Jaw bone metastases: four cases
D. Tamiolakis, I. Tsamis, V. Thomaidis, M. Lambropoulou, G. Alexiadis, I. Venizelos,
Th. Jivanakis, and N. Papadopoulos
A B S T R A C T
Objective: Metastatic tumors make up approximately one percent of all oral malignancies. Such tumors may present in the jawbones and oral soft tissues. The commonest oral site is the mandible. Patients and methods: This is a retrospective study of four cases of metastatic tumors of the jaws seen at the Oral-Maxillofacial Department, General University Hospital of Alexandroupolis, Thrace, Greece from 1989 to 2005, representing 1% of all histologically confirmed malignant tumors at the hospital. Results: Two cases originated from the thyroid gland, one was from the esophagus, and one from the liver. Three metastases occurred in the mandible and one in the maxilla. The oral symptoms were similar to odontogenic infections or to benign neoplasms.
Conclusions: In view of the resemblance in the presentation of metastases and other tumors affecting the jaws, a high index of clinical suspicion is advocated to ensure early, multidisciplinary care of hosts.
Introduction
KEY WORDS
jawbones metastases, four patients, Thrace, Greece
Bone metastases commonly occur following primary malignancies, but metastases to the jaws are very rare. Red marrow, believed to be necessary for the establishment and proliferation of metastases, is scant in the mature jaws; hence, instances of tumor metastases to the jaws are very few (1). It is estimated that only one percent of all oral malignancies occur due to primary malignancies elsewhere (2-6, 7). Although almost any type of malignancy can metastasize to the mouth, some are found more often than others (7). Cancers that com-
monly metastasize to the oral cavity originate from the breast, kidney, lung, and prostate (7-9). Metastatic lesions may mimic odontogenic infections or other conditions in the oral cavity, leading to late diagnosis. In Greece, reports on metastatic jaw tumors are rare. This report presents a series of histologically verified metastatic tumors to the jaws collected over 15 years at a Greek tertiary Oral and Maxillofacial Care Center, highlighting the problems associated with late diagnosis and the multidisciplinary implications of the disease.
Figure 1. Metastatic papillary thyroid carcinoma. Tissue section. Hematoxylin-Eosin stain x 100.
Results
Out of 276 malignancies of the oral cavity seen between 1989 and 2005, four cases (1.4%) were of metastatic origin. The age range of the patients was from 47 to 69 years, two males and two females. Three patients presented with symptoms of jaw swellings and other features localized to the oral cavity. Only one case was treated in our department after the condition developed. The clinical details of our cases of metastatic jaw neoplasms are presented in Table 1. A 69-year-old female was deemed inoperable due to the extent of the tumor. Analgesics were administered until she died one month later at home. Histopathology revealed a metastatic papillary thyroid carcinoma (Figure 1). No post-mortem examination was performed. The second patient, diagnosed with metastatic thyroid carcinoma, was treated by jaw resection and did not return for a follow-up. One patient whose diagnosis was metastatic hepato-cellular carcinoma checked himself out of the hospital (Figure 2). In the last case, the diagnosis was metastatic esophageal adenocarcinoma (Figure 3).
Patients and methods
The materials for our study were obtained from records of malignant diseases of the jaws observed at the Maxillofacial Department of the University Hospital of Alexandroupolis, Thrace, Greece between 1989 and 2005. The records inspected were case notes, histology reports, and operation notes. Jaw malignancy of histologically verifiable metastatic origin was selected for analyses of age at diagnosis, gender, presenting complaints, clinical features, histological diagnosis, and treatment. Records of follow-ups were not available, and the only patient treated by the authors did not even return for a check-up.
