2. Introduction
• Metastasis
• 1-1.5% of all malignant tumors
• Breast, lung, kidney, bone, colorectum
• Hematogenous route
• Batson’s plexus, a valveless vertebral plexus that might allow retrograde
spread of tumour cells, bypassing filtration through the lungs.
• Batson’s plexus extends from skull to sacrum and is a common
thoroughfare for the spread of thoracic, abdominal and pelvic tumors to
the head & neck region, where infiltration through the lungs is
bypassed.
3. Male : Female predilection • Equal in jaw bones
• 2:1 for oral soft tissues
Most common sources Cancers from the lung, breast, kidney and
bone
Most common site of primary tumors • Lungs – soft tissue
• Breast – Jaw bones
Jaw bone predilection Mandible>Maxilla
Jaw bones : Soft tissue predilection Bone>soft tissue (2:1)
Most common oral soft tissue preferred • Dentulous patients: 80% of metastatic
tumors – attached gingiva
• Edentulous patients: equally distributed
between tongue and alveolar mucosa
Most common primary site:
• In males
• Females
• Lungs followed by kidneys, prostate,
liver, bone, thyroid and skin
• Breasts and less frequently from the
female genital organs, bone and
kidneys
4. Why the predilection to mandible?
• Significant amount of active marrow found in the posterior
area of the mandible.
• Marrow contains growth factors which may enhance
colonization of metastatic tumors.
• Moreover mode of spread – usually hematogenous – hence deposited in
vascular medullary tissue.
Why the predilection to gingiva?
• The rich capillary network of chronically inflamed gingiva – suggested mechanism
• that traps malignant cells
• Proliferative capillaries have a fragmented basement membrane through which
tumor cells easily penetrate.
6. Oral metastases can grow rapidly causing pain,
difficulty in chewing, dysphagia, disfigurement and
intermittent bleeding, leading to poor quality of life.
Clinical presentation of metastatic tumors can be
variable, which may lead to erroneous diagnosis or
may create diagnostic dilemma.
In the early stages, gingival
metastases resemble hyperplastic or
reactive lesions such as pyogenic
granuloma, peripheral giant cell
granuloma, fibrous epulis and
periodontal abscesses.
Clinical features
7. Gingival metastases are shown to be polypoid or exophytic, highly vascularized, and
hemorrhagic
The metastatic lesion in other locations of the oral soft tissues manifests as a sub-mucosal
mass particularly in the tongue with few cases presenting as ulcers.
8. • Mandibular molar area
• Bony swelling with tenderness, pain, ulcer, hemorrhage, paresthesia, and pathological
fracture
• Sometimes, tooth mobility and trismus are also present
• Paresthesia in the mandibular metastasis is reported to be located in the area
innervated by the mandibular alveolar dental nerve (“Numb chin syndrome”)
9. • A soft tissue mass extruding from a recent extraction wound accompanied by
pain
• In many of these cases the metastatic tumor is present in the area before the
extraction causing pain, swelling and loosening of teeth
• These symptoms lead the clinician to extract the affected tooth
14. A photomicrograph of the lesion shows a tumor
consisting of adenoid structures with columnar
epithelial cells with prominent nuclei (arrow).
Within the lumen of adenoid tissue, mucus was
present
Histologic features of renal cell carcinoma;
epithelial cellular network shown with clear
cytoplasm and hyperchromatic nuclei
surrounded in a rich vascular network.
15. Conundrums in diagnosis - Histology
Primary
ductal
carcinoma of
salivary gland
origin
metastatic
breast
carcinoma
Primary
intra oral
clear cell
carcinoma
metastatic
renal cell
carcinoma
Primary
intra oral
squamous
cell
carcinoma
metastasis
squamous
cell
carcinoma
from the lung
Primary
intra oral
malignant
melanoma
metastatic
malignant
malanoma
Malignant soft tissue tumors may originate
intra orally but because of the rarity – consider
metastatic origin!!
