Lobular adenocarcinoma of breast metastatic

to the mandibular condyle

Report of a case and review of the literature

Mary Frances Stavropoulos, DDS,a and Robert A. Ord, MD. DDS, FRCS,’
Baltimorr. Md.

DEPARTMLNT OF ORAL AND MAXILLO~ACIAL SURGERY, UNIVERSITY OF MARYLAND HOSPITAL

A case of metastatic breast adenocarcinoma to the condyle in a 55-year-old white woman is

reported. Highlights
condyle, a negative
fracture as the only
temporomandibular
(0R;\I St Kc; 0R-\l. MFII
of this case presentation include the rarity of reported metastatic lesions to the
bone scan 2 months before the bone biopsy, the existence of a pathologic
persistent symptom of the lesion, initial symptoms suggestive of
joint disorder, and the uncommon type of breast carcinoma.
0R41. P\THOI 1993;75:575-81

M etastatic tumors, the most common malignant
tumors of bone, represent advanced stages of cancer.
They most commonly arise from primary tumors of
the breast, lung, kidney, prostate, and thyroid and
most frequently occur in the spine, pelvis, femur,
skull, ribs, and humerus. Adenocarcinoma of the
breast, thyroid, and prostate preferentially metasta-
size to the skeleton rather than the liver, presumably
because of their proclivity for bone marrow.’ Carci-
noma of the breast is reportedly the malignancy that
most frequently metastasizes to bone, in approxi-
mately 55% to 80% of cases.l%3 Furthermore, al-
though less than 1% of all metastatic tumors occur in
the mandible and maxilla,4 carcinoma of the breast
metastasizes to the jaws three times as frequently as
other malignant tumors.‘. 3 Common symptoms and
signs of oral metastases often include pain, swelling,
trismus, paresthesia, and mobility of teeth. Racho-
graphic evidence may or may not exist, depending on
the degree of bony destruction; however, 33% of oral
metastases represent the first clinical indication of a
primary malignancy elsewhere.5
CASEREPORT
A SS-year-oldwhite woman visited her general dentist in
September 1990 with a complaint that her bite had changed
,‘Formerl! Chiel’ Resident. Presently in private
mond. Cd.
“Assistant Professor.
Copyri_eht 1993 by Mosby-Year Book. Inc.
OO30-J220/93/$1.00 + .I0 7/12/40462
and was abnormal. Her dentist radiographically diagnosed
a malpositioned condyle and treated her malocclusion con-
servatively with an acrylic bite splint for several weeks.She
was later referred to an oral surgeon who reevaluated her
radiographically and noted an osteolytic lesion of the left
condyle with a possible old fracture; she was subsequently
referred to the Department of Oral and Maxillofacial Sur-
gery at the University of Maryland Hospital.
Her history revealed that 6 months earlier she had expe-
rienced 2 weeks of pain and swelling in the left temporo-
mandibular joint region that had resolved;however, trismus
and malocclusion persisted. She denied a history of trauma
to the face.
Subsequent clinical evaluation revealed an anterior open
bite of 2 mm. Her right condyle was palpable via the exter-
nal auditory canal, but her left condyle was not. She exhib-
ited full range of motion in all excursive positions and was
without trismus, pain, swelling, or paresthesia. Panograph
evaluation was significant for possible fracture of the left
condylar neck, with shortening of the vertical ramus and a
moth-eaten appearance of the condylar head.
Her medical history was significant for the diagnosis of
an infiltrating lobular adenocarcinomaof the right breast in
March 1983 (Fig. I ). Treatment consisted of a simple right
mastectomy, radiotherapy of 50 Gy to the right chest wall,
and IO mg of tamoxifen twice daily for 2X years. She un-
derwent reconstruction of the right breast in 1986. In Au-
gust 1990, she developed a recurrent lesion of the right chest
wall, adjacent to the implant, which was diagnosed on bi-
practice, Rich- opsy as a lobular adenocarcinoma and treated by local ex-
cision. She was again treated with tamoxifen. A bone scan
performed in September 1990 was used to diagnose diffuse
metastases throughout the skull. spine. ribs, and proximal
