|Year : 2016 | Volume
| Issue : 2 | Page : 234-236
Mandibular metastasis with pulmonary cannon balls: Presentation of follicular carcinoma thyroid
Kaushik Saha1, Debraj Jash2, Arnab Maji3
1 Department of Pulmonary Medicine, Burdwan Medical College and Hospital, Burdwan, India
2 Registrar, CMRI, Kolkata, West Bengal, India
3 Consultant Pulmonologist, Burdwan Medical College and Hospital, Burdwan, India
|Date of Web Publication||1-Mar-2016|
Rabindra Pally, 1st Lane, P.O. - Nimta, Kolkata - 700 049, West Bengal
Source of Support: None, Conflict of Interest: None
Swelling of the jaw due to metastatic lesions needs careful search for an occult malignancy. Thyroid carcinoma is a rare cause of jaw bone metastasis. A 70-year-old female presented in our chest clinic with progressive shortness of breath for last 1-month and associated painful swelled right jaw for last 4 months. Her computed tomography scan thorax showed bilateral cannon ball metastasis involving all lobes of the lung. Fine-needle aspiration cytology (FNAC) from radiographically evident osteolytic lesion of the mandible was suggestive of metastatic carcinoma probably of thyroid origin. Ultrasonography of the thyroid gland revealed well-defined hypoechoic nodule (measuring about 2 cm × 1.8 cm) with few foci of calcification. FNAC from the thyroid nodule followed by immunocytochemistry was suggestive of follicular carcinoma of the thyroid. We report a very rare presentation, as jaw metastasis in follicular carcinoma of the thyroid.
Keywords: Follicular carcinoma, lung, mandibular metastasis, thyroid
|How to cite this article:|
Saha K, Jash D, Maji A. Mandibular metastasis with pulmonary cannon balls: Presentation of follicular carcinoma thyroid. Med J DY Patil Univ 2016;9:234-6
|How to cite this URL:|
Saha K, Jash D, Maji A. Mandibular metastasis with pulmonary cannon balls: Presentation of follicular carcinoma thyroid. Med J DY Patil Univ [serial online] 2016 [cited 2019 Dec 11];9:234-6. Available from: http://www.mjdrdypu.org/text.asp?2016/9/2/234/168007
| Introduction|| |
Metastases to oral tissues are rare which represent 1% of all oral malignancies.  Tumors commonly metastasizing to mandible are breast, lung, adrenal, kidney, gastrointestinal tract, and prostate, respectively. Most common site of metastasis in the oral cavity is the body of the mandible especially the premolar-molar region.  Mandibular metastasis may be the first presenting feature of underlying occult malignancy of another primary site. Among all jaws metastases, thyroid carcinoma as a primary comprises 3.85% of cases.  Here, we report a case of thyroid carcinoma with no clinically palpable nodule in the thyroid gland, metastasizing to mandible as presenting feature.
| Case Report|| |
A 70-year-old female presented with painful swelling in the right side of the jaw for last 4 months. She noticed the swelling 4 months back after right upper second molar tooth extraction for pain and mobility. The swelling increased gradually to reach the present state. Patient also gave a history of shortness of breath for last 1-month. The shortness of breath was persistent, progressive with (modified medical research council) grade 3 at the time of admission. There was no history of smoking, betel nut chewing, and alcohol consumption.
On examination, a firm diffuse swelling measuring about 4 cm × 4 cm was noticed in the retromolar region extending to the ramus of the right side of the mandible. On palpation, bicortical expansion of the ramus of the mandible was noted. There was an erythematous change over the retromolar region and adjacent buccal mucosa in intraoral examination. X-ray orthopantomograph view along with contrast-enhanced computed tomography (CECT) scan of mandible revealed a well-circumscribed osteolytic lesion of about 4.4 cm × 5.09 cm, in the right angle of mandible extending to coronoid process [Figure 1]a and b.
|Figure 1: (a) X-ray orthopantomograph view and (b) contrast-enhanced computed tomography (CECT) scan of the mandible showing a wellcircumscribed osteolytic lesion in the right angle. (c) CECT thorax shows bilateral cannon ball parenchymal opacities. (d) Ultrasonography of thyroid showing a well-defined hypoechoic nodule|
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On chest X-ray posterioranterior view, multiple nodular opacities in both lung fields were noticed. CECT thorax showed bilateral multiple cannon ball opacities involving all lobes of lungs [Figure 1]c. Ultrasonography (USG)-guided fine-needle aspiration cytology (FNAC) from the jaw swelling showed plenty of epithelial cells in the acinar pattern [Figure 2]a. These cytomorphological features were suggestive of metastatic carcinoma possibly of thyroid origin. Thyroid gland was neither enlarged, or any nodule was palpable in lobes of the thyroid. In the search of primary, USG of thyroid gland was done which revealed a well-defined hypoechoic nodule measuring about 2 cm × 1.8 cm with few foci of calcification [Figure 1]d. USG-guided FNAC from the thyroid nodule revealed plenty of thyroid follicular cells along with calcification in a haemorrhagic colloid mixed background [Figure 2]b. Cells were predominantly arranged in clusters and follicles. Mild anisonucleosis was present along with occasional large pleomorphic cells with abundant cytoplasm and atypical nuclei. Background material showed vague psammomatous calcification and cholesterol debris. The overall cytomorphological features were suggestive of a neoplastic lesion. Two possibilities were considered follicular carcinoma of the thyroid or follicular variant of papillary carcinoma of the thyroid. Incisional biopsy of the jaw swelling revealed thyroid follicles filled with colloid material suggestive of metastasis from follicular carcinoma thyroid [Figure 3]a. On immunocytochemistry, most of the follicles contained intra-luminal colloid which was positive for thyroglobulin. USG abdomen was within normal limits. FNAC form lung nodules also showed metastatic lesion. A diagnosis of follicular carcinoma thyroid metastasizing to mandible and lungs was made. Patient was referred to a thyroid surgeon for thyroidectomy and to the radiotherapy department for radiotherapy. After total thyroidectomy, biopsy of the thyroid tissue showed well-differentiated follicles resemble normal thyroid parenchyma with capsular invasion confirming the diagnosis of follicular carcinoma of the thyroid [Figure 3]b.
