Metastatic disease to the condyle: A case report and review of literature

Abstract

Metastatic lesions to the oral cavity are rare, accounting for only 1–8% of all oral malignancies, and involvement of mandibular condyle is a rare phenomenon. The present literature review found only 99 cases reported to date (including the present case). There has been only one documented case of condylar metastatic carcinoma from the bladder. We report the second case of metastasis to the mandibular condyle from a known primary urothelial carcinoma of the bladder. Condylar metastasis can present with non-specific TMJ dysfunction symptoms and can be misdiagnosed. Radiographic findings are typically non-specific, and the differential diagnosis should include osteomyelitis, primary malignant tumors, and metastatic spread. Either a fine needle aspiration or biopsy should be performed to obtain a histopathological diagnosis. Furthermore, metastasis to the condyle can be the first indication of an undiscovered distant primary tumor, making timely evaluation and management crucial from an oncologic perspective.

Highlights

  • Involvement of mandibular condyle with metastatic disease is a rare phenomenon.

  • Condylar metastasis can present with non-specific TMJ dysfunction symptoms.

  • Radiographic findings are typically non-specific.

  • TMJ metastasis can be first indication of an undiscovered distant primary tumor.

  • Biopsy should be performed to obtain a histopathological diagnosis.

Introduction

Metastatic lesions to the oral cavity are rare, accounting for only 1–8% of all oral malignancies [ ], and involvement of mandibular condyle is highly unusual [ ]. The presenting signs and symptoms include pain and swelling in the pre-auricular region, limited mouth opening, clicking, and crepitus, mimicking temporomandibular joint (TMJ) disorders [ ], causing a delay in diagnosis. Prompt diagnosis and management are crucial for improved outcomes. A complete and precise history of the present illness, past and current medical and surgical history, family history, a thorough review of systems, comprehensive physical examination, appropriate imaging, laboratory studies, and tissue biopsy are essential to achieving a diagnosis [ ].

Metastatic spread to the condyle is uncommon due to the sparse hematopoietic bone marrow, limited local vascular supply, and the presence of an osseous plate that prevents the spread of malignant cells into the condylar marrow space [ , , ]. Primary tumors of the breast, lung, kidney, prostate, and less often from the pancreas, rectum, stomach, liver, and colon [ ] can rarely metastasize to the condyle. Even less common is the metastatic spread from the bladder. There has been only one documented case of condylar metastatic carcinoma from the bladder [ ]. We report the second case of metastasis to the mandibular condyle from a known primary urothelial carcinoma of the bladder. Furthermore, we have performed a thorough review of the literature to include all the documented cases of metastasis to the condyle, from its first case in 1947 [ ] to the present. To the authors’ knowledge, this is the first comprehensive literature review reporting 98 published cases of condylar metastases.

Report of case

83-year-old man presented to Strong Memorial Hospital for evaluation of a lytic lesion of his right mandibular condyle. Several weeks before the presentation, he experienced a sudden onset of pain in the right preauricular region while eating. He also reported limited maximal incisal opening (MIO). This prompted the patient to visit his primary care physician, who obtained a maxillofacial computed tomography (CT) scan that revealed “a lytic lesion of the right mandibular condyle with possible fracture concerning for malignancy”.

The patient’s past medical history was significant for urothelial carcinoma of the bladder, diabetes mellitus, chronic kidney disease, nephrolithiasis, hyperlipidemia, and hypothyroidism. His past surgical history included transurethral resection of the tumor, bilateral knee replacement, and colonoscopy. His medications comprised of levothyroxine, atorvastatin, colchicine, tramadol, as well as his chemotherapeutic regimen (5-FU, Mitomycin, Cisplatin, Gemzar, Pembrolizumab) for the urothelial carcinoma of the bladder. He also received radiation therapy in conjunction with chemotherapy. He had no known drug allergies. His social history was positive for a brief smoking period of three years in the 1960s and occasional cigar smoking.

A head and neck examination revealed mild swelling and tenderness to the right preauricular region. He had limited mouth opening with MIO of approximately 20 mm. Intraoral examination was unremarkable and there was no palpable cervical lymphadenopathy. Cranial nerve examination was normal as well.