femurs; however, no jaw lesions were seen.A computerized
575
 Fig. 1. Breast specimen. Lower halfol‘specimen shows infiltrating lobular carcinoma with cells in Indian-
tile fashion. Focus of lobular carcinoma in situ is seen. (Hematoxylin-eosin stain: original magnification,
x 200.)
Fig. 2. Coronal CT shows malpositioned left condylar
head with areas of sclerosis and bony destruction.
tomography (CT) scan of the head, with and without intra-
venous contrast enhancement, from the base of the skull to
the vertex was normal. A repeat bone scan in January I99 I
noted multiple lesions throughout the axial skeleton; how-
ever, the number, location, and intensity of the lesions were
essentially unchanged from the examination in September
1990. In addition, plain facial bone films, taken in January
I991 to rule out metastases, were interpreted as showing no
evidence of fracture or bony destruction.
The differential diagnosis under consideration at that
time was a pathologic fracture as a result of bone metasta-
sis or osteoporosis. A CT scan of the mandible, a complete
serologic work-up, and bone biopsy were then performed.
Physical examination on admission revealed an absent
right breast, replaced by a prosthesis. The chest expanded
symmetrically, and the lungs were clear to percussion and
auscultation. Auscultation of the heart revealed no mur-
murs. Examination of the abdomen, liver, and spleen were
unremarkable. The results of laboratory studies (complete
blood cell count; urinalysis; coagulation stuides; and elec-
trolyte, blood urea nitrogen, calcium, phosphorus, and cre-
atinine levels) were all within normal limits. The alkaline
phosphatase level was 147 units/liter (normal = 38 to 126).
Her chest x-ray was significant for pleural thickening con-
sistent with previous radiation therapy. The CT scan
showed abnormal bony texture of the left mandibular
condyle, with angulation, which suggested metastatic dis-
ease with a possible fracture (Figs. 2 and 3).
The patient was taken to the operating room and, under
nasotracheal general anesthesia, underwent a left temporo-
mandibular joint arthrotomy, high condylectomy, and bone
biopsy via a preauricular approach. The condylar head was
noted to be soft, with perforations of the remaining cortical
plate. Histopathologic examination of the bone revealed a
poorly differentiated adenocarcinoma, consistent with a
primary breast adenocarcinoma (Fig. 4). Lactalbumin and
carcinoembryonic antigen immunohistochemical assays
were subsequently performed on the condylar specimen.
Both tests of the specimen had positive reactions, whereas
those performed on controls were negative, thus confirming
the origin of the metastatic condylar lesion as the primary
breast lesion. The patient’s postoperative course was un-
eventful. She was subsequently discharged with a scheduled
follow-up appointment with her oncologist for evaluation
for further treatment.
ORAL SURGERY OR.IL MEDICINE ORAL PATHOLOGY
Volume 75, Number 5
Fig. 3. Axial CT shows moth-eaten appearance of left
condylar head.
DISCUSSION
The incidence of breast carcinoma has risen dra-
matically in recent years. Today, it affects approxi-
mately one in nine women in the United State@; men
are affected much less frequently. Important etiologic
factors include hereditary factors and, particularly,
estrogens. Women who have previous histories of
breast cancer or who have mothers or sisters with
premenopausal histories of breast cancer have 50
times the control incidence of breast cancer.6 Nullip-
arous women with late menopause are more com-
monly affected than multiparous women. The fre-
quency rises from 25 years of age to menopause and
decreases until 65 years of age, when another increase
occurs. Infiltrating lobular adenocarcinoma, an un-
common type of breast cancer, comprises approxi-
mately 5% to 10% of all breast carcinomas; it has an
incidence of bilateral lesions approaching 40%.‘, a
Malignant oral tumors constitute 5% of all malig-
nant neoplasms in the body, of which 1% are consid-
ered metastatic5% 9 Because of the scarcity of bone
