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CORRESPONDENCE
Year : 2013  |  Volume : 9  |  Issue : 1  |  Page : 108-110

Isolated mandibular condylar metastases: An uncommon manifestation of recurrent cervical cancer


Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, India

Date of Web Publication10-Apr-2013

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Dr E Borges Marg, Parel, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.110397

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 > Abstract 

Bone metastases from recurrent cervical cancer is a rare scenario, with commonly involved sites being lumbar spine and pelvic bones report an extremely rare manifestation of cervical cancer recurrence presenting as a painful jaw swelling due to metastasis to the mandibular condyle.

Keywords: Cervix, condyle, FDG PET, mandible


How to cite this article:
Puranik AD, Purandare NC, Dua S, Deodhar K, Shah S, Agrawal A, Rangarajan V. Isolated mandibular condylar metastases: An uncommon manifestation of recurrent cervical cancer . J Can Res Ther 2013;9:108-10

How to cite this URL:
Puranik AD, Purandare NC, Dua S, Deodhar K, Shah S, Agrawal A, Rangarajan V. Isolated mandibular condylar metastases: An uncommon manifestation of recurrent cervical cancer . J Can Res Ther [serial online] 2013 [cited 2019 Sep 17];9:108-10. Available from: http://www.cancerjournal.net/text.asp?2013/9/1/108/110397


 > Introduction Top


Bone metastases from carcinoma of uterine cervix are infrequent, seen in 0.8-23% of the cases. [1] Metastases have been reported in all bones, with vertebra being the most common site and also in several unusual sites. These uncommon manifestations are related in part to the use of intensive pelvic radiation therapy, which has resulted in shift away from pelvic recurrence towards distant recurrence. [1],[2] In addition, these uncommon patterns of recurrence are being recognized with greater frequency due to use of advanced cross-sectional imaging techniques and more extensive and frequent imaging of patients with suspected recurrence. We report a rare occurrence of cervical cancer recurrence presenting as isolated mandibular metastases.


 > Case Report Top


A 63-year-old postmenopausal woman presented to our institution in 2009 with blood stained and foul smelling vaginal discharge for about a year. Local examination revealed bulky cervix with a large ulceroproliferative growth. The left parametrium was fixed. Rectal mucosa was free. A punch biopsy from the growth was consistent with squamous cell carcinoma. The clinical findings were confirmed on computed tomography (CT) of abdomen and pelvis and she received external beam radiotherapy to whole pelvis with four field three dimensional conformal radiotherapy (3DCRT) technique to the dose of 8 Gray in 20 fractions over 1 month with concurrent weekly Cisplatin (60 mg intravenously). This was followed by 5 fractions of intracavitary brachytherapy over 3 weeks. On the first follow up after treatment there was complete regression of cervical growth and bilateral parametria supple. Cytological examination and ultrasonography were unremarkable. Subsequently she was on regular follow up, when after a year she presented with painful swelling in right preauricular region. She was afebrile and the overlying skin did not reveal any signs of inflammation. Vaginal examination and cytology at this stage were normal. The patient was referred for a whole body 18 F - Fluorodeoxyglucose Positron emission tomography/Computed Tomography ( 18 F - FDG PET/CT) study to characterize the swelling further and to also restage the patient for the possibility of locoregional recurrence or distant metastases, which in turn revealed a lytic lesion involving condyloid process and vertical ramus of right hemimandible with associated soft tissue.

Increased FDG uptake was seen in region of the right jaw (on whole body maximum intensity projection (MIP) images) [[Figure 1], arrow] which corresponded to a lytic lesion involving condyloid process and vertical ramus of right hemimandible with associated soft tissue on the CT and fusion PET/CT components of the study [[Figure 2]a and b, arrow]. A CT-guided biopsy from the mandibular lesion was performed. Immunohistochemistry (IHC) revealed findings consistent with metastasis from squamous cell carcinoma [Figure 3]a-d. The patient was offered palliative chemo-radiation for the mandibular metastasis.
Figure 1: MIP image of FDG PET scan showing focus of increased uptake in right mandible (arrow)

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Figure 2: (a) Axial CT image in bone window showing lytic area with soft tissue component in right mandibular condyloid process (arrow), (b) Axial fused PET/CT image in bone window showing lytic area in the ramus of right mandible (arrow)

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Figure 3: (a) (H and E, × 400) Showing squamous carcinoma cells in blood clots, (b) Immunohistochemistry (IHC) showing Cytokeratin positivity in tumor cells, (c) IHC shows Epithelial Membrane Antigen (EMA) positivity in tumor cells, (d) IHC shows P63 nuclear positivity in tumor cells