Imaging included a panoramic radiograph and a maxillofacial CT scan without contrast revealing a small lytic osseous lesion involving the right condylar head and neck with an associated pathologic fracture ( Fig. 1 A, B, C). The CT scan also showed significant destruction of the mandibular cortex in this location, suggesting a “malignant process”. Biopsy was obtained utilizing the fine needle aspiration (FNA) technique. The cytopathology team reviewed the specimen and confirmed the presence of malignant cells, a diagnosis consistent with metastatic bladder cancer was established ( Fig. 2 A, B).

Fig. 1
A: Coronal view of CT scan showing small lytic osseous lesion involving the right condylar head. B: Axial view of CT scan showing small lytic osseous lesion involving the right condylar head. C: Sagittal view of CT scan demonstrating small lytic osseous lesion involving the right condylar head and neck with an associated pathologic fracture.

Fig. 2
A: Photomicrograph showing large malignant cells arranged singly and in loosely cohesive clusters. The tumor cells demonstrate a high nuclear to cytoplasmic ratio and single “naked” nuclei with notable pleomorphism. Although a DiffQuik stain is not ideal for assessing nuclear features, we can see nucleoli (black arrows) and coarse chromatin (blue arrows). The cytoplasm is homogenous with fine vacuoles (black circle). Diff-Quik stain, 200× magnification. B: Loosely cohesive cluster of malignant cells with high nuclear to cytoplasmic ratio, pleomorphism, irregular nuclear contours, coarse chromatin (blue arrows), prominent nucleoli (black arrows), and homogeneous cytoplasm with fine vacuoles. Diff-Quik stain, 400× magnification. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

At the time of presentation, our patient was also noted to have a recurrent high-grade urothelial carcinoma with muscle invasion with metastasis to the lung found on a positron emission tomography (PET) scan. He was managed by radiation oncology with palliative radiation therapy.

Discussion

Metastatic spread to the mandibular condyle is a rare occurrence and potentially diagnostically challenging [ ]. Solitary metastasis to the mandibular condyle is rather infrequent, and in the majority of the cases, it is an indication of widespread metastases reflecting the terminal stage of malignancy [ ]. These are often suggestive of an undiagnosed distant primary tumor carrying a poor prognosis [ , ]. Due to the commonly acknowledged fact that the mandible lacks the lymphatic system, it is believed that the mechanism of spread to this area must occur via a hematogenous route [ , ]. Furthermore, the sparse hematopoietic bone marrow, limited local blood supply, and the presence of an osseous plate prevents the spread of malignant cells into the condylar marrow space, making this a rare phenomenon [ , , ].

Diagnosis can be challenging because clinical symptoms are usually nonspecific, often mimicking TMJ dysfunction or odontogenic infections [ , , ]. Commonly reported symptoms are pain and swelling in the TMJ region. Other symptoms include trismus, malocclusion, dysfunction, and paresthesia [ , , , ]. Our literature review consisted of 81 publications with a total of 98 published cases of metastasis to the condyle from years 1947–2020 ( Table 1 ). According to the review, the most common presenting signs and symptoms were pain (68 patients) and swelling (39 patients) in the TMJ region. 11 patients also reported trismus/difficulty opening. A few patients complained of paresthesia (6 patients), malocclusion (5 patients), and dysfunction (3 patients) ( Table 2 ).

