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Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 449-451
Metastatic lung malignancy to mandibular gingiva

Department of Oral & Maxillofacial Pathology, VSPM's Dental College & Research Center, Hingna Road, Nagpur, Maharashtra, India

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Date of Submission09-Nov-2009
Date of Decision19-Jan-2010
Date of Acceptance21-May-2010
Date of Web Publication29-Sep-2010


Metastatic tumors of oral cavity are uncommon and may occur in oral soft tissues or jaw bones. Because of their rarity, metastasis to oral cavity are challenging to diagnose and difficult to treat. They often have vague symptoms that mimic dental infections. These lesions generally show poorly differentiated histopathologic picture and have poor prognosis. We reported a case of a 40-year-old male patient of metastatic lesion to the oral cavity and brain with primary tumor, diagnosed as an undifferentiated epithelial malignancy of lung.

Keywords: Lung cancer, metastasis, oral cavity

How to cite this article:
Moharil RB, Khandekar S, Dive A. Metastatic lung malignancy to mandibular gingiva. Indian J Dent Res 2010;21:449-51

How to cite this URL:
Moharil RB, Khandekar S, Dive A. Metastatic lung malignancy to mandibular gingiva. Indian J Dent Res [serial online] 2010 [cited 2019 Oct 17];21:449-51. Available from:
The oral region is not a preferred site for metastatic colonization and comprises of only 1 to 3% of all malignant oral neoplasms. [1] Most common primary sites for oral metastasis in men and women are lung and breast, respectively. 2] Oral metastasis produces distressing symptoms that are difficult to palliate and generally diagnosed as inflammatory lesions. [1] Sometimes the discovery of an oral metastasis leads to the detection of an occult primary malignancy elsewhere in the body. Similarly we reported a case of undifferentiated epithelial malignancy of lung with metastasis to oral cavity and also in brain.

   Case Report Top

A 40 year old male patient reported with chief complaint of painful intraoral swelling on lower left posterior side of jaw since 20 days. Patient was chronic smoker and drinker since last nine years. There was no history of cough, chest pain or weight loss. Left submandibular lymph nodes were enlarged, tender and mobile, other lymph nodes were not involved.

Intraoral findings revealed a reddish-pink pedunculated growth extending from mesial of 36 to distal of 38, having approximate size of 5 × 2 cm, irregular in shape and soft to firm in consistency. Findings of pus discharge, bleeding on probing and slough with indentations were noted [Figure 1].
Figure 1: Intraoral picture showing reddish-pink pedunculated growth extending from mesial of 36 to distal of 38, approximate size of 5×2 cm, irregular in shape

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Based on clinico-radiological findings, differential diagnosis of reactive lesion such as pyogenic granuloma and peripheral giant cell granuloma was made. Histopathological features showed cellular pleomorphism, nuclear hyperchromatism, clear cells, multiple nucleoli and mitotic figures with poor differentiation of cells [Figure 2]. Histopathological findings confirmed features of malignancy, which were not correlating with clinical and radiological findings; hence, the diagnosis of undifferentiated epithelial malignancy was made. The histopathological differential diagnosis of high-grade mucoepidermoid carcinoma and clear cell carcinoma was ruled out.
Figure 2: Photomicrograph showing multiple nucleoli, mitotic figures and presence of clear cells (H and E, ×40)

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An X-ray chest view revealed homogeneous lesion on right upper zone [Figure 3]. Kidney function tests were normal. CT scan of the brain revealed multiple well-defined hyperdense lesions with signs of metastasis [Figure 4]. Cytological findings of lung mass showed atypical cells in lobules, cellular pleomorphism, hyperchromatism and altered nuclear-cytoplasmic ratio [Figure 5] and [Figure 6]. Unfortunately, the patient died within a week during further investigations due to which the biopsy of lung mass was not available. Therefore, based on clinicopathological findings, final diagnosis of undifferentiated epithelial malignancy of lung with metastasis to oral cavity and brain was made.
Figure 3: X-ray chest PA view showing homogeneous radio opaque lesion on right upper zone, with rest of the clear field

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Figure 4: CT scan of brain (axial sections) showing multiple well-defined hyperdense lesions in the frontal, temporal and parietal region with signs of metastasis

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Figure 5: Cytology of lung mass showing atypical cells in clusters(H and E, ×10)

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Figure 6: Cytology of lung mass showing atypical cells with cellular pleomorphism and hyperchromatism (H and E, ×40)

