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Metastatic lesions to the oro-facial region may be the first evidence of dissemination of an unknown tumour from its primary site.
We described a case of metastatic follicular thyroid carcinoma to the mandible presenting with pain and loosening of teeth in a 70 years old female patient leading to extraction of the loose teeth.
The present case emph...
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... the most common clinical symptoms. Thyroid carcinoma metastasizes to the jaw is extremely rare accounting about 3.85% of all jaws metastases [2]. Arriving to a diagnosis is a challenge for this case as there is no previous history of a malignant disease. A 70-year-old Malay female patient reported to the outpatient department of Oral and Maxillofacial Department, Tengku Ampuan Rahimah Hospital, Klang with a complaint of pain and swelling in the left side of the angle of the mandible. She had noticed the swelling three months previously and it had increased gradually to the present size. Three months earlier she had undergone extraction of the left mandibular second premolar for complaints of mobility and pain. She also complained of bouts of nausea and vomiting for the past 1 to 2 months with loss of appetite. The medical history revealed that the patient is been treated for hypertension and diabetes with no history of malignancy. There was no history of smoking, alcohol consumption or betel quid chewing. On examination, a firm, swelling of size 3 to 4 cm was noticed in left side of the mandible, distal canine region extending to the second molar and involving the buccal sulcus at the canine region (Figure 1). On palpation, bicortical expansion of the body of the mandible was noted. Intraorally, there was an erythematous change over the region and adjacent buccal mucosa. No submandib- ular lymph nodes were palpable. Radiographic examination and 3-dimensional CT (computed tomography) scan showed a lesion of the left body of mandible extending from the lower left canine region to second molar region with diffuse margin leaving lower border intact (Figure 2). An incisional biopsy was performed. The histopathologi- cal examination revealed thyroid follicles filled with colloid material (Figure 3) which is positive for PAS stain. The cells surrounding the follicles were intensely positive for thyroglobulin. The interpretation was metastatic follicular carcinoma of the thyroid. Subsequent coronal CT scan of the neck was done showing a mass in the right thyroid region. Chest radiograph and axial CT scan were also taken which showed metastatic lesion and enlarged hilar lymph nodes. Because of their rarity, metastatic tumours to the oral region are difficult to diagnose. The most common primary sites are the breast (21.8%) followed by lung (12.6%), adrenal (8.7%), kidney (7.9%), bone (7.4%), colo-rectum (6.6%) and prostate (5.6%) [2]. Most metastatic tumours to the oral region occur in patients aged 40 to 70 years [1,3]. Metastatic tumours are of great significance since some cases may represent the only symptom of an undiscovered underlying malignancy. In one third of patients, oral metastasis may be the first evidence of metastasis from its primary site [1]. In the jaw, pain, swelling, loosening of tooth and paraesthesia are the most common clinical manifestations [1,3]. Patient complaining of numb chin or mental nerve neuropathy should always raise the possibi- lity of a metastatic disease in the mandible. A peculiar site for metastasis is the post extraction site. Hirshberg et al. reported 55 cases out of 390 cases, in which tooth extraction preceded the discovery of the metastasis [2]. The most common radiographic presentation is a radi- olucent lesion with ill-defined margins. However, in approximately 5% of cases, pathological changes are not detected radiographically [2]. Follicular thyroid carcinoma (FTC) is a well-differentiated tumour which originates in follicular cells and resembles the normal microscopic pattern of the thyroid. It is the second most common cancer of the thyroid after papillary carcinoma [4]. Immunohistochemical marker for FTC is thyroglobulin, which is present in more than 95% of follicular thyroid carcinoma [5]. Distant metastases occur in 10 to 15% of patients with differentiated thyroid carcinoma [6]. Bone metastasis is the second most common site of metastasis after lung. Bone metastasis are found in 1 to 3 percent of well- differentiated thyroid carcinomas, occurring more often in follicular carcinoma and in patients more than 40 years of age [7]. Follicular thyroid carcinoma rarely gives rise to oral metastasis. The other reported sites in the oral region were parotid gland [8], tongue and labial mucosa [9]. The optimal therapy for differentiated thyroid cancer includes thyroidectomy and radiotherapy. The presence of distant metastases is associated with poor prognosis. An overall 10-year survival rate of 27% for bone metastasis of differentiated thyroid carcinoma has been reported [10]. Brennan et al. reported 40% survivors of distant follicular metastases after 5 years [11]. An early detection of metastatic disease improves the overall survival rate and treatment ...
