740 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO.

6, JUNE 2008
C A S E R E P O R T
INTRODUCTION
C
olonic carcinoma is the most frequent malignant
gastrointestinal neoplasm and one of the com-
monest tumors in the general population. Meta-
static carcinoma of the colon is frequently encountered.
But metastatic tumors to the oral cavity are relatively
uncommon, occurring in <1% of all malignancies.
1
So,
metastatic carcinoma of the colon to the mandible has
been reported infrequently. We report a case of a patient
who initially presented as trismus and trigeminal neu-
ralgia under the diagnosis of mandible metastatic from
a primary adenocarcinoma of the colon. Diagnostic and
management strategies for this unusual presentation of
carcinoma of the colon are reviewed.
CASE REPORT
A 64-year-old man underwent emergency laparotomy
for acute appendicitis. When the pathologist found sero-
sal implants of adenocarcinoma in an acutely gangre-
nous appendix, colonoscopy was undertaken, revealing
an 8-cm mass occupying the entire rectal lumen. A low
anterior resection was performed to remove the lesion,
which revealed moderately differentiated adenocarci-
noma. The patient had previously been seen for numb-
ness, burning and intermittent sharp pains of his left
chin, which a neurologist had diagnosed as trigeminal
neuralgia. These symptoms persisted despite treatment
with carbamazepine. During his admission for surgery,
he was also noted to have trismus. There was tenderness
of the left mandible and swelling of the left masseter. A
biopsy was performed, and nests of moderately differen-
tiated metastatic colon adenocarcinoma were seen in the
brotic bone marrow (Figure 1). Computed tomography
revealed a soft-tissue mass with destruction of the left
mandibular ramus and involvement of the left medial
pteryigoid and masseter muscles (Figure 2). The patient
chose to forgo further surgery and was given only pallia-
tive chemotherapy and radiotherapy. He died six months
after diagnosis.
DISCUSSION
Fewer than 1% of all oral malignant tumors are met-
astatic, and their primary origin can be anywhere.
2
The
most common primary tumors are the breast in women
and lung in men,
3
followed by the adrenals, kidneys,
prostate, thyroid and colon.
4
Micrometastases frequently
lodge in the hematopoietically active marrow of skeletal
bone, because the marrow cavity is rich with sinusoidal
vascular spaces that permit penetration by tumor cells.
5

