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CORRESPONDENCE
Year : 2019  |  Volume : 15  |  Issue : 5  |  Page : 1177-1180

Metastatic breast cancer to bilateral mandibular ramus regions


Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Necmettin Erbakan University, Konya, Turkey

Date of Web Publication4-Oct-2019

Correspondence Address:
Guldane Magat
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Necmettin Erbakan University, Konya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_447_17

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 > Abstract 


Metastatic carcinomas to the jaw bones are uncommon and comprise to about 1% of all malignant oral neoplasms. The purpose of this report is to present a rare case of metastatic breast carcinoma to bilateral mandibular ramus regions. The present case report is about a 40-year-old female patient with the complaints of a paresthesia in the right mandibular area of the last month duration. She was referred to our department by her oncologist with the differential diagnosis of osteonecrosis or metastasis. She had undergone modified radical mastectomy for invasive lobular carcinoma of the left breast. Oral cavity examination did not reveal the existence of any ulcer or fistula. Panoramic, cone-beam computed tomography (CBCT), and positron-emission tomography (PET) were used for diagnosing the lesions. In panoramic radiography and CBCT images, there were lytic lesions on the both of right and left coronoid, condyle, and ramus of the mandible. PET results showed us fluoro-2-deoxy-D-glucose uptake in the mandible and vertebrae. On the basis of the patient's medical history and paresthesia of the lower lip and chin, the metastatic disease was highly suspected. The patient was referred to her oncologist for further treatment since it was not amenable to the surgical management. The general dentist or dental specialist should maintain a high level of suspicion while evaluating patients with a history of cancer. Paresthesias of the lower lip and the chin should be considered ominous signs of metastatic disease.

Keywords: Breast, cancer, mandible, metastases


How to cite this article:
Magat G, Sener SO, Cetmili H. Metastatic breast cancer to bilateral mandibular ramus regions. J Can Res Ther 2019;15:1177-80

How to cite this URL:
Magat G, Sener SO, Cetmili H. Metastatic breast cancer to bilateral mandibular ramus regions. J Can Res Ther [serial online] 2019 [cited 2019 Oct 20];15:1177-80. Available from: http://www.cancerjournal.net/text.asp?2019/15/5/1177/244460




 > Introduction Top


Metastases in the oral cavity are rare and comprise approximately 1% of newly detected oral cancers.[1] In a study of over 2400 oral and jaw malignant tumors, only 1% constituted metastases.[2] They usually involve the jaws but may also be found in the soft tissue of oral cavity and salivary glands. The most common metastatic malignancies in women are from primary cancers in the breast, kidneys, colorectal region, genital organs, and thyroid glands, and they arise from the lungs, prostate, kidneys, and colorectal region in men.[3] Invasive lobular carcinoma is the second most common type of breast cancer. The incidence of invasive lobular breast carcinoma has been increasing due to the increasing use of combined hormonal replacement treatment.[4]

The mandible is affected more frequently than the maxilla, with the predilection for the regions distal to canines including the body and ramus.[1],[5] These areas are more prone to the deposition of cancerous cells due to the presence of hematopoietic bone marrow, subdivision of local blood vessels, and reduced velocity of blood flow.[5] A wide range of clinical signs and symptoms may be seen in association with metastatic tumors of the oral cavity, with the most common being pain, swelling, altered sensation, halitosis, gum irritation, tooth loosening and mobility, exophytic masses of soft tissues, ulceration, regional lymphadenopathy, trismus, and rarely, pathologic fractures. Numbness and paresthesia of the lower lip and chin are considered an important sign of metastatic disease.[1],[5] The disease might be totally asymptomatic as well.[1],[3],[5] These symptoms may not be drawn attention to a potential malignancy at the time of initial presentation.[1]

Metastatic tumors of the oral cavity do not exhibit a pathognomonic radiographic appearance; therefore, radiographic examination is rarely considered diagnostically important. The radiographic appearance of metastatic diseases in the jaws varies from well circumscribed to poorly circumscribed radiolucencies; the latter also known as a moth-eaten appearance. Since metastatic neoplasm from the breast and prostate stimulate bone formation, the metastasis appears as mixed lesions. In an analysis of 390 cases of metastatic tumors of the jaw, it was found that 5.4% of them did not show any important radiographic change. Sometimes, these lesions might be mistaken for inflammatory or infectious diseases of jaws and adjacent structures as a result of clinical and radiographic similarities.[6]

The purpose of this report is to describe and discuss a metastatic tumor of the mandible originating from breast carcinoma.