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Citations
... 8 Prognosis of patients with distant thyroid cancer metastases is generally poor, with an average of 40% of patients alive 4 years after the diagnosis of metastasis and an overall 10-year survival rate of 27% for bone metastases of differentiated thyroid carcinoma. 9 Our patient underwent hemi-manibulectomy with total thyroidectomy. ...
Papillary carcinoma is the most common malignancy of thyroid accounting for about 80-90% of thyroid cancers. The most common site of metastasis is lung and bone. Distant metastasis is associated with poor prognosis in thyroid cancers in terms of decreased survival rates. Metastasis to mandible is a rare occurrence in thyroid cancers and very few cases have been reported in literature. Here we present a case of 45-year-old female who presented with complaints of pain and swelling in right side of mandible for past 10 months. On examination, a 3x3 cm hard, non-mobile growth on right side of mandible was seen. Microscopy revealed features of metastasis from papillary thyroid carcinoma, which were later confirmed by immunohistochemistry. Mandibular metastasis of thyroid cancer is exceedingly rare, however in cases presenting initially with jaw swelling it must be kept as a differential diagnosis.
... [8] And the mandible is affected more frequently than the maxilla. [9] Literature search reveals that 40 cases of metastatic FTC to the mandible have been recorded till date [ Table 1]. We present another unusual case of metastatic follicular thyroid cancer (FTC) to the mandible in an elderly male [52] 60/female Right mandible NR First manifestation NA NA Ripp et al. (1977) [53] Draper et al. (1979) [33] NA/female Mandible Ulcerated oral lesion NA Radiotherapy NA Osguthorpe and Bratton (1982) [34] 53/male Right mandible Slowly enlarging vascular lesion ...
... [8] The Mandible is more commonly affected than the maxilla in the jaw bone, with the body of the mandible, particularly the premolar-molar region, being the most commonly affected region. [9] This is due to the presence of rich red marrow and increased trapping of metastatic cells due to sluggish blood flow regulation in this region. [29] In addition, this marrow contains growth factors that may help some metastatic cancers colonize. ...
... A primary oral soft -tissue malignancy with osseous invasion, as well as a second primary malignant mandibular bone lesion, should be examined with the appropriate medical history. [9] Draper et al. in 1979 [33] and Krishnamurthy et al. in 2016 [12] both documented ulceration in their patients. A patient with a progressively growing vascular lesion was documented by Osguthorpe et al. in 1982. ...
Metastasis is one of the most common consequences of malignant tumors, and it is one of the leading causes of morbidity and mortality. Metastatic cancers to oral cavity are extremely rare. Moreover, the true incidence has yet to be determined. Despite their rarity, they are important clinically, since they can be the first and the only evidence of spread in many situations. Breast, kidney, lung, prostate and gastrointestinal tract are the most common sources of metastases in the oral cavity. Thyroid carcinoma is the most prevalent type of endocrine cancer, yet it rarely spreads to the oral cavity. After papillary thyroid carcinoma, follicular thyroid carcinoma is the second-most frequent kind of thyroid cancer. Jawbones are more commonly affected than soft tissues. Literature research revealed that till date, 44 cases of metastatic follicular thyroid cancer to the jawbones have been documented with mandibular preponderance (40 cases). With the rising occurrence of oral metastatic tumors in recent years, it has become increasingly important to diagnose them early to avoid future consequences. We present here an unusual case of metastatic follicular thyroid cancer in the mandible of an elderly adult along with a comprehensive review of the literature.
... The lesion can also cause pain in the temporomandibular joint region or as osteomyelitis in the jaw or as trigeminal neuralgia [16] . However, some cases do not show symptoms.Sometimesthe symptoms or signs may be the only manifestation of an undiscovered malignancy [17] . Among the 43 cases, 16 cases were diagnosed with distant metastasis as the initial presentation, while in 9 cases, the timing between the diagnosis of the primary and metastatic disease was not speci ed. ...
Objectives: The mandibular metastatic spread of carcinoma from the thyroid gland is exceedingly rare. In August 2020, we treated a 69-year-old woman exhibiting thyroid follicular carcinoma metastasis to the ascending ramus region of the mandible showing evidence of detailed radiological and pathological features.
Methods: We present a case report of thyroid carcinoma that metastasized to the ascending ramus region of the mandible at 21 years after partial thyroidectomy. We also present relevant information in a literature review of 35 articles, consisting of 43 cases (including our case) of thyroid carcinomas with jaw bone metastasis. We statistically analyzed the demographical and clinical results in terms of age, sex, type of primary cancer, site and time of metastasis, treatment, and outcome.