marrow in the maxilla and mandible, lesions in these
areas account for less than 1% of the overall incidence
of bone metastasis. However, bone metastasis to the
oral cavity accounts for approximately 90% of oral
metastatic lesions, with the preponderance of lesions
(70%) occurring in the mandible, primarily in the
molar and premolar regions that exhibit the greater
quantity of bone marrow.’ Moreover, the separate
blood supply to the condyle from the remaining man-
Stavropoulos and Ord 577
Fig. 4. Condyle specimen. Tumor cells are seen invading
bone. Within connective tissue stroma, hyperchromatic
cells are seen in clusters or Indian-file fashion. (Hematox-
ylin-eosin stain; original magnification, X 200.)
dible contributes further to the rarity of metastatic
lesions to the condyle. lo Less than 30 cases of condy-
lar metastasis have been described in the litera-
ture 1,9,1’
Diagnosis of metastatic lesions to the maxillofacial
region is problematic for several reasons. They are
uncommon, and symptoms and signs of pain and
swelling are more commonly observed with diseases of
odontogenic origin. Because metastatic lesions are
usually centrally located, symptoms occur late in their
course. Changes are also not evident on plain radio-
graphs until late in the course of the disease; 30% to
50% osteolysis is required before becoming evident
radiographically. In addition, the metastatic tumor
may serve as the first indication of an unrecognized
primary lesion.12
Pain is frequently the first symptom; within 6
months, 90% of such cases exhibit radiographic evi-
dence of metastases.2. 3 Swelling, paresthesia, and
trismus are also clinical features, with the loosening
of teeth of notable significance in a patient free of pe-
riodontal disease. Although spontaneous pathologic Orthupacdic i t.~tlmatoiog~, Shock I r;~tma C’enter ul the
fracture has been reported as occurring rarely (ap- Maryland Institute for Emergency Medical Services S!s-
proximately 0.58%), it may lead the practitioner to ;I tcnls: and Janet C, Stavropoulos, PhD, for her assistance in
the preparation and editing of the initial manuscript.
prompt diagnosis.3. Ii Moreover, 50% of patients with
condylar metastasis have symptoms mimicking tem- REFERENCES
poromandibular joint disorder.” which clouds the di-
agnostic process. particularly when the existence ol
the primary lesion has not yet been established.
Radioisotope bone scanning has been determined to
be more sensitive than radiography in the detection 01
metastatic bone lesions.“, ” Radionucleotide uptake
by the bony lesion depends on the degree of new boric
formation in response to the lesion and the integrit!
of the blood supply, independent of the osteoblastic OI
osteolytic nature of the lesion. In approximately 5’%
of bone metastases with radiographically existing
Iytic lesions, the bone scan is normal. presumably bc-
cause of the lack of disparity between the osteogenc-
sis and vascular supply in the tumor and the unaf-
fected surrounding bone.‘“. ”
CT scan and magnetic resonance imagery scan arc
helpful in delineating the extent of :I lesion: however.
bone biopsy for histologic examination is the uneyuii -
ocal diagnostic criteria of this disease.
Treatment of metastatic tumors to the oral cavil)
is primarily palliative, focusing on pain relief and
avoidance of infection. fracture, hemorrhage. and
cachexia. These goals arc accompli&cd chiefly bq rz
diotherapy and chemotherapy; surgical intervention
is rarely used. It is incumbent on the practitioner to
thoroughly evaluate the patient’s medical histor) and
clinical and radiographic examinations to prompt1~
reach an appropriate diagnosis anti to <ubsequcntl\
manage the discasc.
We gratefully 3cknwledge the clinical contributions 01
Dr. John Sauk. Chairman of’ the Department of Oral
f’athologq. IlniverGt\ of Mar!l:~nd School ol’I>entistry. arid
Dr. John Papdimitriou. Department of l’atl~olog~. L’ni-
vorsit! of Maryland liospital. in the evaluation ul’ the his-
tologic speciniens and the preparation of thk manuscript:
the editorial assistance of Elaine P. Kicc. B.I. St:~vropoulo~