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   Discussion Top

Metastasizing is a complex process, the biological basis of which requires tumor cells to breach a sequence of barriers. Pathogenesis of oral metastasis is unclear. Secondary deposits occur more commonly in the mandible than the maxilla; the premolar region is the most frequent site to be affected. This region is rich in hemopoietic tissue and as the mode of metastasis is hematogenous, the neoplastic cells get deposited in this area easily. A reduced flow of blood in this region could help the cells for deposition [3] It is stated that in oral soft tissues, rich capillary network of chronically inflamed mucosa, especially of gingiva, can trap the malignant cells and may cause metastasis. [1],[4]

Metastatic tumors to the oral cavity are uncommon. Literature review revealed that the jawbones, particularly the mandible were more frequently affected than the oral soft tissues (2:1). In the oral soft tissues, the attached gingiva was the most commonly affected site (54%). The major primary sites presenting oral metastases were the lung, kidney, liver, prostate in men, breast, female genital organs (FGO), kidney and colorectum in women. [5] Oral metastasis arises as a secondary spread from other metastatic lesion, especially from the lungs. In about 30% of oral metastasis, lung is the first site of metastatic disease. Most metastatic tumors were found in patients in their fifth to seventh decade of life. There was almost equal gender distribution in jawbone metastases, whereas in oral soft tissues there was 2:1 male to female ratio. [1]

The primary site differs according to oral site colonization. In men, the lung was the most common primary site affecting both the jawbones and oral mucosa (22 and 31.3%, respectively). In women, the breast was the most common primary tumor site affecting the jawbones and soft tissues (41% and 24.3, respectively. Metastasis to oral region often have vague or innocus symptoms that mimic dental infections such as pyogenic granuloma, epulis, peripheral giant cell granuloma and usually have an undiagnosed primary malignancy at some other site. [5]

The criteria by which one can consider a malignant jaw lesion to be a metastatic tumor include: (a) Histologic verification; (b) The fact that the metastatic tumor is not found in a site typical to primary oral tumors; (c) The fact that the possibility of direct extension to the jawbones from a primary oral tumor can be excluded; (d) Genetic analysis - namely, the identical cytogenetic findings in both the primary tumor and in the metastatic jaw lesion, can be an important contribution to the histopathologic diagnosis of the lesion, being a metastasis.

Hirshberg A et al. 2008 reviewed 673 cases of oral metastasis. In 112 cases of oral metastasis, the primary tumor was located in the lung. Out of 112 cases of oral metastasis, 58 were noted in jaw bones and other 54 in oral mucosa. [5] Data obtained in the literature correlates well in regard to this clinical, histopathological and radiological findings to diagnose it as a metastatic lesion.

Oral metastasis is considered as a late complication and is commonly associated with multiple organ metastasis. In some patients surgery with or without local radiation therapy may improve the patient's quality of life. Oral metastasis is usually resistant to chemotherapy. Oral mucosal metastasis is associated with extremely poor outcome and difficult to palliate.

   Conclusion Top

Because of its rarity, the diagnosis of metastatic lesion in the oral region is challenging, both to the clinician and to the pathologist, in recognizing that the lesion is metastatic and to determine the site of origin. These can also be misdiagnosed as benign lesions. So more planned approach is needed to evaluate the importance of the metastatic lesion in the oral cavity.

   Acknowledgment Top

The authors are thankful to Dr. Anna Wilkinson for her kind support. [6]

   References Top

1.Rajappa S, Loya A, Rao RD. Metastasis to oral cavity: A report of two cases and review of literature. Indian J Med Pediatr Oncol 2005;26:43-6.  Back to cited text no. 1      
2.Vander wall RI, Butler J, Vander wall J. Oral metastasis: Report of 24 cases. Br J Oral Maxillofac Surg 2003;41:3-6.  Back to cited text no. 2      
3.Zacchariades N. Neoplasms metastatic to mouth, jaws and surrounding tissues. J Cranio maxillofac Surg 1989; 17:283-90.  Back to cited text no. 3      
4.Herbst RS, Heymach JV, Lippman SM. Lung cancer. Engl J Med 2008;80:1367-80.  Back to cited text no. 4      
5.Hirshberg A, Shapiro AS, Kaplan I, Berger R. Metastatic tumors to the oral cavity-pathogenesis and analysis of 673 cases. Oral Oncol 2008; 44:743-52.  Back to cited text no. 5      
6.Bodne L, Sion-Vardy N, Geffen DB, Nash M. Metastatic tumors to the jaws: A report of eight new cases. Med Oral Patol Oral Cir Bucal 2006;11:32-5.  Back to cited text no. 6      

Correspondence Address:
Rohit B Moharil
Department of Oral & Maxillofacial Pathology, VSPM's Dental College & Research Center, Hingna Road, Nagpur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.70795

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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