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<titleStmt>
<title xml:lang="en">Mandibular metastasis in a patient with follicular carcinoma of thyroid</title>
<author>
<name sortKey="Bhadage, Chetan J" sort="Bhadage, Chetan J" uniqKey="Bhadage C" first="Chetan J." last="Bhadage">Chetan J. Bhadage</name>
<affiliation>
<nlm:aff id="aff1"></nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Vaishampayan, Sagar" sort="Vaishampayan, Sagar" uniqKey="Vaishampayan S" first="Sagar" last="Vaishampayan">Sagar Vaishampayan</name>
<affiliation>
<nlm:aff id="aff2">
<italic>Department of Head and Neck Oncology, TATA Memorial Hospital, Mumbai, Maharashtra, India</italic>
</nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Umarji, Hemant" sort="Umarji, Hemant" uniqKey="Umarji H" first="Hemant" last="Umarji">Hemant Umarji</name>
<affiliation>
<nlm:aff id="aff3">
<italic>Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra, India</italic>
</nlm:aff>
</affiliation>
</author>
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<idno type="pmid">22919227</idno>
<idno type="pmc">3425110</idno>
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<idno type="doi">10.4103/0976-237X.96835</idno>
<date when="2012">2012</date>
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<title xml:lang="en" level="a" type="main">Mandibular metastasis in a patient with follicular carcinoma of thyroid</title>
<author>
<name sortKey="Bhadage, Chetan J" sort="Bhadage, Chetan J" uniqKey="Bhadage C" first="Chetan J." last="Bhadage">Chetan J. Bhadage</name>
<affiliation>
<nlm:aff id="aff1"></nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Vaishampayan, Sagar" sort="Vaishampayan, Sagar" uniqKey="Vaishampayan S" first="Sagar" last="Vaishampayan">Sagar Vaishampayan</name>
<affiliation>
<nlm:aff id="aff2">
<italic>Department of Head and Neck Oncology, TATA Memorial Hospital, Mumbai, Maharashtra, India</italic>
</nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Umarji, Hemant" sort="Umarji, Hemant" uniqKey="Umarji H" first="Hemant" last="Umarji">Hemant Umarji</name>
<affiliation>
<nlm:aff id="aff3">
<italic>Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra, India</italic>
</nlm:aff>
</affiliation>
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<series>
<title level="j">Contemporary Clinical Dentistry</title>
<idno type="ISSN">0976-237X</idno>
<idno type="eISSN">0976-2361</idno>
<imprint>
<date when="2012">2012</date>
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<div type="abstract" xml:lang="en">
<p>Mandibular metastasis due to thyroid carcinoma is not very frequent and the cases described in the literature are few. Due to its bloodstream dissemination, most of them are a consequence of the follicular variant of thyroid carcinomas. We are presenting a case in which the metastatic lesion of mandible was detected before diagnosis of primary malignancy.</p>
</div>
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<pmc article-type="case-report">
<pmc-dir>properties open_access</pmc-dir>
<front>
<journal-meta>
<journal-id journal-id-type="nlm-ta">Contemp Clin Dent</journal-id>
<journal-id journal-id-type="iso-abbrev">Contemp Clin Dent</journal-id>
<journal-id journal-id-type="publisher-id">CCD</journal-id>
<journal-title-group>
<journal-title>Contemporary Clinical Dentistry</journal-title>
</journal-title-group>
<issn pub-type="ppub">0976-237X</issn>
<issn pub-type="epub">0976-2361</issn>
<publisher>
<publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name>
<publisher-loc>India</publisher-loc>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="pmid">22919227</article-id>
<article-id pub-id-type="pmc">3425110</article-id>
<article-id pub-id-type="publisher-id">CCD-3-212</article-id>
<article-id pub-id-type="doi">10.4103/0976-237X.96835</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Case Report</subject>
</subj-group>
</article-categories>
<title-group>
<article-title>Mandibular metastasis in a patient with follicular carcinoma of thyroid</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname>Bhadage</surname>
<given-names>Chetan J.</given-names>
</name>
<xref ref-type="aff" rid="aff1"></xref>
<xref ref-type="corresp" rid="cor1"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Vaishampayan</surname>
<given-names>Sagar</given-names>
</name>
<xref ref-type="aff" rid="aff2">1</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Umarji</surname>
<given-names>Hemant</given-names>
</name>
