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.
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.
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).
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.
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 ).
|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|
|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|
|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|
|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|
|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|
|1981||Compere [ ]||Swelling||Bronchus*||SCC||Resection||48||M|
|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|
|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|
|1954||Thoma [ ]||Pain/Swelling||Unknown*||Transitional cell Carcinoma||Resection||51||F|
|1947||Thoma [ ]||Pain/Swelling||Unknown||Adenocarcinoma||Resection||49||M|