|Figure 2: (a) Fine-needle aspiration cytology from jaw swelling showing epithelial cells in the acinar pattern suggestive of metastatic carcinoma from thyroid. (b) Thyroid nodule showing clusters of thyroid follicular cells with large atypical pleomorphic cells suggestive of follicular carcinoma of the thyroid (H and E, ×200)|
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|Figure 3: (a) Photomicrography of the jaw swelling showing thyroid follicles fi lled with colloid material suggestive of metastasis from follicular carcinoma thyroid (H and E, ×20). (b) Biopsy specimen of thyroid tissue showing well-differentiated follicles resemble normal thyroid parenchyma with capsular invasion confirming the diagnosis of follicular carcinoma of the thyroid (H and E, ×20)|
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| Discussion|| |
Although many primary neoplasms commonly metastasize to bones, metastases to jaw bones are uncommon.  As they are rare, they are difficult to diagnose. Metastatic tumors to the oral region are common in patients aged 40-70 years.  Amount of red bone marrow and blood vessels in the jaw bones tends to decrease with age due to the gradual replacement of red marrow with yellow or fatty marrow.  This is why jaw metastasis is less common than other bones. Among jaw bones, metastasis to mandible (predominantly premolar-molar region) is more common than the maxilla.  As the mode of metastasis is hematogenous, neoplastic cells get deposited in rich vascular hematopoietic tissues of the region. A decreased flow of blood may contribute to deposition of neoplastic cells. In a study done by Batsakis, among 115 metastasizing jaw tumors, thyroid tumors constitute 6.1% of cases.  The most common primary sites in order of frequency are the breast (21.8%) followed by lung (12.6%), adrenal (8.7%), kidney (7.9%), bone (7.4%), colo-rectum (6.6%), and prostate (5.6%).  Symptoms of metastatic jaw tumors may give an important clue to of an underlying occult primary malignancy. In one-third of patients of jaw metastasis, they are the first symptom of an underlying malignancy from a primary site.  Presenting features of metastatic jaw tumors are pain, swelling, mobility of teeth delay in healing of extraction sockets and pathologic fractures or paresthesia.  Radiologically, metastatic lesions are most often ill-defined and are usually osteolytic or radiolucent, although they may be osteoblastic, radiopaque mixed lesions. Possibility of a metastatic disease in the mandible should be kept in mind in patient complaining of numb chin or mental nerve neuropathy. In our patient, swelling got noticed following extraction of the tooth. In a study conducted by Hirshberg et al.,  tooth extraction precedes the metastasis in 55 out of the 390 cases. Follicular carcinoma of the thyroid is the second most common carcinoma of the thyroid gland after papillary carcinoma of the thyroid accounting for 17% of all thyroid malignancies. Immunohistochemical marker of follicular carcinoma of the thyroid is thyroglobulin which is present in 95% of cases.  It is most common in women between the ages of 22 and 50 years.  The presenting symptom is usually a long lasting neck lump that may be noted incidentally during head and neck examination. Bone is the second most common site of metastasis after lung in a patient of thyroid malignancy. The optimal therapy for differentiated thyroid cancer includes thyroidectomy and radiotherapy. The presence of distant metastases carries a poor prognosis. An overall 10-year survival rate of 27% for bone metastasis of differentiated thyroid carcinoma has been reported.  An early detection of metastatic disease improves overall prognosis.
The present case is reported as jaw metastasis is itself very rare. Moreover, among jaw metastasis, thyroid cancer comprised 3.85% of cases. In the present case report, although the patient had no clinically palpable lump or nodule in the thyroid gland, patient had jaw metastasis and widespread cannonball metastasis in lungs at presentation which was highly unusual. Age of the patient was also 70 years which did not fit with the usual age of occurrence of follicular carcinoma of the thyroid which was usually 20-50 years.
| Acknowledgment|| |
Department of Oral and Maxilofacial Surgery, R Ahmed Dental College, Kolkata.
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[Figure 1], [Figure 2], [Figure 3]