Results: Unlike most of the other cases, in our case, the thyroid cancer had metastasized to the ascending ramus region of the mandible, which made the diagnosis relatively difficult. The patient underwent partial mandibular resection, thyroidectomy, and iodine-131 treatment. The patient was followed up regularly, and no new symptoms were observed at seven months after post-treatment.
Conclusions: Surgery is the most common treatment for thyroid metastases of the mandible. Clinicians should ask thyroid cancer patients for follow-up to monitor whether any new complications have occurred. Patients must undergo complete examination of the maxillofacial bone for up to 40 years or more. Otolaryngologists and stomatologists should pay extra attention to patients with thyroid cancer or nodules to avoid misdiagnosis or missing the recognition of thyroid metastatic cancer.
... Few cases of Thyroid carcinoma metastases to the jaws were reported in the literature. It is uncommon and accounts for 3% of all jaws metastases [2]. Follicular thyroid carcinoma (FTC) is the second most common histologic variant of thyroid cancer, representing from 10% to 20% of all thyroid malignancies. ...
Metastatic tumors to the oral cavity affecting either the jaws or the soft tissue are unusual and accounts approximatively for 1% of all oral malignant neoplasms. Morever, a thyroid primary tumor is considered almost rare. The present paper describes a case of metastatic follicular thyroid carcinoma to the right maxillary sinus, bone and alveolar mucosa in a 73-year-old male patient. Our aim is to highlight the importance of considering oral metastasis in the diagnosis of jaws and soft tissue lesions especially in patients with known primary malignant tumor.
... Afterward, a thyroid nodule as well as enlarged hilar lymph nodes was detected. [10] Vural and Hanna concluded from their studies that the ramus and angle are more commonly involved, which is due to their better vascularity. [11] Other investigators discussed the possible causes of jaw metastasis, via hematological pathways; some report the presence of hematopoietic active bone marrow well connected with the sinusoidal vascular spaces at the site of deposition of malignant cells, whereas others believe that that the reason is the high bone turnover in this region. ...
Follicular thyroid carcinoma (FTC) is the second most common cancer of the thyroid, after papillary carcinoma. Oral metastasis arising from FTC is very rare. Mandible is more commonly affected than maxilla, with the premolar—molar region being the most frequent site of metastasis. We present the case of a 68yearold female, with swelling in the region of the parotid gland, complaining of periodic rightsided pain in the temporomandibular joint, which occurred most often in the morning with numbness and pain, and difficulty in opening the mouth. After ultrasound and X-ray, the patient was operated and the pathohistological finding was in favor of metastasis of FTC. After 3 months, a total thyroidectomy was performed, and FTC was detected in the right thyroid lobe. Laboratory results were as follows: FT4 = 9.92 pmol/L, thyroid-stimulating hormone = 9.9 mIU/L, and hTG >300 μg/L. Bone scan showed no bone metastasis. Radioablation with 131I of 150 mCi was given to the patient, followed by substitutional therapy with levothyroxine. Mandible metastasis as a single skeletal deposit from follicular thyroid carcinomas is a rare clinical finding. Maxillofacial surgeons should consider and rule out thyroid pathology before performing operation of tumor formation in the mandible region. If feasible, surgical-based treatment options offer the best survival outcomes.
... A great majority of the appendicular skeletal metastasis from thyroid cancers can be effectively managed by external beam radiation therapy or radioactive iodine ablations [12,13], however, some of the bony metastasis require surgical intervention due to the associated symptoms and fracture risk [12,14]. ...
Introduction:
Papillary carcinoma is the most frequent differentiated malignant thyroid neoplasm, Metastasis occurs frequently in regional lymph nodes and mandibular metastasis are very rare and most are secondary to follicular carcinomas due to their blood diffusion, The mandibular metastasis of papillary carcinoma is exceptional.
Case report:
We report a rare case of mandibular metastasis revealing papillary thyroid carcinoma in a 52-year-old patient, with a review of the literature on clinical features, radiological aspect, and treatment options.
Discussion conclusion:
Mandibular metastasis of thyroid cancer are rare and the initial metastases revealing papillary carcinoma are exceptional, few cases are reported in the literature, and due to their rarities and relative lack of data on their management, There is no clearly defined processing algorithm.
... Hemithyroidectomy is a favorable therapy to that tumour control, it reduces surgical complications and the patients are spared of therapy with iodine; the treatment is still multidisciplinary and the prognosis is considered reserved and somber, as a result of the high degree of histological aggressiveness of primary tumor, and advanced stage of the disease [8]. ...
