Abstract
The authors describe a pooled analysis of 23 French patients presenting with oral metastasis between 1981 and 2008. The reviewed cases were collected from the medical records of two cancer institutes. The inclusion criteria were: the histology of the metastases must be known; the primary location must be known; metastasis and primary location must be physically separated; and oral primary locations were excluded. This sample represent 0.48% of all oral malignancies treated during the period. The sex-ratio was 2.3:1 in favour of men, the mean age was 64.5 years (±13.2). Lungs and kidneys represent 52.2% of the primary cancer locations. In most cases, the primary cancer was a carcinoma or an adenocarcinoma (82.6%). The most affected oral regions were the gingiva and alveolar mucosa (60.7%), followed by the tongue (17.9%). The mean survival was 16.6 months. This sample is characterized by the relative absence of specific symptoms and quite different distribution in primary sites. Even if oral metastases are rare, their semiological value necessitates the histopathological examination of any oral tumour, and a systematic search in all patients with cancer history.
Oral malignant lesions make up 5–6% of all forms of human body cancer. 1–3.2% of these oral lesions are metastastatic. Metastasis in jaw bones is more common than metastasis in oral soft tissues (28.7–38.8% of oral metastasis).
Oral metastases have a diagnostic (a quarter of them reveal an unknown cancer) and prognostic significance (their presence is correlated with limited survival of the patients). The identification of these lesions, particularly soft tissue metastasis, can become a real diagnostic challenge, because their clinical aspect sometimes mimics benign lesions or they present non-specific symptoms.
Patients and methods
The medical records of two French cancer institutes were used to find patients: the Alexis Vautrin Centre in Nancy and the Georges-François Leclerc Centre in Dijon. Both ethical committees had approved this study. The ICD criteria used were C79.8 (secondary malignant neoplasm of other specified sites) and C79.9 (secondary malignant neoplasm, unspecified site). The records allowed searching specifically for maxillofacial and otorhinolaryngologic metastasis. Only cases of oral metastasis (including salivary glands) were retained. Radiological examinations were performed to verify if underlying bone was affected and in this instance, information was mentioned. Central jawbone metastases without mucosal involvement were excluded.
The inclusion criteria were those defined by Clausen and Poulsen in 1963: the location and the histology of the primary cancer must be known (no unknown primary); the metastasis diagnosis has to be confirmed by histological studies; no invasion by contiguity; and no oral primary location. 23 cases between 1981 and 2008 were studied retrospectively.
Results
Table 1 summarizes the cases. This series represent 0.48% of all oral malignancies treated in these institutes between 1981 and 2008.
| Case # | Sex | Age (at diagnosis) | Site of primary tumour | Histology of primary tumour | Delay in appearance | Isolated metastasis | Oral localisation of metastasis | Follow-up (months) |
|---|---|---|---|---|---|---|---|---|
| 1 | M | 62 | Lung | Adeno-carcinoma | Synchronous | No | Mandibular gingiva, in molar region | Dead (24) |
| 2 | M | 79 | Lung | Small-cells carcinoma | Revealing | No | Base of the tongue | Dead (4) |
| 3 | M | 63 | Lung | Squamous-cell carcinoma | 3 months | No | Maxillary gingiva, in premolars region | Dead (5) |
| 4 | M | 65 | Lung | Adeno-carcinoma | Revealing | No | Maxillary gingiva and alveolar mucosa Mandibular anterior gingiva | Dead (1) |
| 5 | M | 49 | Lung | Squamous-cell carcinoma | Revealing | No | Base of the tongue | Dead (5) |
| 6 | M | 53 | Lung | Carcinoma | 5 months | No | Maxillary gingiva Mandibular gingiva |
Dead (2) |
| 7 | M | 62 | Lung | Adeno-carcinoma | Revealing | No | Maxillary anterior gingiva | Dead (4) |
| 8 | F | 50 | Lung | Squamous-cell carcinoma | Synchronous | No | Retro-molar trigone | Dead (20) |
| 9 | M | 73 | Kidney | Clear-cell adeno-carcinoma | Synchronous | No | Maxillary sinus Palatal bone |
Dead (6) |
| 10 | F | 84 | Kidney | Clear-cell adeno-carcinoma | 316 months | No | Maxillary tuberosity | Dead (22) |
| 11 | M | 78 | Kidney | Clear-cell adeno-carcinoma | 55 months | Yes | Right parotid and internal posterior region of cheek | Alive (88) |