<xref ref-type="aff" rid="aff3">2</xref>
</contrib>
</contrib-group>
<aff id="aff1">
<italic>Department of Oral Medicine and Radiology, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India</italic>
</aff>
<aff id="aff2">
<label>1</label>
<italic>Department of Head and Neck Oncology, TATA Memorial Hospital, Mumbai, Maharashtra, India</italic>
</aff>
<aff id="aff3">
<label>2</label>
<italic>Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra, India</italic>
</aff>
<author-notes>
<corresp id="cor1">
<bold>Correspondence:</bold>
Dr. Chetan Jalandar Bhadage, Department of Oral Medicine and Radiology, MGV's KBH Dental College and Hospital, Panchavati, Nashik 400 003, Maharashtra, India. E-mail:
<email xlink:href="drchetanb@yahoo.co.in">drchetanb@yahoo.co.in</email>
</corresp>
</author-notes>
<pub-date pub-type="ppub">
<season>Apr-Jun</season>
<year>2012</year>
</pub-date>
<volume>3</volume>
<issue>2</issue>
<fpage>212</fpage>
<lpage>214</lpage>
<permissions>
<copyright-statement>Copyright: © Contemporary Clinical Dentistry</copyright-statement>
<copyright-year>2012</copyright-year>
<license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0">
<license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p>
</license>
</permissions>
<abstract>
<p>Mandibular metastasis due to thyroid carcinoma is not very frequent and the cases described in the literature are few. Due to its bloodstream dissemination, most of them are a consequence of the follicular variant of thyroid carcinomas. We are presenting a case in which the metastatic lesion of mandible was detected before diagnosis of primary malignancy.</p>
</abstract>
<kwd-group>
<kwd>Follicular carcinoma of thyroid</kwd>
<kwd>mandible</kwd>
<kwd>metastasis</kwd>
</kwd-group>
</article-meta>
</front>
<body>
<sec id="sec1-1">
<title>Introduction</title>
<p>Metastatic tumors of oral cavity are very rare, accounting for 1% of neoplasm in the area and their primary origin can be anywhere.[
<xref ref-type="bibr" rid="ref1">1</xref>
] Most such patients were previously diagnosed with primary neoplasm. The literature states that in about 30% of cases of patients with gnathic bone metastases, the primary tumor is asymptomatic and not diagnosed.[
<xref ref-type="bibr" rid="ref2">2</xref>
] The most common primary tumors leading to mandibular metastasis were lung in men and breast in women.[
<xref ref-type="bibr" rid="ref3">3</xref>
] These metastatic lesions (or tumors) usually are carcinomas rather than sarcomas.[
<xref ref-type="bibr" rid="ref4">4</xref>
]</p>
<p>Mandibular metastasis due to thyroid carcinoma is not very frequent and the cases described in the literature are few. Due to its bloodstream dissemination, most of them are a consequence of the follicular variants of thyroid carcinomas.[
<xref ref-type="bibr" rid="ref5">5</xref>
] We are presenting a case in which the metastatic lesion of mandible was detected before diagnosis of primary malignancy.</p>
</sec>
<sec id="sec1-2">
<title>Case Report</title>
<p>A 40-year-old female patient reported to the oral medicine and radiology department with complaint of growth arising through nonhealing extraction socket since 3 months.</p>
<p>Three months back the patient developed diffuse extraoral swelling over lower left side of the face. After consultation with a local dentist, the patient underwent extraction of lower left first, second, and third molars. However, the swelling persisted even after extraction. Few days after extraction, the patient noticed a small growth arising from extraction socket. It was tender and used to bleed spontaneously. No history of paresthesia/numbness with the concerned region was reported.</p>
<p>The patient also revealed the presence of a small lump in the neck region, which she noticed 3–4 months prior; however, she neglected it as it was asymptomatic.</p>
<p>The patient was averagely built and had been cleaning her teeth with
<italic>mishri</italic>
(fine black powder of roasted tobacco leaves) since last 30–35 years.</p>
<p>General examination revealed the presence of lump in the midline of anterior region of neck; it was about 3.5 cm × 3 cm in size, soft to firm in consistency and was nontender. It used to move with swallowing.</p>
<p>Extraoral examination revealed swelling in the lower left side of the face. The swelling was oval shaped and was extending horizontally from mid-portion of left body of mandible to left angle of mandible and vertically from mid-ramus region to inferior border of mandible. It was tender, about 4.5 cm × 4.5 cm in size with bony hard consistency. The patient also presented with bilateral submandibular lymphadenopathy.</p>