Introduction: Thyroid carcinoma is a malignant neoplasia associated with radiation exposure, which is a risk factor for the disease, which induces cell mutation of that gland. Objective: On the basis of the above, the objective of this work is to present a clinical case of a patient whosought the Stomatology Service of the Federal University of Paraíba, complaining of swelling in the mandibular region. Case Report: Patient JMC, a 54-year old woman, melanoderma, sought the Stomatology Service of UFPB, bearing apanoramic radiography and reportings welling in the region of the body, on the left branch of the mandible, and the presence of local painful symptoms. The patient reported thyroid nodule removal two years ago. The clinical examination showed that the lesion presented exophytic growth and firm consistency, numerous diagnostic measures were performed, however, the only that provided the best results and accuracy of diagnosis was the biopsy. But as the diagnosis was very late, she came to death even before the completion of the usual surgical management. Conclusion: The diagnosis of primary and metastatic malignant gnathic bone neoplasms is primarily made on anamnesis, clinical, laboratorial, radiological, and histopathological data; thus being a multidisciplinary work.
... It is next only to papillary carcinoma of thyroid, in terms of prevalence. [4] Among thyroid malignancies, follicular carcinoma of thyroid account for 10-20% and is most often seen in patients over 40 years of age. [1] Thyroglobulin, an immunohistochemical marker for follicular carcinoma of thyroid, is present in more than 95% of cases. ...
Follicular carcinoma of thyroid is the second most common type of carcinoma of thyroid, and it may metastasize to bone, lung, brain, and skin. However, the initial presentation of follicular carcinoma of the thyroid as a large intrathoracic mass without any symptoms of thyroid gland enlargement and dysfunction is very rare. We hereby report a case of a 50-year-old male who presented with chief complaints of chest and low back pain. Preliminary evaluation led to the provisional diagnosis of left-sided intrathoracic mass with vertebral metastasis which was suspected to be a case of bronchogenic carcinoma with distant metastasis. Surprisingly, transthoracic biopsy and histopathology revealed metastasis from follicular carcinoma of thyroid. This prompted us for a retrograde evaluation for a primary thyroid malignancy for which an ultrasound and contrast enhanced computed tomography (CECT) of the neck was done which confirmed the presence of a solitary thyroid nodule. Ultrasonography-guided fine-needle aspiration cytology of the nodule revealed follicular carcinoma of thyroid. Histopathological evaluation subsequent to total thyroidectomy revealed follicular carcinoma thyroid, further confirming the diagnosis. The patient was then referred to Department of Nuclear Medicine and Radiotherapy for radionuclide ablation and chemotherapy. We chose to report this case because of its rare presentation as a large intrathoracic mass and the retrograde diagnosis of follicular carcinoma of thyroid. To the best of our knowledge, this is the first report of such a rare case.
... Moreover, though patients' overall prognosis is considered excellent, it is widely accepted that thyroid carcinomas have a high risk of metastases occurrence, mainly through perineural filtration; cancerous cells could be installed on any tissue along the neural axis filter and then be transferred to the respective blood vessel (7,3,12). Moreover, once the nerve fibers from metastatic cells of the thyroid's primary tumors are affected, this metastasis can be applied to the same nerve fibers, resulting in their overstimulation or understimulation (6,13). These distant metastases are used as prognosis markers. ...
The double innervation of the thyroid comes from the sympathetic and parasympathetic nervous system. Injury rates during surgery are at 30% but can be minimized by upwardly preparing the thyroid vessels at the level of thyroid capsule. Several factors have been accused of increasing the risk of injury including age and tumor size. Our aim was to investigate of there is indeed any possible correlations between these factors and a possible increase in injury rates following thyroidectomy. Seven studies were included in the meta-analysis. Statistical correlation was observed for a positive relationship between injury of the sympathetic nerve and thyroid malignancy surgery (p 2 = 74%) No statistical correlations were observed for a negative or positive relationship between injury of the sympathetic nerve and tumor size. There was also no statistically significant value observed for the correlation of the patients' age with the risk of sympathetic nerve injury (p = 0.388). Lack of significant correlation reported could be due to the small number of studies and great heterogeneity between them.
... In this context, an average of 40% of patients are alive 4 years after the diagnosis of the metastatic lesion, and 27% after 10 years in the case of tumors located in bone. 19 Thus, bone metastasis represents a worse prognosis for thyroid carcinoma. 13,20 Not many cases of this metastatic tumor to the mandible have been reported in the literature, and this is a limitation for precise determination of the prognosis. ...