However, the oral cavity is not a site of active marrow
in humans, particularly in older individuals. If metasta-
ses do occur there, they are found most commonly in the
mandible,
2
where any remaining marrow reserve is most
likely to be in the posterior mandible. In a review of 390
cases of metastatic tumors to the jawbone, the condyle,
angle and ramus of the mandible were affected in 32.5%
of cases.
6
And the primary tumor was colon carcinoma
2008. From the Division of Gastroenterology, Department of Internal Medi-
cine, Mackay Memorial Hospital, Mackay Medicine (Chen, Chang, Shih),
Nursing and Management College, Taipei, Taiwan; and Department of Radi-
ology (Pang), Division of Gastroenterology, Department of Internal Medicine
(Bair), Mackay Memorial Hospital, Taitung Branch, Taiwan. Send correspon-
dence and reprint requests for J Natl Med Assoc. 2008;100:740742 to: Dr.
Ming-Jong Bair, No. 1, Lane 303, Changsha Street, Taitung, Taiwan; phone:
886-89-310150; fax: 886-89-321240; e-mail: a5963@ttms.mmh.org.tw
A 64-year-old man got trismus and trigeminal neuralgia
under the diagnosis of colon cancer with mandibular metas-
tasis after emergency appendectomy and elective hemi-
colectomy. The patient chose to forgo further surgery and
was given only palliative chemotherapy and radiotherapy.
He died six months after diagnosis.
Metastatic tumors to the oral cavity are relatively uncom-
mon. They are found most commonly in the mandible, and
70% of cases are adenocarcinomamost commonly from
breast and lung, followed by adrenals, kidneys, prostate,
thyroid and colon. Mandibular mass is usually the first sign,
then soft-tissue swelling, pain and paresthesias. Tissue proof is
needed to confirm the diagnosis. The treatment depends on
the nature of the primary, the degree of dissemination and
the precise location. However, the prognosis is grim, with the
mean survival after diagnosis being only about 67 months.
Key words: metastasis n colon n cancer n head
Trismus and Trigeminal Neuralgia in One
Patient with Colon Cancer
Huan-Lin Chen, MD; Wen-Hsiung Chang, MD; Shou-Chuan Shih, MD; Kwok-Kuen Pang, MD; and
Ming-Jong Bair, MD
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 6, JUNE 2008 741
TRISMUS AND TRIGEMINAL NEURALGIA
in only 7%. In the gastrointestinal tract, colonic carcino-
mas usually display metastasis to regional lymph nodes,
liver, peritoneum, lung or ovaries, rarely at the supracla-
vicular organs.
7
Hence, the diagnosis of metastatic ade-
nocarcinoma of the colon to the mandible in this patient
represents one of a few such case reports in the English-
language literature.
According to Mason et al., a mandibular mass is usu-
ally the rst sign, followed later by soft-tissue swelling,
pain and paresthesias.
5
Our patient presented with tri-
geminal neuralgia and trismus, which related to man-
dibular metastasis, but the accurate diagnosis was con-
rmed several months later. So it is needed to evaluate
trismus and trigeminal neuralgia adequately. Tissue
proof is needed to conrm the diagnosis. In our case,
the primary tumor was already apparent. If, however, the
metastases are the rst evidence of malignancy, a thor-
ough investigation for the source should be initiated.
5
A
complete history and physical examination, including
hemoccult stool testing, is essential. If there is a sus-
picion that a primary colonic lesion is the origin of the
metastasis, appropriate endoscopic evaluation to iden-
tify a mass should be performed.
Once a cancer of the colon lesion is diagnosed, ther-
apeutic intervention must judiciously be entertained,
because patients with adenocarcinoma of the colon pre-
senting with distant metastases have a recognized poor
prognosis, with the mean survival after diagnosis of
mandibular metastasis being only about 67 months.
1,6

So, the treatment of mandibular metastases depends
on the nature of the primary, the degree of dissemina-
tion and the precise location.
2
Surgical resection is rea-
sonable for an oral bone metastasis if it appears to be
the only metastatic lesion present. If, however, the can-
cer is already widely disseminated, as was the case in
our patient, palliative radiotherapy or chemotherapy is
recommended.
1
The development of novel chemother-
apeutic regimens has been useful in providing palli-
ation in advanced colorectal cancer,
8,9
such as the u-
orouracil plus leucovorin, irinotecan and oxaliplatin
combinations, and capecitabine plus oxaliplatin regi-
mens. Recent studies indicate that monoclonal antibod-
ies targeted against angiogenic proteins (epithelial call
adhesion molecule and vascular endothelial growth fac-
tor) or against growth factors (epidermal growth factor
Figure 1. Nests of metastatic tumor cells in the
fibrotic bone marrow space of the mandible
were noted (H&E, 200X)
Figure 2. Computed tomography of head and neck showed a soft-tissue mass with destruction of the left
mandibular ramus (arrow) and involving the left medial pterygoid and masseter muscles
742 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 6, JUNE 2008
TRISMUS AND TRIGEMINAL NEURALGIA
receptor) may be useful in the treatment of advanced
colorectal cancer.
10
Because cancer of the colon is apt
to be quite advanced locally, palliation for obstructive
symptoms can be offered. Mason et al. noted that a stent
may be useful for relieving symptoms if there is obstruc-
tion of the parotid gland duct.
5
Whatever therapeutic
strategies, these therapies are certainly available should
the patient and the family be interested.
CONCLUSION
Although rare, metastatic tumors should be included
in the differential diagnosis of an intraoral malignant
neoplasm. Trismus and trigeminal neuralgia may be one
of the presentations as colon cancer with mandibular
metastasis. The prognosis in any case is grim, but ade-
quate evaluation is needed for accurate diagnosis. And
further therapeutic strategies is suitable for patients.
ACKNOWLEDGEMENTS
We are grateful to the surgery and pathology teams at
Mackay Memorial Hospital. We also thank Dr. M.J. But-
trey for revision of the English manuscript and Dr. K.F.
Li for preparation of the gures.
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C A R E E R O P P O R T U N I T I E S
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