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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
CASE REPORT Table of Contents   
Year : 2007  |  Volume : 11  |  Issue : 1  |  Page : 32-34
 

Metastatic thyroid carcinoma to the mandible


Department of Oral and Maxillofacial Pathology, SDM College of Dental Sciences and Hospital, Dharwad - 580 009, India

Correspondence Address:
H Kaveri
Department of Oral and Maxillofacial Pathology, SDM College of Dental Sciences and Hospital, Dharwad - 580 009, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-029X.33962

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   Abstract 

Metastatic tumours account for 1% of all oral malignancies and are relatively uncommon. The primary tumours from the lung, breast and kidney frequently metastasize to the jaw bones. Mandible appears to be the most common site of involvement.
We present a rare case of thyroid carcinoma metastasizing to the mandible so as to highlight the consideration of metastatic neoplasms in the differential diagnosis of jaw lesions.


Keywords: Mandible, metastatic tumours, thyroid carcinoma


How to cite this article:
Kaveri H, Punnya V A, Tayaar AS. Metastatic thyroid carcinoma to the mandible. J Oral Maxillofac Pathol 2007;11:32-4

How to cite this URL:
Kaveri H, Punnya V A, Tayaar AS. Metastatic thyroid carcinoma to the mandible. J Oral Maxillofac Pathol [serial online] 2007 [cited 2020 Jul 7];11:32-4. Available from: http://www.jomfp.in/text.asp?2007/11/1/32/33962



   Introduction Top


Metastatic tumours to the jawbones are infrequent and account for 0.1% of all the malignancies. [1],[2] Most of the documentation is presented as isolated case reports or in a small series. [3] Various sources for metastasis include lungs, breast, kidney, prostate, thyroid etc. [1],[2] Mandible is more commonly involved compared to maxilla, with premolar- molar region being the usual site for metastasis. [1] Most metastatic tumours present with pain, swelling and paraesthesia frequently mimicking other common jaw lesions posing difficulties in clinical diagnosis. A definite diagnosis relies on microscopic examination of the tissue. [4] We present such a rare case of metastatic thyroid carcinoma to the mandible.


   Case Report Top


A 65-year-old male patient presented with pain and swelling in the left lower jaw since five months. Clinical examination revealed a well-defined swelling, measuring 10×5 cms in the region of mandible. The swelling extended supero-inferiorly from the tragus to the lower border of the mandible and anterio- posteriorly from behind the angle of mouth to the ramus of the mandible [Figure - 1]. On palpation, the swelling was tender and soft to firm in consistency. The skin over the swelling appeared normal.

Intraoral examination confirmed with extraoral findings on extension of the lesion. Both buccal and lingual cortical plates showed expansion with eggshell crackling.

The OPG revealed a large radiolucency extending distal to second molar destroying the condyle. Mild resorption of the distal roots of mandibular second and third molar was also evident [Figure - 2].

The patient on general examination was moderately built and nourished. A mild swelling was appreciated in the lower right half of the neck. The swelling was painless, soft in consistency and showed diffuse margins [Figure - 3]. A PA-chest radiograph was advised and it revealed a large expansile lytic lesion involving lateral 1/3 rd of 7 th rib on the left side [Figure - 4].

Based on the clinical and radiographic findings, a provisional diagnosis of a metastatic tumour was considered. Either a metastases from thyroid or prostate was more in favour for the given factors like age, gender and clinical presentation. A fine needle aspiration from the intraoral lesion was suggested.

Fine needle aspiration cytology was performed and it revealed round to ovoid cells with scanty cytoplasm and intensely stained basophilic nuclei arranged in clusters with lumen formation. Homogenous eosinophilic coagulum was appreciated within the clusters of cells. Few chronic inflammatory cells were also evident [Figure - 5]. A biopsy was further considered to confirm the diagnosis of metastatic thyroid tumour.

The incisional biopsy microscopically revealed the presence of cuboidal cells with eosinophilic cytoplasm arranged in the form of follicles and in the form of small clusters. Various duct-like structure were also evident with eosinophilic coagulum within them [Figure - 6]. Presence of well-developed duct-like structures, eosinophilic secretory material and a thyroid swelling made us to seek a second opinion from a pathologist. The pathologist suggested it to be metastatic tumour, probably a follicular thyroid carcinoma. The patient was advised for hormonal levels and other specific investigations for the evaluation of the primary. The patient was referred for further management to an Oncology unit.