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 > Discussion Top


Uterine cervical carcinoma recurs in a predictable manner, locally, and by lymphatic route. Pelvic nodes are first to get involved, followed by para aortic and/or supraclavicular nodes. Hematogenous dissemination is relatively unusual, and most commonly involves lung and liver, followed by bone. [1] Bone metastases occur secondary to direct extension from adjacent lymph nodes, most commonly involving the lumbar spine, followed by pelvic bones, hips, and extremities. [2] Hematogenous spread occurs in more advanced cases, and is rather uncommon. [3] Such unusual sites of distant metastatic involvement are clavicle, scapula, fibula, tarsal and metatarsal bones and innominate bones, and extremely rarely to the jaw bone. [4],[5],[6] Occurrence of metastases from primary distal malignancies to the jaw is a rare scenario, and these are usually carcinomas, consistent with malignancies of epithelial origin in more than 80% of cases. [7] Jaw metastases constitute less than 1% of all bone metastases, most common primary site being breast in females and lung in males. [8] Presenting symptoms in a majority of these patients is local swelling, with some having pain and paresthesia, and rarely bleeding from local site and temperomandibular joint-related symptoms. [9] Detailed analyses of 390 cases of jaw metastases, showed that mandible is the most common site of metastatic involvement, within which molar region is the most common, this is followed by premolar region, angle and ramus of mandible. Condylar involvement accounts for only 3.5% of cases of jaw metastasis, out of which only one case was reported to be from a primary cervical cancer. [7] There have been three explanations given for this low incidence. One possible explanation is that, the bone marrow in condylar region is sparse, as compared with mandibular body. Moreover, condyle has a separate vascular supply from circulating penetrating branches of maxillary and superficial temporal artery. [10] The presence of a limiting osseous plate which isolates the condylar marrow cavity from spongiosa of mandible proper prevents the spread of metastatic cells to the mandible. [11] These could be the likely reasons for the fact, that only 21 cases of condylar metastases have been reported, so far. [12] Analysis of recurrence patterns of cervical cancer in a post definitive radiotherapy setting showed that hematogenous recurrence occurred within 2 years of treatment, [13] as seen in our patient. Thus, our case of isolated mandibular condylar metastases from treated case of cervical cancer is an extremely rare scenario, and suggests a poor prognosis. Our case emphasizes that even though a jaw swelling is more often a presentation of a local pathology, on certain occasions particularly when there is a known history of cancer (carcinoma cervix in our case), it can be a rare manifestation of cancer recurrence and should be worked up thoroughly to initiate timely treatment.

 
 > References Top

1.Fulcher AS, O'Sullivan SG, Segreti EM, Kavanagh BD. Recurrent cervical carcinoma: Typical and atypical manifestations. Radiographics 1999;19:S103-16.  Back to cited text no. 1
    
2.Drescher CW, Hopkins MP, Roberts JA. Comparison of the patterns of metastatic spread of squamous cell cancer and adenocarcinoma of uterine cervix. Gynecol Oncol 1989;33:340-3.  Back to cited text no. 2
    
3.Fagundes H, Perez CA, Grigsby PW, Lockett MA. Distant metastases after irradiation alone in carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 1992;24:197-204.  Back to cited text no. 3
    
4.Matsuyama T, Tsukamoto N, Imachi M, Nakano H. Bone metastases from cervical cancer. Gynecol Oncol 1985;20:307-16.  Back to cited text no. 4
    
5.Henriksen E. The Dispersion of cancer of the Cervix. Radiology 1950;54:812-15.  Back to cited text no. 5
    
6.Rangarajan V, Dua S, Purandare NC,Shah S, Sharma AR. Unusual lower limb skeletal metastases from carcinoma of the cervix: Detection by F-18 FDG PET/CT. Clin Nucl Med 2010;35:534-6.  Back to cited text no. 6
    
7.Hirschberg A, Leibovich P, Buchner A. Metastatic tumors to the jaw bones: Analysis of 390 cases. J Oral Pathol Med 1994;23:337-41.  Back to cited text no. 7
    
8.Keller EE, Gunderson LL. Bone diseases metastatic to jaws. J Am Dent Assoc 1987;115:697-701.  Back to cited text no. 8
    
9.D'Silva NJ, Summerlin DJ, Cordell KG, Abdelsayed RA, Tomich CE, Hanks CT, et al. Metastatic tumors in the jaws: A retrospective study of 114 cases. J Am Dent Assoc 2006;137:1667-72.  Back to cited text no. 9
    
10.Blackwood H. Metastatic carcinoma of mandibular condyle. Oral Surg Oral Med Oral Pathol 1956;9:1318-23  Back to cited text no. 10
    
11.Voy ED, Fuchs M. Anatomical studies of blood vessels in temporomandibuar joint area. Fortschr Kiefer Gesichtschir 1980;25:2-5.   Back to cited text no. 11
    
12.Wolujewick MA. Condylar metastases from a carcinoma of prostate gland. Br J Oral Surg 1980;18:175-82.  Back to cited text no. 12
    
13.Sakurai H, Mitsuhashi N, Takahashi M, Akimoto T, Muramatsu H, Ishikawa H, et al. Analysis of recurrence of squamous cell carcinoma of uterine cervix after definitive radiotherapy alone: Patterns of recurrence, latent periods and prognosis. Int J Radiat Oncol Biol Phys 2001;50:1136-44.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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