 > Case Report Top


A 40-year-old female patient with the complaint of a paresthesia in the right mandibular area for the last month duration was referred to our department by her oncologist to make the differential diagnosis of osteonecrosis or metastasis. Her medical history revealed a radical mastectomy 6 years ago for invasive lobular carcinoma of the left breast. The tumor was negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (c-erb B2) (HER2/neu) expression in immunohistochemistry. She received chemotherapy and radiotherapy 6 years ago, and chemotherapy was initiated 1 year ago again. In addition, 4 mg of intravenous zoledronic acid was administered every 3 weeks for bone metastasis. The complaint of the patient was the paresthesia on the right inferior lip and posterior mandibular area of the face.

Oral cavity examination did not reveal the existence of any ulcer, fistula, and expansion. She had poor oral hygiene. There were no palpable regional lymph nodes or swelling on the head-and-neck region.

A panoramic radiograph showed generalized horizontal bone loss throughout the patient's dentition. There were lytic lesions with well circumscribed on the both of right and left coronoid, condyle, and ramus of the mandible [Figure 1] and [Figure 2]. Sagittal 1 mm-thick cone-beam computed tomography (CBCT) showed small radiolucent areas in proximity to the ramus region [Figure 3] and [Figure 4] that were not diagnostic of metastases. In addition, the lytic lesion was also observed on vertebrae on CBCT images [Figure 5]. The patient was referred to positron-emission tomography (PET) which include mandible to her oncologist. PET results showed us fluoro-2-deoxy-D-glucose uptake in the mandible and vertebrae [Figure 6].
Figure 1: The panoramic radiograph of the patient

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Figure 2: Multiple lytic lesions on cone-beam computed tomography panoramic reconstruction

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Figure 3: Sagittal cone-beam computed tomography image of the right mandibular ramus

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Figure 4: Sagittal cone-beam computed tomography image of the left mandibular ramus

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Figure 5: Multiple lytic lesions on vertebrae are shown in the cross-sectional cone-beam computed tomography image

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Figure 6: Positron-emission tomographic images

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On the basis of the patient's medical history and paresthesia of the lower lip and chin, radiographic appearance and location of the lesion and metastatic disease was highly suspected. The patient was referred to her oncologist for further treatment since it was not appropriate to surgical management.


 > Discussion Top


Metastases to the oral cavity and the jaws are uncommon, estimated to comprise only about 1% of all diagnosed oral malignancies.[1] The lower jaw is commonly affected compared to the upper jaw with tendency for the areas posterior to canines including ramus and body of the mandible.[1],[5] These areas are more prone to the deposition of cancerous cells due to the presence of hematopoietic bone marrow, subdivision of local blood vessels, and reduced velocity of blood flow.[5] Above findings are in favors of presented case.

Breast cancer is the most common site-specific cancer in women and is the leading cause of death from cancer for women aged 20–59 years. It accounts for 26% of all newly diagnosed cancers in females and is responsible for 15% of the cancer-related deaths in women. There tends to be a histological preference for the site of distant metastasis, invasive ductal carcinoma of the breast tends to metastasize more commonly to the liver, lung, and brain compared to a lobular carcinoma that tends to spread to bones, gynecological organs, peritoneum, retroperitoneum, and the gastrointestinal tract.[4] The reason for this has not been identified.

Breast carcinoma metastasizes to the mandibles three times as often as any other malignant tumor. Furthermore, it has been reported that periodontal diseases are associated with breast cancer.[7] In this report, our patient had severely periodontal problems too. Consequently, diversified insights into the molecular mechanism of breast cancer metastasis to the mandible are necessary to devise preventive and therapeutic approaches.

