Metastatic malignancy of the jaws

Abstract

Metastatic malignancy from a distant primary site involving the jaws, although rare, is worthy of special attention. If for no other reason, metastatic malignancy involving the jaws should be emphasized as a possibility in the diagnosis of jaw neoplasms in order to spare a significant number of patients with occult malignancy the tragedy of useless disfiguring radical surgery. Based on mathematical probabilities it is likely that at least 100 instances of jaw metastasis from distant occult carcinomas could be seen in this country every year. Indeed, with increasing awareness of the possibility, the number of cases reported is growing. In this article jaw metastasis is sharply distinguished from invasion of the mandible by oral malignancy which occurs with relatively great frequency. The authors are not convinced that other workers describing and reporting metastasis to the jaws from primary intraoral carcinoma have critically differentiated between direct invasion and metastasis. In some cases jaw metastasis may be the first and only symptom of malignant disease which is growing silently elsewhere in the body. Usually, however, if the mandible is involved, there is detectable metastatic disease elsewhere. The possibility of multiple primary carcinomas with one involving the jaw should always be considered. Obviously the prognosis in this type of case could be better than the case in which the oral lesion is metastatic from a distant primary. In the first instance each case of malignancy occurring at the same time in the same patient would have to be evaluated on its individual merits. In the latter case the patient has widely disseminated metastasis and is in a hopeless state. A review of the literature from 1902 to 1953 revealed a total of 176 cases of metastatic malignancy involving the jaws. The primary lesions most frequently accounting for jaw metastasis were carcinoma of the thyroid, hypernephroma, carcinoma of the breast, carcinoma of the lung and carcinoma of the prostate. Metastatic lesions have also been reported from carcinoma originating in the following organs: stomach, large intestine, rectum, parotid gland, tonsil, adrenal gland, ovary, testes, lip and nasal mucous membrane; sarcoma of the ovary, breast and bone; lymphosarcoma, Kaposi's sarcoma and malignant melanoma. The pathologic features are essentially those found in metastatic malignancy involving osseous structures elsewhere. Osteoclastic or osteoblastic lesions may be found, although the majority of reported lesions were osteoclastic. The mental nerve and the teeth may be involved. The symptomatology included paresthesia, numbness and swelling of the lip, pain and tenderness in the involved area, “toothache,” external tumor mass, soft tissue mass and loosening of the teeth. A complete and accurate history of present symptoms, history of past illnesses, systemic review and complete physical examination are essential to correct diagnosis. Perhaps the most essential point in the diagnosis is to think of the possibility. Roentgenographically, metastatic malignancy may be confused with primary oral malignancy, primary mandibular malignant tumors, benign tumors, cysts and infections of dental origin. Occasionally symptoms may be present in patients with known malignancy and yet roentgenograms of the jaw are normal. Adequate biopsy is essential for accurate diagnosis and should be interpreted by a competent tumor pathologist. Treatment should consist only of palliative roentgen therapy to reduce the size of the lesion and relieve pain. Seven new cases of metastatic malignancy involving the jaws are reported. These lesions originated in the following sites: three cases of carcinoma of the breast, one case of carcinoma of the lung, one case of seminoma of the testis, one case of carcinoma of the rectum and one case of lymphosarcoma. The first known case of seminoma of the testis with mandibular and maxillary metastases as the presenting symptoms is reported.