Secondary Tumors of the Mandible (About 3 Cases)
Corresponding author: Dr. Lezrag M, N’Department of ENT, 20 August Hospital, Ibn Rochd University Hospital, Casablanca, Morocco
The secondary malignant tumors of the mandible are rare diseases and represent 1 to 3% of all malignant oral neoplasms. Some authors explain the rarity of this condition by the relative paucity of hematopoietic tissue in the mandible, which is necessary for the reception of a metastatic embolus. Mandibular metastases of thyroid papillary carcinomas are exceptional [1,2].Our study is a review of the literature of cases of metastatic thyroid cancer to the mandible.
A 59-year-old North African female presented with a 6 x 6cm right cheek mass. This mass was painless and fixed, with associated anterior cervical tumefaction that is mobile with deglutition, without lymphadenopathy.The orthopantomogram, maxilla-facial and cervical computed tomography showed a blown out lytic process of right mandibular ramus involving endosteum and cortex. The soft tissue component of the tumor is enhancing by the contrast agent with multinodular goiter without cervical lymphadenopathy. Right hemimandibulectomy was performed.
Histopathologically study of the excised right mandible demonstrated a vesicular form of papillary thyroid carcinoma. The patient underwent staged total thyroidectomy with bilateral functional neck lymphadenectomy.
The surgical specimen revealed a thyroid primary neoplasm of the same histopathologically subtypes. The postoperative course was uncomplicated.
IRAtherapy and hormone replacement therapy were indicated.
50-years-old North African female presented with a 5 year history of dental pain gingivolaveolar ulceration compared to the 31th and 32th teeth associated with anterior cervical tumefaction without lymphadenopathy.
The orthopantonogram and the tom densitometry showed (Figure1,2,3):
Osteocytes lesions involving the teeth 31 and 31 (picture 2a,2b).
Left lobe tumor of the thyroid.
The biopsy of gingival ulceration demonstrated mandibular metastasis of a vesicular carcinoma of the thyroid.
Thyroid scintigraphy showed a multinodular goiter with a dominant nodule in the left lob.
Total thyroidectomy, left functional lymphadenectomy and right hemi-mandibulectomy were performed. IRAtherapy and hormone replacement therapy were indicated.
Figure 1. Right mandibular metastasis peripherally enhancing.
A 47 years old North African female presented with progressive bulging of the right cheek, found to have an anterior cervical tumefaction related to thyroid without cervical lymphadenopathy. Orthopantomogram and computed tomography showed:
An osteocytes lesion of the right mandibular angle and ramus is seen with cortical destruction, heterogeneous contrast enhancement, with some soft tissue infiltration of the submandibular gland, the retro-zygomatic-maxillary fossa, the external pterygoid muscle.
Thyroid ultrasonography demonstrated multinodular goiter plunging at the level of his right lobe.
Right interruptive hemimandibulectomy was performed.
Histopathologically analysis revealed mandibular metastasis of vesicular papillary thyroid carcinoma.
The patient underwent a staged total thyroidectomy with a bilateral functional lymphadenectomy.
Surgical pathology revealed histological subtype as the mandibular metastasis.
The postoperative course was uncomplicated.
The premolar-molar region is the most frequent site affected. This region is rich in haemopoietic tissue and as the mode of the metastasis is hematogenous become deposited in the vascular haemopoietic tissue [7,8].
According to Hirshberg, the most common sources of tumors metastasizing to the mandible are the breast for women and lung for men. These are also the most common tumors that metastasize to the skeletal bone .
The diagnosis of mandibular metastasis is a challenge because the clinical symptomatology is nonspecific, characterized by a high clinical latency leading to delayed diagnosis. Facial swelling, paresthesia, pain and tooth mobility are the most frequent clinical signs . In about 30% of the cases, the metastatic lesion in mandible is the first indication of an undiscovered malignancy at a distant site . In all cases, confirmation of the secondary character requires histopathologically examination of the primary tumor which must be identical to that of the presumed metastatic lesion [4,11,12].
The diagnosis of mandibular metastasis is synonymous with a disseminated pathological process. The prognosis remains poor despite of therapeutic advances. More than 60% of patients die within 12 months of the diagnosis of oral cavity metastasis .
The treatment of mandibular metastasis is often palliative, consisting of radiotherapy and/or chemotherapy depending on the nature of the primary tumor [5,11]. Radical surgery may be suggested for single metastases and could improve the prognosis and quality of life of patients .
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