<p>Intraoral examination revealed sessile growth [
<xref ref-type="fig" rid="F1">Figure 1</xref>
] arising from extraction socket of lower left first, second, and third molars. It was about 3.5 cm × 2 cm × 2.5 cm in size with soft consistency and corrugated surface.</p>
<fig id="F1" position="float">
<label>Figure 1</label>
<caption>
<p>Intraoral photograph showing granulomatous growth arising from extraction socket</p>
</caption>
<graphic xlink:href="CCD-3-212-g001"></graphic>
</fig>
<p>As the growth was arising from an extraction socket and the patient was a chronic tobacco chewer, a provisional diagnosis of malignant tumor of mandible was considered. The patient was then referred for radiographic examination, computed tomography (CT) scan imaging, complete blood count, and incisional biopsy of the intraoral growth.</p>
<p>OPG [
<xref ref-type="fig" rid="F2">Figure 2</xref>
] revealed an osteolytic lesion in the lower left first, second, and third molars, which was ill defined, uncorticated. A pathologic fracture of the inferior border of the mandible was also noticed. Bone and soft tissue algorithm of CT scan [Figures
<xref ref-type="fig" rid="F3">3</xref>
and
<xref ref-type="fig" rid="F4">4</xref>
] examination revealed destructive lesion involving posterior region of body and ramus of the left mandible. On careful examination, soft tissue window revealed an expansile lesion with hyperintense periphery involving thyroid gland.</p>
<fig id="F2" position="float">
<label>Figure 2</label>
<caption>
<p>Orthopantomograph showing ill-defined osteolytic lesion with islands of remaining bone within the interior and pathologic fracture of lower border of mandible left side. (Digitally enhanced image)</p>
</caption>
<graphic xlink:href="CCD-3-212-g002"></graphic>
</fig>
<fig id="F3" position="float">
<label>Figure 3</label>
<caption>
<p>Coronal section at bone window level showing osteolytic lesion causing erosion of lower border of left mandible</p>
</caption>
<graphic xlink:href="CCD-3-212-g003"></graphic>
</fig>
<fig id="F4" position="float">
<label>Figure 4</label>
<caption>
<p>Axial section at soft tissue window level showing destructive lesion involving posterior region of body and ramus of left mandible</p>
</caption>
<graphic xlink:href="CCD-3-212-g004"></graphic>
</fig>
<p>Incisional biopsy of the intraoral growth revealed a metastatic follicular thyroid carcinoma.</p>
<p>The patient was then referred to higher center for further management.</p>
</sec>
<sec sec-type="discussion" id="sec1-3">
<title>Discussion</title>
<p>Follicular thyroid cancer tends to be a malignancy of older persons, with the mean age of patients in most studies being more than 50 years. Although papillary thyroid carcinomas are generally more common than follicular cancers, the latter are more prone to spread hematogenously, especially to lung and bones, with a rate of 5%–20%. Conversely, follicular cancers exhibit a relatively small propensity for lymphatic spread.[
<xref ref-type="bibr" rid="ref6">6</xref>
]</p>
<p>Metastasis is a consequence of complex biologic cascade that begins with the detachment of tumor cell from primary tumor spreading into the tissues, invading the lymphovascular structures followed by their survival in the circulation.[
<xref ref-type="bibr" rid="ref7">7</xref>
] The microvasculature of the target organ provides room for the metastatic tumor cells to harbor, from where they can extravagate, proliferate, and invade within this target tissue. Angiogenesis is mandatory for the tumor cell load beyond 2–3 mm for adequate supply of oxygen and nutrients.[
<xref ref-type="bibr" rid="ref8">8</xref>
] Recent studies on the mechanism by which cancer metastasizes to bone have shown that cancer cells alter the physiologic balance between bone resorption and bone formation. Breast cancer metastases are frequently osteolytic and this has been attributed to overexpression of osteoclasts, inducing factors such as parathyroid hormone–related protein, interleukin (IL)-8, and IL-11.[
<xref ref-type="bibr" rid="ref9">9</xref>
] Predominantly osteoblastic metastasis is mediated by osteoblast-mediating factors, such as bone morphogenetic proteins, Wnt family ligands, endothelin 1, and platelet derived growth factors (PGDF). Furthermore, the release of matrix embedded growth factors, such as insulin-like growth factors and transforming growth factor-beta upon osteolysis promotes the induction of osteoclast-promoting factors.[