Discussion
Metastatic jaw tumors originate from distant body sites and exclude lesions that spread from adjacent sites or those due to local recurrence. Metastatic lesions are highly significant because their appearance may be the only symptom of an underlying malignancy and/or the first evidence of dissemination from the primary site (7, 10). The exact incidence of secondary malignancies in the jaws is difficult to ascertain because skeletal radiographic surveys are not routinely done in Greece. Even when such scans are performed, the jaws are usually excluded. Also, religious and cultural factors make it difficult to obtain consent for post mortem examina-
Figure 2: Metastatic hepatocellular carcinoma. Figure 3. Metastatic esophageal
Tissue section. Hepatocyte N marker	adenocarcinoma. Tissue section. Hematoxylin-
immunostain x 200.	Eosin stain x 200.
Table 1. Clinical characteristics of four cases of jawbone metastases.
Patient	Symptoms	Histology	Origin Affected jaw	Treatment
1	Facial swelling, pain	Metastatic cancer	Liver Maxilla	Discharged himself
2	Facial swelling, oral	Adeno-carcinoma	Thyroid Mandible	Jaw resection
	mucosal ulcerations,			
	ulcerations anterior to swelling			
3	Facial swelling, pain, oral	Adeno-carcinoma	Esophagus Mandible	Referred to oncologists
	bleedings, mucosal ulcer			
4*	Facial swelling, nasal	Adeno-carcinoma	Thyroid Mandible	Inoperable
	obstruction, epistaxis			
*Patient no. 4 died one month after diagnosis.
tions. In the opinion of several authors, only 1% of all oral malignant neoplasm is of metastatic origin (2-6, 7). The relative frequency of 1% obtained in this series is in agreement with such a view. In a review of 110 cases of metastases to the maxilla, patients' ages ranged from 3 months to 81 years, and the overall male-to-female ratio was 1.5:1 (11). In our study there were 2 females and 2 males.
According to Batsakis (5), only 6.1% of 115 metastatic jaw tumors originated from the thyroid. In a further review of 110 cases of upper jaw metastases, 44% originated in the kidneys, 13% in the bronchi, 9% in the breast, 7% in the testicles, 6% in the uterus, 5% in the thyroid, 5% in the colon and rectum, 5% in the stomach, and 3% in the prostate (11). Hanahan and Weinberg (12) have brilliantly described the processes involved in the detachment of tumor cells from the primary cancer site, their transport through the lymphatics or blood stream, and the establishment of a metastatic tumor site. The literature indicates that metastases are more frequent in the mandible than the maxilla due to the paucity of active red marrow in the latter (1, 4, 6, 13). Other oral sites of metastatic tumor are the gingiva, buccal mucosa, soft palate, and the tongue (7). Tumor metastases to the jaws occur through the blood because
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In conclusion, metastases to the oral cavity are quite uncommon among the Greek population. They usually present with symptoms similar to odontogenic infections and benign tumors, causing a delayed diagnosis and treatment. Careful examination and a high degree of clinical suspicion as well as a multidisciplinary approach are suggested.
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AUTHORS' Demetrio Tamiolakis, MD, Resident B, Department of Cytology, Regional ADDRESSES Hospital of Chania, Crete, Greece
Ioannis Tsamis, MD, Director, Department of Oral and Maxillofacial Surgery, University Hospital of Alexandroupolis, Thrace, Greece. Vasilios Thomaidis, MD, Resident B, Department of Oral and Maxillofacial Surgery, University Hospital of Alexandroupolis, Thrace, Greece.
Maria Lambropoulou, MD, Lecturer, Department of Histology-Embryology, Democritus University of Thrace, Faculty of Medicine, Alexandroupolis, Thrace, Greece.
George Alexiadis, MD, Radiodiagnostic Center, Alexandroupolis, Thrace, Greece.
Ioannis Venizelos, MD, Associate Director, Department of Pathology, Hippokration Hospital of Thessaloniki, Greece.
Theodoros Jivanakis, MD, Director, Department of Pathology, Regional Hospital of Drama, Greece.
Nikolas Papadopoulos, MD, Associate Professor, Department of Histology-Embryology, Faculty of Medicine, Democritus University of Thrace, Dragana, 68100 Alexandroupolis, Greece, corresponding author, E-mail: npapad@med.duth.gr