   Discussion Top


The real incidence of metastatic tumours in the jaw bones is unknown. [3] This is due to the fact that the jaws are seldom involved in the radiographic skeletal survey for metastasis or examined in autopsies. [2],[5]

A malignant neoplasm to be considered metastatic should fulfill the following criteria namely the presence of histologically verified primary, its histological similarity to the secondary lesion and exclusion of direct extension from the primary. [2],[6]

The various routes of metastasis to the jaws include lymphatics, blood vessels and rarely iatrogenic reasons. The most common mode for metastasis to jaw bones is by hematogenous route. [2]

The frequency of jawbone involvement appears to be less common in comparison to other bones because the red bone marrow and blood vessels tend to decrease with age in the jaws. [1],[4] Mandible accounts to 60-80% of the metastases of the jaw bones with molar, premolar areas (38-55%) being the most common sites of involvement due to anatomy of the region, presence of hematopoietic bone marrow and slowing down of regulation that favour the entrapment of metastatic cells. [3],[7]

Metastatic tumours are most commonly encountered in the fifth to seventh decade of life. [3] Controversy exists regarding the sex predilection. [1],[3],[8],[9] Common sources of metastasis also show gender variation. Breast, genital organs and thyroid are common sources in females while lungs, prostrate, kidney and liver in males. [1],[2],[3],[10]

The occurrence of thyroid metastasis in a male patient is a rarity and it accounts to only 3.3% of jaw metastasis. [2] Metastatic tumours either present as pain, swelling, mobility of tooth, delay in healing of extraction socket, pathological fractures or paraesthesia. [1],[4] The radiographic presentation can vary from no manifestation to a lytic /opaque lesion with ill-defined margins. [2],[3],[5] However it should be noted that in 29-33% of the cases, the metastatic lesion might be the first indication of an undiscovered malignancy at a distant site. [1],[3],[11]

The present case presented with a painful swelling involving the left posterior mandible and paraesthesia. Radiography showed extensive lytic lesion involving the ramus and condyle with destruction of inferior border of mandible posteriorly.

A combination of various treatment modalities is commonly used in the management of metastatic lesions with less success rates. Therefore, a palliative therapy is often advised. [4],[5] The prognosis of jaw metastasis is usually grave and average time from appearance of metastasis to a fatal outcome appears to be around 7.3 months. [2],[3],[5]

This case report was presented to emphasize the inclusion of metastatic neoplasms in the differential diagnosis of jaw lesions and an early detection may improve the prognosis of the patient.

 
   References Top

1.Lim SY, Kim SA, Ahn SG, Kim HK, Kim SG, Hwang B, et al . (2006): Metastatic tumours to the jaws and oral soft tissues: A retrospective analysis of 41 Korean patients, Int J Oral Maxillofac Surg, 35: 412-5.  Back to cited text no. 1    
2.Zachariades N (1989): Neoplasms metastatic to the mouth, jaws and surrounding tissues, J Cranio Max Fac Surg, 17: 283-90.  Back to cited text no. 2    
3.Hirshberg A, Leibovich P, Buchner A (1994): Metastatic tumours to the jaw bones: Analysis of 390 cases, J Oral Pathol Med, 23:337-41.  Back to cited text no. 3    
4.Gregorio S A, Penin AG, Pages RM and Moreno JJMM (1990): Tumours metastatic to the mandible: Analysis of nine cases and Review of the literature. J Oral Maxillofac Surg 48: 246-51.  Back to cited text no. 4    
5.Zachariades N, Koumoura F, Vairaktaris E and Mezitis M (1989): Metastatic tumours to the jaws: A report of seven cases, J Oral Maxillofac Surg 47: 991-6.  Back to cited text no. 5    
6.Solomon MP and Gardner B (1975): Metastatic malignancy in the submandibular gland, Oral Surg 39: 469-71.  Back to cited text no. 6    
7.Shankar S (1984): Dental Pulp metastasis and pan-osseous mandibular involvement with mammary adenocarcinoma, Br J Oral Maxillofac Surg 22: 455-7.  Back to cited text no. 7    
8.Schwartz Ml, Baredes S and Mignogna FV (1988): Metastatic disease to the mandible, Laryngoscope 98: 270-3.  Back to cited text no. 8    
9.Nishimura Y, Yakata H, Kawasaki T and Nakajima T (1982): Metastatic tumours of the mouth and jaws. A review of the Japanese literature, J Maxillofac Surg 10: 253-8.  Back to cited text no. 9    
10.Carrol KO, Krols SO, Mosca NG, Jackson E (1993): Metastatic carcinoma to the mandible: Report of two cases, Oral Surg Oral Med Oral Pathol 76: 368-74.  Back to cited text no. 10    
11.Peacock TR and Fleet JD (1982): Condylar metastasis from bronchogenic carcinoma, Br J Oral Maxillofac Surg 20: 39-41.  Back to cited text no. 11    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]


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