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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 843
Metastatic follicular thyroid carcinoma to the mandible


Department of Oral and Maxillofacial Pathology, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda (dt), Andhra Pradesh, India

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Date of Submission31-Mar-2012
Date of Decision24-Oct-2012
Date of Acceptance23-Nov-2012
Date of Web Publication3-May-2013
 

   Abstract 

Metastatic tumors are of great significance since few cases may represent the only symptom of an undiscovered underlying malignancy. Metastatic tumors rarely metastasize to the oral region despite the fact that many common primary neoplasms frequently metastasize to bone. The true incidence of metastatic tumors in the bones of the jaw is unknown, as jaws are not always included in radiographic skeletal surveys for metastasis. Sometimes oral metastasis may be the first evidence of metastasis from its primary site. A case of metastatic follicular thyroid carcinoma to the mandible is presented here, along with the discussion of clinical and histological features. The present case not only emphasizes the importance of considering metastasis in the differential diagnosis of a radiolucent lesion in the mandible, but also emphasizes in the improvement of the overall survival rate and treatment results by an early detection of metastatic disease.

Keywords: Follicular thyroid carcinoma, mandible, metastasis

How to cite this article:
Pasupula AP, Reddy Dorankula SP, Thokala MR, Kumar M P. Metastatic follicular thyroid carcinoma to the mandible. Indian J Dent Res 2012;23:843

How to cite this URL:
Pasupula AP, Reddy Dorankula SP, Thokala MR, Kumar M P. Metastatic follicular thyroid carcinoma to the mandible. Indian J Dent Res [serial online] 2012 [cited 2020 Dec 4];23:843. Available from: https://www.ijdr.in/text.asp?2012/23/6/843/111292
Metastatic tumors are of great significance since few cases may represent the only symptom of an undiscovered underlying malignancy. It may be the first evidence of dissemination of the known tumor from its primary site. They rarely metastasize to the oral region, making it at approximately 1% of all oral malignancies, despite the fact that many common primary neoplasms frequently metastasize to bone. The most common site of metastasis in the oral cavity is the body of the mandible, in particular, molar-premolar region. [1],[2]

The most frequently diagnosed endocrine carcinoma is the thyroid carcinoma. It also accounts for the most common cause of death among patients with these tumors. [3] In 1-3% of well-differentiated thyroid carcinomas, metastasis to bone is found, and it is more often with follicular thyroid carcinoma (FTC) type. The patients are found to be more than 40 years of age. The presence of a distant metastasis in an adult is associated with poor prognosis, with an overall mortality of only 50% within 1-6 years postoperatively, which emphasizes the severity of the disease process and the need to detect them at an early stage for the betterment of the results. [4],[5],[6] A case of metastatic thyroid carcinoma in the mandible is presented here, along with the discussion on clinical and histopathologic features.


   Case Report Top


A 40-year-old female patient presented with painful swelling in the left parotid region since 6 months. Pain was dull aching from the onset of the swelling and used to increase on mastication. There was history of low-grade fever which was intermittent in nature. The patient on general examination was moderately built and nourished. Clinical examination revealed a well-defined swelling, measuring about 8 × 8 cm in the region of mandible on the left side. The swelling extended superio-inferiorly from the zygomatic arch to 1 cm above the angle of the mandible and anterio-posteriorly from anterior border of masseter to the tragus of left ear [Figure 1]. The skin over the swelling was pigmented as the patient applied herbal latex. On palpation, the swelling was tender and firm in consistency. Bicortical expansion of the mandible, near the angle, was also noted. No palpable submandibular lymphnodes were evident.
Figure 1: Clinical photograph showing a well-defined swelling in the left side of the mandible, along with pigmentation as the patient applied herbal latex

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The orthopantomogram (OPG) revealed a large radiolucency extending from distal to third molar up to the angle of the mandible involving ramus of the mandible too. Three-dimensional computed tomography (CT) scan showed a lesion of the left body of mandible, extending from the lower left third molar region to almost left condyle, as if the lesion was arising from ramus of the mandible with complete destruction [Figure 2]. A PA-chest radiograph was advised and it revealed a large expansile lytic lesion in the posterior aspect of left 3 rd rib. Radiolucency appeared to be smooth with ill-defined borders. Based on the clinical and radiographic findings, a provisional diagnosis of a metastatic tumor was considered, probably ameloblastoma of the mandible with malignant transformation, with metastasis to left 3 rd rib.
Figure 2: CT showing the mass arising from ramus of left mandible with complete destruction