The diagnosis of metastasis to the oral cavity is a significant challenge to the clinician due to the lack of pathognomonic signs and symptoms.[8] A broad range of clinical characteristics might be seen with metastatic tumors of the oral cavity, most commonly are pain, swelling, paresthesia, foul smell, gingival irritation, tooth mobility, exophytic growths of the soft tissues, reduced mouth opening, and infrequently pathological fractures.[1],[5] The only symptom was the paresthesia of the right lower lip and chin in the present case. Pathognomonic sign of metastatic lesion is paresthesia of the lower lip and chin.[8]

The radiographic appearance of the metastatic disease in the jaws varies from well circumscribed to poorly circumscribed radiolucencies; the latter also is known as a “moth-eaten” appearance. Involvement of alveolar bone probably can mislead diagnosis with the periodontal disease. Since metastatic neoplasms from the breast and prostate stimulate bone formation and this metastasis appears as mixed lesions. In this case, panoramic and CBCT images showed the presence of multiple irregular radiolucent areas in areas of mandibular ramus, coronoid and condyle.

The patient was referred to our clinic for the evaluation of possible osteonecrosis of the jaw caused by bisphosphonate treatment by her oncologist. There were no signs and symptoms, of exposed avascular necrotic bone and pain in intraoral examination and history. The existence of exposed necrotic bone over 8 weeks with past or recent use of bisphosphonates is an essential element for rendering the diagnosis of osteonecrosis associated with bisphosphonates, along with the absence of previous radiation therapy to the jaws.[9] Furthermore, bisphosphonate-related bone necrosis is usually developed in regions of dentate and susceptible to trauma in jaws.[10] Therefore, by the clinical characteristics of our patient and this type of lesion was excluded from the study.


 > Conclusion Top


Metastases to the oral cavity are quite uncommon. The prognosis for patients with metastatic lesions of the oral cavity is generally poor and primarily due to the delay in the detection of the lesions. Most of the patients with oral metastases have already developed generalized metastases by the time of diagnosis; however, in many cases, a solitary mandibular metastasis can be the initial manifestation of the primary tumor.

The general dentist or dental specialist should maintain a high level of suspicion while evaluating patients with a history of cancer. Paresthesia of the lower lip and the chin should be considered ominous signs of metastatic disease. Despite their rarity, metastatic tumors should be considered in the differential diagnosis of inflammatory, reactive, and bisphosphonate-related lesions of the jaws. This case emphasizes the importance of a complete and careful workup with particular attention to detailed medical history as well as careful clinical, radiographic, and histopathologic examination. As these lesions are associated with a poor prognosis, early detection is of extreme importance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Dib LL, Soares AL, Sandoval RL, Nannmark U. Breast metastasis around dental implants: A case report. Clin Implant Dent Relat Res 2007;9:112-5.  Back to cited text no. 1
    
2.
Wu YT. Metastatic carcinoma to the oral tissues and jaws: A study of 25 cases. Zhonghua Kou Qiang Yi Xue Za Zhi 1990;25:258-61, 317.  Back to cited text no. 2
    
3.
Friedrich RE, Abadi M. Distant metastases and malignant cellular neoplasms encountered in the oral and maxillofacial region: Analysis of 92 patients treated at a single institution. Anticancer Res 2010;30:1843-8.  Back to cited text no. 3
    
4.
Harris M, Howell A, Chrissohou M, Swindell RI, Hudson M, Sellwood RA, et al. A comparison of the metastatic pattern of infiltrating lobular carcinoma and infiltrating duct carcinoma of the breast. Br J Cancer 1984;50:23-30.  Back to cited text no. 4
    
5.
Akinbami BO. Metastatic carcinoma of the jaws: A review of literature. Niger J Med 2009;18:139-42.  Back to cited text no. 5
    
6.
Ogütcen-Toller M, Metin M, Yildiz L. Metastatic breast carcinoma mimicking periodontal disease on radiographs. J Clin Periodontol 2002;29:269-71.  Back to cited text no. 6
    
7.
Söder B, Yakob M, Meurman JH, Andersson LC, Klinge B, Söder PÖ, et al. Periodontal disease may associate with breast cancer. Breast Cancer Res Treat 2011;127:497-502.  Back to cited text no. 7
    
8.
Poulias E, Melakopoulos I, Tosios K. Metastatic breast carcinoma in the mandible presenting as a periodontal abscess: A case report. J Med Case Rep 2011;5:265.  Back to cited text no. 8
    
9.
Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B, et al. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws–2009 update. J Oral Maxillofac Surg 2009;67:2-12.  Back to cited text no. 9
    
10.
Ficarra G, Beninati F. Bisphosphonate – Related osteonecrosis of the jaws: The point of view of the oral pathologist. Clin Cases Miner Bone Metab 2007;4:53-7.  Back to cited text no. 10
    


    Figures

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



 

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