Table 1
List of all published cases of metastatic spread to the condyle between 1947 and 2021.
Year of publication Author(s) Presentation Primary lesion Diagnosis Treatment Age Gender
2020 Shulz, Rocha [ ] Pain/Paresthesia Breast No biopsy Radiation 52 F
2018 Mauricio Hale [ ] Pain Lung* Adenocarcinoma Palliative 72 M
2017 Seo-Young An [ ] Pain Neck vs Lung No biopsy Palliative 75 F
2017 Guarda-Nardini [ ] Pain/Deflection Lung* Carcinoma Resection 59 F
2017 Dodo [ ] Trismus/Difficulty chewing Breast* No biopsy Chemotherapy 55 F
2014 Sugiyama [ ] Pain Uterus Adenocarcinoma Radiation 65 F
2014 Kolokythas [ ] Pain Pancreas* Adenocarcinoma Palliative 66 F
2014 Klasser [ ] Pain/Difficulty opening Liver FNA HCC Palliative 75 M
2014 Chiesa [ ] Pain/Swelling Breast No biopsy Radiation 48 F
2013 Qiu [ ] Pain/Swelling Bladder* Carcinoma Resection/Chemotherapy 49 M
Swelling/Discomfort Prostate* Adenocarcinoma Resection/Chemotherapy 85 M
Pain/Paresthesia Lung* No biopsy Chemotherapy 62 F
Swelling/Paresthesia Penis FNA SCC Chemotherapy 53 M
Pain/Swelling Colon FNA Carcinoma Chemotherapy 64 M
Pain Breast Carcinoma Resection/Radiation 47 F
2013 Puranik [ ] Pain/Swelling Cervix FNA SCC Palliative 63 F
2013 Peacock [ ] Pain/Malocclusion Kidney RCC (Angiosarcoma) Resection 64 M
2012 Scolozzi [ ] Pain/Malocclusion Lung* Large cell lung CA Palliative 72 F
2012 Gonzalez-Perez [ ] Pain/Swelling Breast* Adenocarcinoma Chemotherapy 73 M
2012 Kelles [ ] Trismus Kidney Clear cell RCC Unknown 59 F
2011 Patricia [ ] Pain/Trismus Breast Adenocarcinoma Palliative 51 F
2011 Tabib [ ] Pain/Swelling Lung* No biopsy Palliative 49 M
2011 Cristofaro [ ] Pain/Swelling Prostate* Adenocarcinoma Resection 60 M
2010 Katnelson [ ] Pain/Trismus Lung* FNA Carcinoma Chemotherapy 51 M
2010 Freudlsperger [ ] Pain Prostate* Carcinoma Radiation 75 M
2010 Kruse [ ] Pain/Swelling Lung* Lung CA Palliative 73 M
Pain/Difficulty opening Lung* FNA Adenocarcinoma Palliative 75 F
Malocclusion Thyroid No biopsy Palliative 85 M
2009 Shintaku [ ] Pain Lung* Adenocarcinoma Chemotherapy 71 F
2009 Panossian [ ] Pain/Swelling Breast* Carcinoma Chemoradiation 79 F
2009 Gomes [ ] Swelling Unknown Adenocarcinoma Palliative 51 F
2008 Baber [ ] Pain/Swelling Neural crest* FNA Neuroblastoma Chemotherapy 15 F
2008 Schulze [ ] Pain/Swelling Bronchus* No biopsy Unknown 52 F
2008 Menezes [ ] Pain/Swelling Breast* Adenocarcinoma Chemotherapy 42 F
2008 Boniello [ ] Pain Lung* Adenocarcinoma Radiation 60 M
2008 Kamatani [ ] Pain/Swelling Liver HCC Chemotherapy 59 M
2006 Miles [ ] Trismus Breast Adenocarcinoma Resection 78 F
2006 Sari [ ] Pain/Dislocation Bronchus* SCC Resection/Chemotherapy 65 M
2006 Duker [ ] Pain Breast No biopsy Unknown 60 F
2006 Jia [ ] Paresthesia Breast No biopsy Radiation 46 F
2005 Kaufmann [ ] Discomfort Lung No biopsy Radiation 48 M
2005 Mason [ ] Pain/Swelling Colon* Adenocarcinoma Palliative 73 M
2004 Smolka [ ] Facial asymmetry Stomach Adenocarcinoma Radiation 67 M
2003 Kolk [ ] Malocclusion Stomach Adenocarcinoma Resection 51 M
2002 Meneghini [ ] Pain/Swelling Sacro-coccygeal Chordoma Resection 63 F
2002 Bokelund [ ] Paresthesia Pancreas Adenocarcinoma Palliative 77 F
1999 Robiony [ ] Swelling Lung* Adenocarcinoma Radiation 64 F
1998 Cohen [ ] Pain Unknown SCC Unknown 66 M
