J Clin Exp Dent. 2020;12(10):e999-1004. Two rare cases of oral metastasis Journal section: Oral Medicine and Pathology doi:10.4317/jced.57125 Publication Types: Case Report https://doi.org/10.4317/jced.57125 Two rare cases of oral metastasis arising from lung adenocarcinoma and esophageal carcinoma Breno-Amaral Rocha 1, Lívia-Maris-Ribeiro Paranaiba 2, Ciro-Dantas Soares 3, Maria-Goretti-Freire de Carvalho 4, Mário-Rodrigues de Melo-Filho 5, Lucianne-Maia-Costa Lima 6, Giovanna-Ribeiro Souto 1, Martinho-Campolina-Rebello Horta 1 1 Graduate Program in Dentistry, School of Dentistry, Pontifícia Universidade Católica de Minas Gerais (PUC Minas), Belo Hori- zonte, Minas Gerais, Brazil 2 Department of Pathology and Parasitology, Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas, MG, Brazil 3 Department of Oral Diagnosis, School of Dentistry, State University of Campinas, Sao Paulo, Brazil 4 Full professor, Pathology Department, Potiguar University, Natal, Brazil 5 Dental School, University of Montes Claros, Montes Claros, Minas Gerais, Brazil 6 Radiotherapy Service, Santa Casa Hospital, Montes Claros, MG, Brazil Correspondence: Pontifícia Universidade Católica de Minas Gerais (PUC Minas) Avenida D. José Gaspar, 500. Prédio 46 – Sala 101 Belo Horizonte, Minas Gerais, Brazil. 30535901 [email protected] Rocha BA, Paranaíba LMR, Soares CD, Carvalho MGF, Melo-Filho MR, Lima LMC, Souto GR, Horta MCR. Two rare cases of oral metastasis arising from lung adenocarcinoma and esophageal carcinoma. J Clin Exp Received: 02/04/2020 Dent. 2020;12(10):e999-1004. Accepted: 02/07/2020 Article Number: 57125 http://www.medicinaoral.com/odo/indice.htm © Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488 eMail: [email protected] Indexed in: Pubmed Pubmed Central® (PMC) Scopus DOI® System Abstract Metastasis to the oral cavity are rare, representing only 1% of all oral malignancies, and originate from various sites such as the breast, prostate, lung and kidney. Clinically, they can simulate reactive and inflammatory lesions com- mon in the oral cavity, and the clinical and microscopic diagnosis of these metastasis is a challenge. In this article, we report two new cases of esophageal and lung metastasis to oral tissues, highlighting their clinical characteristics and the process of diagnostic elucidation. We emphasize the importance for clinicians to consider the possibility of metastatic lesions in the oral cavity in patients previously diagnosed with malignant lesions in distant tissues and organs. Key words: Diagnosis, esophageal squamous cell carcinoma, adenocarcinoma of lung, oral cavity, metastasis. Introduction a known tumor from its primary site (3). These lesions Metastatic tumors of the oral cavity are uncommon, may occur in the oral soft tissues, in the jawbones or accounting for only 1% of all oral malignancies (1,2). in both osseous and soft tissue. When it occurs in the These tumors, however, are of great clinical significan- jawbones, the mandible is the most common location, ce, since they may represent the first evidence of the dis- with the molar area being the most frequently involved semination of another (previously unknown) tumor from site. When it affects the oral soft tissues, the attached its primary site, or the first evidence of dissemination of gingiva is the most affected site (4). Any malignant tu- e999 J Clin Exp Dent. 2020;12(10):e999-1004. Two rare cases of oral metastasis mor can metastasize to the oral cavity. Such lesions are x 3.0 cm. The teeth presented accumulation of biofilm most commonly found in males, primarily with lung, fo- with gingival bleeding to the touch (Fig. 1A,B). Teeth llowed by prostate, kidney, bone and adrenal malignan- 41 and 42 showed grade 3 mobility. The imaging exams cies, and in females with breast followed by genital and highlighted a radiolucent lytic lesion around teeth 41 thyroid malignancies (4,5). There are few case reports of and 42. In view of the previous oncological diagnosis metastasis to the oral cavity from relatively uncommon and the characteristics of the lesion, the hypothesis of a sites such as esophagus and liver (2,6). diagnosis of oral metastasis was considered. The lesion Metastatic solid tumors to the oral cavity are highly indi- was biopsied and the histology (Fig. 1C-F) and immuno- cative of a widespread disease process and can obvious- histochemistry analysis of the mass revealed the lesion ly modify the prognosis and treatment strategy. In addi- to be an adenocarcinoma of the lung (Fig. 2A-D) (Table tion, this condition is associated with poor survival rates, 1). The patient progressed with disease progression and with survival time after oral metastasis diagnosis at 3.7 respiratory failure, and one month later died. to 8.25 months (5,7,8). Most patients who present with -Case 2 a metastatic lesion in the oral cavity have already been In April 2016, a 61-year-old male was referred to the diagnosed with primary tumors; however, in 23%–30% Oncologic Dentistry Service for evaluation of