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A fine needle aspiration from the intraoral lesion was suggested and the same was performed. It revealed chondro-myxoid elements in the stroma [Figure 3]. A biopsy was further considered to confirm the diagnosis. Microscopically, the incisional biopsy from the left angle of the mandible revealed the presence of lobules of thyroid follicles with trabecular pattern, infiltrating into fibrocollagenous stroma. Well-developed duct-like structures were also evident. Tumor cells showed mild pleomorphism and hyperchromatism [Figure 4] and [Figure 5]. Subsequent ultrasound (USG) of thyroid was performed which showed the presence of two nodules, one in each lobe of the thyroid [Figure 6]. USG-guided FNAC was performed which showed colloid strand in the eosinophilic stroma, suggesting follicular neoplasm.
Figure 3: FNAC showing chondromyxoid elements in the stroma

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Figure 4: Incisional biopsy - H and E staining shows thyroid follicles, infiltrating into fibro-collagenous stroma (×4)

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Figure 5: Incisional biopsy - H and E staining shows lobules of thyroid follicles with trabecular pattern (×10)

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Figure 6: USG thyroid shows two nodules, one in each lobe of thyroid

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Presence of well-developed duct-like structures, eosinophilic secretory material with lobules of thyroid follicles in the incisional biopsy specimen, and the presence of two nodules, one in each lobe of the thyroid under USG, suggested it to be primary tumor in thyroid, probably a metastatic FTC to the mandible.

The patient was referred for further management to oncology unit where further investigations such as hormonal levels and other specific investigations for the evaluation of the primary were performed. Total thyroidectomy was performed on the patient with subsequent excision of the metastatic tumor of the mandible. Excisional biopsy specimen of the primary had confirmed FTC which microscopically showed thyroid follicles of colloid, lined by tumor cells, and the tumor cells showed pleomorphism and hyperchromatism [Figure 7] and [Figure 8].
Figure 7: Total thyroidectomy was performed

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Figure 8: Excisional biopsy of the primary - H and E staining shows thyroid follicles of colloid lined by tumor cells and the tumor cells exhibit pleomorphism and hyperchromatism (×10)

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   Discussion Top


Metastatic tumors are of great significance since some cases may represent the only symptom of an undiscovered underlying malignancy. Despite the fact that many common primary neoplasms frequently metastasize to bone, they rarely metastasize to the oral region. [1],[2] As jaws are not always included in radiographic skeletal surveys for metastasis, the true incidence of metastatic tumors in the bones of the jaw is not known. [7],[8] The following criteria should be fulfilled for a malignant neoplasm to be considered metastatic, namely the presence of histologically verified primary, its histological similarity to the secondary lesion, and exclusion of direct extension from the primary. [7],[9] The amount of red bone marrow and blood vessels in the jaw bones tends to decrease with age, so the involvement of the jaw in metastasis appears to be less common than that of other bones. This is due to the gradual replacement of red marrow with yellow or fatty marrow. Most (60-80%) metastasis involving jaw bones occurs in the mandible, mainly in the molar and premolar areas, when compared to other bones of the facial skeleton due to the greater presence of hematopoietic tissue in the mandible and also due to reduced flow of blood in the area, helping the tumor cells become deposited here. [10],[11]

Metastatic tumors are most common in the fifth to seventh decades of life. The most common origins of metastasis vary with gender: Breast, ovary, and thyroid in female patients, and lung, prostate, kidney, and liver in men. The lung is the most common origin of metastasis into oral soft tissues, whereas the breast is the most common origin of metastatic tumors in the jaw bones. In one-third of the patients, oral metastasis may be the first evidence of metastasis from its primary site. [7],[10],[12] In the jaw, pain, swelling, loosening of tooth, and paresthesia are the most common clinical manifestations. Patient complaining of numb chin or mental nerve neuropathy should always raise the possibility of a metastatic disease in the mandible. A peculiar site for metastasis is the post extraction site. The most common radiographic presentation is a radiolucent lesion with ill-defined margins. [1],[2],[10] FTC is a well-differentiated tumor which originates in follicular cells and resembles the normal microscopic pattern of the thyroid. It is the second most common thyroid cancer after papillary carcinoma, accounting for 10-20% of all thyroid malignancies, and is most often seen in patients over 40 years of age. The tumor usually presents as an asymptomatic solitary intrathyroid nodule. At times, these neoplasms tend to metastasize hematogenously, affecting lung and bone most commonly. While distant metastases at the time of diagnosis are reported in 11-20% of patients, less than 1% of these cases are seen in patients younger than 45 years of age. There have been a few case reports of FTC causing unusual bony metastases to skull, mandible, maxilla, spine, and orbit. Immunohistochemical marker for FTC is thyroglobulin, which is present in more than 95% of FTC cases. [13],[14]

