jaws are metastases of primary tumors located elsewhere in the body. In 22%–30% of cases, the oral presentation of metastasis is the first sign of malignant disease.[1] The most common sites of primary tumors that lead to metastases of jaws are breast (42%), adrenals (8.5%), genital organs (7.5%), and thyroid (6%) in women. The most common sites of primary tumors are lungs (22.3%), prostate (12%), kidney (10.3%), bone (9.2%), and adrenals (9.2%) in men.[2] Prostate carcinoma prefers jawbone because of its significant red marrow component as a metastatic target. The present case report describes a case of prostate adenocarcinoma metastasizing to the mandible.
| Case Report | | |
A 70-year-old male patient reported to the Department of Oral Medicine and Radiology with a chief complaint of swelling in the left lower facial region for 6 days [Figure 1]. The swelling was associated with dull, intermittent, and nonradiating pain. He had a history of uneventful extractions 1 year back. The patient was taking Urimax–D for urine infection for 6 months.
On inspection, nothing relevant was noted as the lower third of the patient's face was covered with beard. On palpation, bony hard swelling was appreciated in the left mandibular posterior region, extending 2 cm posterior from labial commissure, till the angle of mandible; superoinferiorly, 1 cm superior to the lower border of mandible involving submandibular region inferiorly [Figure 1]. The swelling was spherical, with well-defined margins, nontender, and bony hard in consistency. On further examination, paresthesia was elicited in relation to the lower lip on the left side with associated numbness. Lymphadenopathy was absent.
On intra-oral examination, diffuse swelling with vestibular obliteration was appreciated in relation to left mandibular posterior tooth region, extending from 35 to retromolar region and mediolaterally from alveolar ridge to left buccal vestibule, measuring 3 cm × 1.5 cm. The swelling was nontender and bony hard in consistency [Figure 2].
Radiographic investigations were done, which included mandibular cross-sectional occlusal and digital orthopantomogram (OPG). On mandibular cross-sectional occlusal, periosteal reaction was appreciated in relation to the left buccal and lingual cortical plates resembling a sunray pattern. Both cortices were intact. Digital OPG revealed multiple radiolucent areas along with focal areas of sclerosis, extending from the 35 to the anterior ramus, involving the body of the mandible, resembling “moth-eaten pattern.” The inferior alveolar nerve canal could not be appreciated on the left side [Figure 3]. | Figure 3: Multiple radiolucent areas along with focal areas of sclerosis, extending from 35 till the anterior ramus
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After initial radiographic appearance, cone-beam computed tomography (NewTom 3G, at 90 kVp for 9 s) at the field of view of 11 × 8 was done. Multiple areas of rarefaction, with remnant thin and sparse trabeculae, were noted extending from the premolar to mid ramus region. The inferior nerve canal cortices were effaced at multiple focal areas [Figure 4]. Findings were suggestive of a primary malignancy involving left mandible with the possibility of secondary metastasis. | Figure 4: (a) Transverse section depicting periosteal reaction in the posterior body ramus region (b) coronal section depicting effacement of lingual cortices (c) multiple areas of rarefaction, with remnant thin and sparse trabeculae extending from the premolar till mid ramus region. The inferior nerve canal cortices effaced at multiple focal areas
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The patient was sent for further investigations to rule out metastasis. Ultrasonography of the abdomen revealed prostatomegaly with no other relevant findings. The prostate-specific antigen levels were markedly raised, i.e., 41.04 ng/mL. The levels of serum alkaline phosphatase and parathyroid hormone were within the normal range. To rule out any further possibility for metastasis, radiograph of spine and pelvis was carried out for the patient, but there were no relevant findings. The patient was then posted for biopsy.
An incisional biopsy was planned from the left alveolar ridge, 37 region. Tissue bits obtained were brownish-black and firm in consistency. Special stains: PAS, Alcian blue, and mucicarmine were used. The specimens were viewed at × 10 and × 40. Histopathological examination revealed as follows:
- Metaplastic bone formation around the tumor mass
- Pale nuclei and prominent nucleoli
- The resemblance of tumor cells with histopathology of prostate malignancy.
For further confirmation, α-methylacyl coenzyme A racemase was used as a positive cancer marker to confirm the primary site. Based on the histopathological examination, a final diagnosis of adenocarcinoma was given.
| Discussion | | |
The appearance of oral metastatic lesions is a sign of advanced-stage malignant disease, with multiple metastases in other locations. The most frequent sign of paresthesia in a mandibular metastasis is located in the area innervated by the mandibular alveolar dental nerve which has been termed as the “numb chin syndrome.”[2] Numb chin syndrome is a sensory neuropathy that includes the perineural spread of metastatic disease. Special attention should be given to patients with this syndrome, which should always raise the suspicion of metastatic disease in the mandible.
The premolar and molar region is a common site for metastases in mandible. A previous study revealed that the presence of hematopoietic areas in the mandible favors early deposit of hematopoietic cells.[3] Clinical presentation can mimic as toothache, temporomandibular joint pain, osteomyelitis, inflammatory hyperplasia, periodontal conditions, and pyogenic or giant cell granuloma.[1] Hirshberg et al.[4] stated that rapid swelling, pain, and paresthesia can be cardinal symptoms of jaw metastases. Evaluation of NCS in a patient with known malignancy should include thorough physical examination, followed by radiographic investigations and advanced imaging. Radiographically, lesions can simulate an infected cyst with irregular outlines or as osteomyelitis by a moth-eaten appearance, as seen in this case. Metastasis from the prostate can present as osteoblastic lesion seen as radiopaque or mixed radiopaque-radiolucent lesion.
Clausen and Poulsen[5] mentioned that prostatic carcinoma is the primary source of >6% metastatic lesions of the mandible. Vrebos et al.[6] revealed that 5% of the malignant lesions metastatic to jaws were from the prostate. In a study of Daley and Darling,[7] 38 cases of metastatic disease were evaluated, and prostate carcinoma was found to be the most common primary site (21%) for oral metastases. van der Waal et al.[1] reported similar rates of 12% prostatic cancers in 24 cases.
This clinical situation highlights the relevance of proper history taking. A thorough clinical examination using radiographs and histopathology should be carried out. An awareness of this condition is crucial, especially in cases with symptoms of unexplained facial pain and numbness.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | van der Waal RI, Buter J, van der Waal I. Oral metastases: Report of 24 cases. Br J Oral Maxillofac Surg 2003;41:3-6.  |
| 2. | Aksoy S, Orhan K, Kursun S, Kolsuz ME, Celikten B. Metastasis of prostate carcinoma in the mandible manifesting as numb chin syndrome. World J Surg Oncol 2014;12:401. |
| 3. | Reyes Court D, Encina S, Levy I. Prostatic adenocarcinoma with mandibular metastatic lesion: Case report. Med Oral Patol Oral Cir Bucal 2007;12:E424-7. |
| 4. | 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. |
| 5. | Clausen F, Poulsen H. Metastatic carcinoma of the jaws. Acta Pathol Microbiol Scand 1963;57:361-74. |
| 6. | Vrebos JE, Masson JK, Harrison EG Jr. Metastatic carcinoma of the mandible with primary tumor in the lung. Am J Surg 1961;102:52-7. |
| 7. | Daley T, Darling MR. Metastases to the mouth and jaws: A contemporary Canadian experience. J Can Dent Assoc 2011;77:b67. |
[Figure 1], [Figure 3], [Figure 2], [Figure 4]
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