Challenges in the diagnosis of mandible metastasis

Abstract

Aim: To report the clinical course of a patient with long-lasting pain and swelling of mandible who was subsequently diagnosed with large cell neuroendocrine carcinoma (LCNEC) of the lung and to point out the importance of expanding the diagnostic approach. Case report: A 61-year-old female patient was referred to the Department of maxillofacial surgery due to severe pain in the area of temporomandibular joint (TMJ) spreading to the upper and lower jaw. Physical examination revealed tenderness, swelling and pain of the preauricular area. MR imaging showed anterior disc displacement with degenerative signs on the left side which indicated arthrocentesis. It resulted with clinical improvement that lasted for 1.6 years. Newly made orthopantomogram revealed unclear changes of the left mandibular corpus. Due to the unclear diagnosis patient underwent biopsy on two occasions, which excluded IgG4 disease, other rheumatology and hematology diseases as well as the tumor. Five years after the initial admission, the patient stated the occasional dyspnea and cough leading to administration of the chest RTG, showing visible round mass in the upper left lobe of the lung. PET/ CT showed accumulation of radiopharmaceutical substance in the corresponded area, affected regional and distant lymph nodes and accumulation within mandible. Somatostatin receptor scintigraphy confirmed the diagnosis, which may indicate the possibility of distant malignancies. Wedge resection of the lung mass was performed and pathohistological examination confirmed the large-cell neuroendocrine carcinoma (LCNEC) stage 3. Chemotherapy was administrated. Patient referred to an emergency medical tract due to the threatening cardiac tamponade and died 11 days after. Conclusions: Mandibular metastases are often presented by atypical signs and symptoms and often present the first sign of the malignant disease. Broad spectrum of examinations must be performed in order to prove or exclude distant malignancies so the best therapy option can be provided.