<xref ref-type="bibr" rid="ref10">10</xref>
]</p>
<p>Reports from different parts of the world show a variable incidence of metastasis to jaw bone from different primary sites, ranging from 1–4 cases per year.[
<xref ref-type="bibr" rid="ref1">1</xref>
<xref ref-type="bibr" rid="ref7">7</xref>
] Most of the metastatic tumors occur in 5
<sup>th</sup>
, 6
<sup>th</sup>
, and 7
<sup>th</sup>
decades[
<xref ref-type="bibr" rid="ref3">3</xref>
<xref ref-type="bibr" rid="ref7">7</xref>
<xref ref-type="bibr" rid="ref11">11</xref>
]; however, in an Indian study the metastatic tumors were found to occur at an early age between the 3
<sup>rd</sup>
and 7
<sup>th</sup>
decade. In the younger age group (first to second decade) the metastasis was found to occur from adrenal neuroblastoma, medulloblastoma, and osteogenic sarcoma.[
<xref ref-type="bibr" rid="ref12">12</xref>
] The clinical presentations of the metastatic lesions include pain, swelling, loosening of tooth, paresthesia, and pathologic fracture.[
<xref ref-type="bibr" rid="ref1">1</xref>
<xref ref-type="bibr" rid="ref3">3</xref>
] Less frequently the lesion can present as pain in the temporomandibular joint region or as an osteomyelitis in the jaw or as trigeminal neuralgia.[
<xref ref-type="bibr" rid="ref13">13</xref>
] Studies have shown that chronic trauma to the oral tissue favors metastatic spread to the oral cavity.[
<xref ref-type="bibr" rid="ref14">14</xref>
] In another study it was found that in 55 cases tooth extraction preceded the discovery of metastasis.[
<xref ref-type="bibr" rid="ref15">15</xref>
] In the majority of the cases, a latency period of 2 months between the extraction and the development of the metastasis was reported. In our case also we observed a similar finding. Thus the role of trauma to the oral mucosa in the causation of oral metastasis needs further investigation.</p>
<p>Emre and Ehab studied various cases and observed that the most frequent location for metastasis among jaw bones is mandible. In the mandible, ramus and angle are more commonly involved. They concluded that the propensity of posterior mandible for metastasis is due to its better vascularity.[
<xref ref-type="bibr" rid="ref16">16</xref>
] A few investigators believe that metastasis to jaw bone through hematogenous route requires the presence of hematopoietically active bone marrow well connected with the sinusoidal vascular spaces at the site of deposition of malignant cells.[
<xref ref-type="bibr" rid="ref17">17</xref>
<xref ref-type="bibr" rid="ref18">18</xref>
]</p>
<p>The posterior mandible and the focal osteoporotic bone marrow defects in the edentulous mandible have been shown to be the hematopoietically active sites that may attract the metastatic tumor cells.[
<xref ref-type="bibr" rid="ref19">19</xref>
<xref ref-type="bibr" rid="ref20">20</xref>
] Still some other investigators believe that the high bone turnover in this region may be the cause.[
<xref ref-type="bibr" rid="ref21">21</xref>
]</p>
<p>Although the incidence of metastatic tumors in oral cavity is considered low, a significant number of such lesions have a high tendency to go undetected, this is because of the following:</p>
<p>
<list list-type="alpha-upper">
<list-item>
<p>Micrometastasis is rarely detected by radiographic survey.[
<xref ref-type="bibr" rid="ref22">22</xref>
]</p>
</list-item>
<list-item>
<p>Cases with poor prognosis and terminal stage of the disease lose or are dead before presenting to a clinician.[
<xref ref-type="bibr" rid="ref12">12</xref>
]</p>
</list-item>
<list-item>
<p>Earlier jaw bones were not included in the radiographic survey for metastatic workup.[
<xref ref-type="bibr" rid="ref3">3</xref>
]</p>
</list-item>
</list>
</p>
<p>The exact incidence of metastatic diseases that affect the mandible is still unknown. Hence all medical and dental clinicians must include malignant disease, primary or metastatic, alongside the more common benign pathologies when considering the differential diagnosis of oral complaints. This is particularly important in the primary care setting, especially when dealing with elderly patients, or those with a history of malignancy.</p>
</sec>
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</fn>
<fn fn-type="conflict">
<p>
<bold>Conflict of Interest:</bold>
None declared.</p>
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