The present case, a female patient about 40 years of age, presented with a swelling involving the left posterior mandible. Radiography showed extensive lytic lesion involving the ramus, up to condyle. USG of thyroid showed the presence of two nodules, one in each lobe of thyroid. Incisional biopsy of the mandible as well as excisional biopsy of the primary and secondary favored and confirmed FTC (primary) that had metastasized to the mandible (secondary).

The lack of large numbers of patients with mandibular metastasis prevents accurate determination of the prognosis of FTC. Some evidence indicates that resection of solitary bony metastasis, along with total thyroidectomy, may increase survival among those with FTC. An early detection of metastatic disease improves the overall survival rate and treatment results.

 
   References Top

1.Van der Waal RI, Buter J, Van der Waal I. Oral metastases: Report of 24 cases. Br J Oral Maxillofac Surg 2003;41:3-6.  Back to cited text no. 1
    
2.Hirshberg A, Buchner A. Metastatic tumours to the oral region. An overview. Eur J Cancer B Oral Oncol 1995;31B: 355-60.  Back to cited text no. 2
    
3.Lee KY, Lore JM Jr. The treatment of metastatic thyroid disease Otolaryngol Clin North Am 1990;23:475-93.  Back to cited text no. 3
    
4.Hoie J, Stenwig AE, Kullmann G, Lindegaard M. Distant metastasis in papillary thyroid cancer; a review of 91 patients. Cancer 1988;61:1-6.  Back to cited text no. 4
    
5.Mc Cormack KR. Bone metastasis from thyroid carcinoma. Cancer 1966;19:181-4.  Back to cited text no. 5
    
6.Mazzaferri EL. Papillary and follicular thyroid cancer: A selective approach to diagnosis and treatment. Annu Rev Med 1981;32:73-91.  Back to cited text no. 6
    
7.Zachariades N. Neoplasms metastatic to the mouth, jaws and surrounding tissues. J Craniomaxillofac Surg 1989;17:283-90.  Back to cited text no. 7
    
8.Zachariades N, Koumoura F, Vairaktaris E, Mezitis M. Metastatic tumours to the Jaws: A report of seven cases. J Oral Maxillofac Surg 1989;47:991-6.  Back to cited text no. 8
    
9.Solomon MP, Gardner B. Metastatic malignancy in the submandibular gland. Oral Surg 1975;39:469-71.  Back to cited text no. 9
    
10.Hirshberg A, Leibovich P, Buchner A. Metastatic tumours to the jaw bones: Analysis of 390 cases. J Oral Pathol Med 1994;23:337-41.  Back to cited text no. 10
    
11.Shankar S. Dental Pulp metastasis and pan-osseous mandibular involvement with mammary adenocarcinoma. Br J Oral Maxillofac Surg 1984;22:455-7.  Back to cited text no. 11
    
12.Carrol KO, Krols SO, Mosca NG, Jackson E. Metastatic carcinoma to the mandible: Report of two cases, Oral Surg Oral Med Oral Pathol 1993;76:368-74.  Back to cited text no. 12
    
13.Gilliland FD, Hunt WC, Morris DM, Key CR. Prognostic factors for thyroid carcinoma: A population-based study of 15, 698 cases from the Surveillance. Epidemiology and End Results (SEER) program 1973-1991. Cancer 1997;79:564-73.  Back to cited text no. 13
    
14.Tatic S. Histopathological and immunohistochemical features of thyroid carcinoma. Arch Oncol 2003;11:173-4.  Back to cited text no. 14
    

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Correspondence Address:
Shyam Prasad Reddy Dorankula
Department of Oral and Maxillofacial Pathology, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda (dt), Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111292

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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