1997 Balestreri [ ] Swelling Rectum Adenocarcinoma Palliative 57 M
1997 Yoshimura [ ] Pain/Swelling Liver HCC Chemotherapy 61 M
1997 Beck-Mannagetta [ ] Pain Lung Adenocarcinoma Radiation 67 F
1996 Porter [ ] Pain/Swelling Testicle No biopsy Radiation 43 M
1996 Nortje [ ] Dysfunction Nose No biopsy Chemotherapy 43 M
1994 Johal [ ] Pain Kidney* Clear cell carcinoma Palliative 65 F
1993 MacAfee [ ] Swelling Colorectal Adenocarcinoma Resection 59 M
1993 Stavropoulos [ ] Malocclusion Breast Adenocarcinoma Resection 55 F
1990 Rutsatz [ ] Pain/Swelling Lung Adenocarcinoma Radiation 76 F
1990 Catrambone [ ] Pain/Swelling Prostate* Adenocarcinoma None 78 M
1990 Bavitz [ ] Pain/Swelling Unknown* Malignant Schwannoma Radiation 48 F
1990 Sanchez [ ] Swelling Unknown* Adenocarcinoma Resection 30 M
1989 Rubin [ ] Pain Unknown* Adenocarcinoma Radiation 67 F
1988 Webster [ ] Pain Breast No biopsy Palliative 52 F
Pain Breast No biopsy Palliative 54 F
1987 Lowicke [ ] Pain Kidney Hypernephroid Carcinoma Unknown Unknown Unknown
1986 Thatcher [ ] Swelling Prostate* Adenocarcinoma Resection 68 M
1986 Sokolov [ ] Pain Breast Adenocarcinoma Radiation 52 F
Pain Breast No biopsy Chemotherapy/Radiation 54 F
1985 DeBoom [ ] Pain Prostate* Adenocarcinoma Chemotherapy 68 M
1985 Owen [ ] Unknown Lung No biopsy Palliative Unknown Unknown
1985 Hecker [ ] Swelling/Trismus Unknown* Adenocarcinoma Radiation 63 F
1985 Sailer [ ] Pain Breast Adenocarcinoma Radiation 56 F
1982 Gerlach [ ] Pain/Swelling Bronchus SCC Radiation 42 Unknown
1982 Peacock [ ] Pain/Swelling/Trismus Bronchus* SCC Radiation 53 M
1982 Giles [ ] Dysfunction Rectum Adenocarcinoma Radiation 55 F
1981 Peron [ ] Pain Intestine Adenocarcinoma Radiation 55 M
Pain Bronchus Adenocarcinoma Unknown 74 M
Pain Unknown Unknown Unknown 39 F
1981 Compere [ ] Swelling Bronchus* SCC Resection 48 M
Swelling Pancreas* Adenocarcinoma Resection 73 M
Pain Breast Adenocarcinoma Resection 65 F
1980 Wolujewicz [ ] Swelling Prostate* Adenocarcinoma Palliative 74 M
1980 Mizukawa [ ] Pain Breast Adenocarcinoma Radiation 32 F
1978 Mace [ ] Trismus/Paresthesia Breast Adenocarcinoma Palliative 54 F
1975 Butler [ ] Pain/Dysfunction Breast Autopsy/Carcinoma Palliative 49 F
1974 Agerberg [ ] Pain Breast Ductal carcinoma Radiation 46 F
1974 Winiker-Blanck Unknown Bronchus Unknown Unknown Unknown Unknown
1973 Hartman [ ] Pain/Trismus Breast Autopsy Radiation 52 F
1969 Epker [ ] Pain/Swelling Breast No biopsy Radiation 45 F
1966 Worth [ ] Unknown Rectum Adenocarcinoma Unknown Unknown M
1965 Ameli [ ] Pain/Swelling Bronchus Bronchogenic carcinoma Palliative 55 M
1956 Blackwood [ ] Pain Breast Polygonal cell carcinoma Palliative 24 F
1954 Salman [ ] Pain Breast Adenocarcinoma Palliative 53 F
Pain Renal Adenocarcinoma Palliative 62 F
Pain Uterus Epidermoid carcinoma Palliative 64 F
Swelling Prostate Palliative 65 M
1954 Thoma [ ] Pain/Swelling Unknown* Transitional cell Carcinoma Resection 51 F
Unknown Toe Melanosarcoma Unknown Unknown Unknown
1947 Thoma [ ] Pain/Swelling Unknown Adenocarcinoma Resection 49 M
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Aug 14, 2022 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Metastatic disease to the condyle: A case report and review of literature
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