Mandibular metastases as first clinical sign of an occult male breast cancer

Abstract

A 73-year-old man presented with a painful swelling of the left temporomandibular joint with no other symptoms. Panoramic radiography showed an osteolytic lesion in the left mandibular body, while magnetic resonance imaging provided the most accurate view of an osteolytic lesion in the left condyle. Skeletal scintigraphy showed increased uptake in the mandibular anatomical area. A diagnosis of metastatic breast adenocarcinoma was made from mandibular biopsies which proved to be ductal carcinoma, with no evidence of any other metastases. Clinicopathologic features of this case are reviewed.

Male breast cancer is uncommon. Presentation is usually a lump or nipple inversion, but is often late, with more than 40% of patients having stage III or IV disease by the time of diagnosis, markedly decreasing the survival rate. The diagnosis is easily made by breast biopsy. In 2009, there were an estimated 1910 new cases and 440 deaths related to male breast cancer, accounting for 0.25% and 0.15%, respectively, of all new cases of cancer and cancer deaths for males in the USA. Historical cohorts demonstrate that the peak incidence of male breast cancer occurs at approximately 71 years of age.

The purpose of this study is to evaluate the clinical and pathological features of an occult male breast cancer with mandibular metastasis in a 73-year-old man.

Case report

A 73-year-old man was referred for the evaluation of a localized swelling and increased pain in the left preauricular region, initially diagnosed as TMJ dysfunction syndrome. The patient’s medical history included diabetes and hypertension, and there was no history of tobacco or alcohol use. There was history of cancer in his family (lung cancer in his father and breast cancer in his mother). The patient reported that the left mandibular first molar had been extracted 2 years earlier, but the area had been slow to heal.

On examination, no extraoral abnormality was visible and there was no limitation of mandibular movements. Intraorally, very slight elevation of the crest of the ridge was observed just posterior to tooth No. 35, but the mucosa of the edentulous space appeared normal in colour and there was no significant lateral expansion of the alveolus in this area. No local tenderness or discharge was noted, and there was no evidence of palpable cervical lymphadenopathy. A panoramic radiograph revealed a poorly defined radiolucent area underlying and posterior to teeth No. 33, 34 and 35, with basal mandibular erosion ( Fig. 1 A) . Magnetic resonance imaging (MRI) provided the most accurate view of an osteolytic lesion in the left condyle ( Fig. 1 B). Skeletal scintigraphy showed increased uptake in the mandibular area ( Fig. 2 ). Under local anaesthesia, a double mandibular biopsy (body of mandible and left condyle) was performed. Light microscopy examination of the biopsy revealed osseous trabecular structures with nests of ductal carcinoma surrounded by connective tissue tumour. A diagnosis of metastatic breast adenocarcinoma was made from these two mandibular biopsies ( Fig. 3 A and B) . A complete physical examination revealed an inverted left nipple with a partially circumscribed retroareolar mass ( Fig. 4 ), to which the patient had not paid attention. Fine-needle aspiration of the lesion confirmed the existence of breast cancer as the primary tumour.

Fig. 1
(A) Panoramic radiograph showing a radiolucent area underlying and posterior to teeth No. 33, 34 and 35, with basal mandibular erosion. (B) Sagittal MRI demonstrating the osteolytic lesion in the left mandibular condyle. There was no extraosseous infiltration.

Fig. 2
Skeletal scintigraphy showed increased uptake in the mandibular area.

Fig. 3
(A) Body of mandible. Light microscopy examination revealed osseous trabecular structures with nests of ductal carcinoma surrounded by tumoral connective tissue. (B) Left mandibular condyle. Osteolytic mandibular metastasis occurs because the breast cancer cells secrete factors that interact with the naturally occurring cells in the bone. A diagnosis of metastatic breast adenocarcinoma was made from these two mandibular biopsies.

Fig. 4
Mammogram showing an inverted left nipple with a partially circumscribed mass beneath the areola. Note the visible skin retraction overlying the mass.

Surgery of the primary tumour was performed under general anaesthesia. It was decided to perform a left mastectomy with axillary dissection, with the tumour identified as an infiltrating ductal carcinoma ( Fig. 5 ). The histological diagnosis was pT4b, pN3, cM1 (Stage IV), G3 (3 + 3 + 2), RH (+), Her-2 (−). Given the evolution of the process, the patient began hormonal therapy (tamoxifen plus goserelin) and chemotherapy with cyclophosphamide, epirubicin and fluorouracil (CEF scheme) 600/90/600 mg/m 2 × 4 cycles, followed by weekly paclitaxel 100 mg/m 2 × 8, and radiotherapy to the mandibular and axillary areas. The clinical condition of the patient was not favourable for segmental mandibulectomy and reconstruction. The patient remained disease-free 3 years later.

Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Mandibular metastases as first clinical sign of an occult male breast cancer
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