a gingival of cases, oral metastasis is the first manifestation of an lesion to be clarified. The patient complained of dental undiscovered primary malignancy (4,7,8). mobility and gingival swelling for approximately the Clinically, the metastatic lesions in the oral cavity mimic past 15 days. He had local discomfort and hypoesthesia both benign and malignant lesions, making the diagnosis on the lower lip on the right. The patient reported being a challenging and interesting. Benign or inflammatory le- former smoker and ex-alcoholic. The patient’s past me- sions, which enter into the differential diagnoses, inclu- dical history revealed an oropharyngeal cancer treated in de pyogenic granuloma, peripheral giant cell granuloma, 2013 and a squamous cell carcinoma of the esophagus peripheral ossify fibroma, and vascular anomaly. On the (T3NXM1 - IV) with cerebral metastasis in 2016. He other hand, the differential diagnoses for malignant le- was submitted to radiotherapy directed to the region of sions include squamous cell carcinoma, lymphoma, soft supraclavicular fossas, cervico-thoracic and esophageal tissue sarcoma and salivary gland carcinoma (1,8). concomitant to chemotherapy (Al-Sarraf Protocol). He In this article, we report two new cases of metastatic tu- was also submitted to stereotactic cranial radiosurgery mor of oral soft tissue and their clinical features and ma- covering two metastatic targets. Were administered sin- nagement, highlighting the importance to the clinicians gle doses of 1.500 cGy to the right subcortical parietal of the possibility of metastatic lesion in the oral cavity lesion and 800 cGy to the right fronto-parietal region in patients previously diagnosed with malignant lesions near the convexity, respectively. Intraoral examination in distant sites. showed a firm consistency swelling overlapped by mu- cosa with telangiectasias, located in the region of teeth 43, 44 and 45, extending to the posterior region of the Case Report mandible. The lesion extended to the buccal and lin- -Case 1 gual surfaces of the abovementioned teeth, measuring In February 2015, a 55-year-old male was referred to the approximately 5.0 x 2.0 cm (Fig. 3A). Teeth 43, 44 and Oncologic Dentistry Service with the chief complaint of 45 showed marked mobility. On the panoramic radio- gingival bleeding and dental mobility. He reported that graph, there was a radiolucent lesion with irregular “mo- this complaint had begun five months previously with th-eaten” borders, involving the roots of teeth 43, 44 and the appearance of a “lump” in the gingiva. The patient 45, extending to the posterior region of the mandible on denied any odontogenic symptoms prior to the appea- the right (Fig. 3B). In view of the previous oncologi- rance of the gingival bleeding and dental mobility. The cal diagnosis and the characteristics of the lesion, the patient reported being an ex-smoker and ex-alcoholic. diagnostic hypothesis of oral esophageal metastasis was The patient’s past medical history was significant for raised. The lesion was biopsied and histologic and im- adenocarcinoma of the lung (cT4cN2Mx – IIIB). The munohistochemistry examination showed a moderately tumor was unresectable by invasion of the pulmonary differentiated squamous cell carcinoma confirming the artery, and therefore the treatment plan was radiotherapy diagnostic hypothesis (Fig. 3C-F) (Table 1). The patient and chemotherapy. The physical examination revealed progressed with disease progression and one month later a mobile nodule approximately 1 cm in greatest diame- died. ter, subcutaneously, in the right parotid region. Intraoral examination showed an exophytic tissue mass, with a Discussion smooth and lobulated surface, firm consistency, and a Invasion and metastasis are the most important causes of reddish-pink color located in the gingiva around teeth cancer-related morbidity and mortality and are the biolo- 32, 31, 41, 42, 43 and 44. The tumor mass measured 6.0 gical hallmarks of malignant tumors. Although millions e1000 J Clin Exp Dent. 2020;12(10):e999-1004. Two rare cases of oral metastasis Fig. 1: Metastasis of adenocarcinoma from lung to mandible. A: Clinical aspect of the lesion. B: Multinodular enlargements of mandible. C, D and E: Microscopic aspects of the lesion showing an adenocarcinoma with prominent duct-forming structures and large amounts of mucin through the epithelial proliferations. F: PAS stain after diastase digestion highlighted the mucin. Fig. 2: Immunohistochemical features of the lesion. A: HE stain in low magnification. B: Positivity for CK-7. C: Negativity for CK-20. D: Thyroid transcription factor-1 (TTF1) positivity in most of the nuclei of the neoplastic cells. e1001 J Clin Exp Dent. 2020;12(10):e999-1004. Two rare cases of oral metastasis Fig. 3: Metastasis of esophageal carcinoma to mandible. A: Clinical aspect of the volumetric increase of the mandible on the right. B: Osteolytic lesion with poorly defined margins involving the right side of the anterior mandible.