| 12 | M | 66 | Kidney | Carcinoma | 5 month | No | Right side of the tongue | Dead (1.5) |
| 13 | F | 62 | Breast | Ductal carcinoma | 22 months | Yes | Anterior region of maxillary bone Maxillary sinus |
Dead (63) |
| 14 | F | 64 | Breast | Carcinoma | 24 months | No | Right posterior mandible | Dead (25) |
| 15 | F | 73 | Thyroid | Follicular carcinoma | 61 months | No | Soft palate | Dead (9) |
| 16 | M | 83 | Thyroid | Follicular carcinoma | 104 months | No | Soft palate Mandibular gingiva in the premolars region |
Dead (12) |
| 17 | M | 32 | Soft parts | Clear-cell sarcoma | 28 months | Yes | Base and mobile portion of the tongue | Dead (38) |
| 18 | F | 68 | Soft parts (gluteal) | Undifferentiated spindle-cell sarcoma | 6 months | No | Mandibular gingiva | Dead (44) |
| 19 | F | 82 | Soft parts (elbow) | Undifferentiated spindle-cell sarcoma | 10 months | No | Mandibular gingiva in molars region | Dead (2) |
| 20 | M | 71 | Pancreas | Adeno-carcinoma | Revealing | Yes | Maxillary gingiva | Dead (19) |
| 21 | M | 47 | Ureter | Carcinoma | Synchronous | No | Right mandible | Dead (10) |
| 22 | M | 49 | Bone (femur) | Chondro-sarcoma | 14 months | No | Maxillary gingiva | Dead (4) |
| 23 | M | 69 | Nasal fossa | Neuroendocrine carcinoma | Revealing | No | Base of the tongue | Dead (44) |
There was a predominance of male patients (69.6%). The mean age was 64.5 ± 13.2 years with a median of 65 years. Lungs and kidneys represent 52.2% of the cases, followed by soft tissues (13%), breasts and thyroid (8.7% each). The sample contained 52.2% carcinoma, 30.4% adenocarcinoma and 17.4% sarcoma. 73.9% were limited to soft tissue and 26.1% of them had reached the subjacent bone. The spatial distribution was: gingiva or alveolar mucosa (equally divided in maxillary and mandible) 60.7%; tongue 17.9%; soft palate and pharyngopalatine arch 7.1%; hard palate mucosa (and extension to maxillary sinuses) 7.1%; and cheek 3.6%.
The mean survival time at the time of diagnosis was 16.6 months, and the median survival was 9.5 months. The prognosis for isolated metastasis is better, with a mean survival of 40 months. The survival rates at 6, 12, and 18 months, and 2 and 4 years are 60.9%, 47.8%, 43.5%, 30.4% and 17.4%, respectively.
Clinical presentation
Table 2 gives further information about clinical presentation and Fig. 1 gives an overview of the presentation of these lesions. Figures 2 and 3 reveal the histology of one of the cases. Ulceration is present in 19% of cases, pain (including dysphagia) in 38.1%, bleeding and hypoesthesia in 4.8% each, difficulties in healing after oral surgery was reported in 9.5%. In 10.5% the authors noted a radiological lesion in subjacent bone. A small cup-shaped form under the mucosal lesion, conveyed an aggressive or advanced lesion.
| Case # | Clinical presentation | Lymphadenopathy | Number of oral lesion | Radiological aspect |
|---|---|---|---|---|
| 1 | Ulcerated mucous mass | Submandibular, unilateral | 1 | None |
| 2 | Nodular mass | Submandibular, bilateral | 1 | None |
| 3 | Painless mucous tumefaction | None | 1 | None |
| 4 | Bleeding | Sub-clavicular, unilateral | 2 | None |
| 5 | Painless, ulcerated mucous mass | Jugulo-carotid, unilateral | 1 | None |
| 6 | Mucous mass in maxillary and mandibular gingiva Dysphagia |
Cervical, bilateral | 2 | None |
| 7 | Ulcerated and slightly painful mucous mass | Submandibular, unilateral | 1 | None |
| 8 | Unknown | None | 1 | Osteolytic lesion |
| 9 | 6 cm exophytic mass | None | 1 | Osteolytic lesion |
| 10 | Pain, discomfort wearing dentures | None | 1 | Unknown |
| 11 | Rapid growth mass in submandibular and ramus regions | Cervical, unilateral | 1 | None |
| 12 | Voluminous exophytic mass | None | 1 | None |
| 13 | Difficulties healing after oral surgery Mucous mass | None | 2 | Unknown |
| 14 | Unknown | Unknown | 1 | Unknown |
| 15 | Painful hyperplasic lesion | Cervical, unilateral Submandibular, unilateral |
1 | None |
| 16 | Two slightly painful masses Dysphagia |
Cervical, unilateral | 2 | None |
| 17 | Nodular mass | None | 1 | None |
| 18 | Painless mucous mass | None | 1 | None |
| 19 | 4 cm mass, discomfort wearing dentures | None | 1 | None |
| 20 | Difficulties healing after oral surgery | Cervical, unilateral Submandibular, unilateral |
1 | None |
| 21 | Pain, mandibular hypoesthesia, ulcerated mass | Submandibular, unilateral | 1 | Unknown |
| 22 | Pain, mucous mass | None | 1 | None |
| 23 | Exophytic mass | None | 1 | None |
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