Metastatic Neoplasms to the Oral Cavity Clinical Presentation

Symptoms develop in a relatively short period. Note the following:

• In the oral soft tissues, most patients report a lump.
• In the jawbones, swelling, pain, and paresthesia of the affected nerve are the chief reported symptoms.
• Give special attention to patients with numb chin syndrome or mental nerve neuropathy. The numb chin syndrome is the consequence of loss of function of the terminal sensory division of the mandibular branch of the trigeminal nerve. Any pathological process involving the mental nerve, the mandibular nerve, and even the mandibular trunk of the fifth nerve may produce this loss of function. The appearance of a mental nerve neuropathy should always raise the possibility of a metastatic disease in the mandible.^[18]
• With the progression of the disease, oral metastatic lesions (especially those in soft tissues) cause progressive discomfort. Pain, bleeding, superinfection, dysphagia, interference with mastication, and disfigurement are some of the main reported symptoms.
• In some cases, the metastasis is discovered in a recent extraction site. The main symptom is a soft tissue mass extruding from a recent extraction wound and accompanied by pain. In many of these cases, the metastatic tumor is present in the area before the extraction; it can cause pain, swelling, and loosening of the teeth. These symptoms lead to the extraction of the affected tooth. In some cases, metastasis probably develops after extraction. Tooth extraction can serve as a promoting factor in the metastatic process.

The clinical presentation of the metastatic tumors differs among the various oral sites, as follows:

• In the oral soft tissues, the attached gingiva is the most commonly affected site, followed by the tongue and, with much less frequency, the remaining mucosa.
• The presence of teeth seems to have a crucial effect on the oral site preference of metastases. In the dentulous patient, about 80% have metastasis in the attached gingiva. In the edentulous patient, metastatic lesions are distributed equally between the tongue and alveolar mucosa.
• In the jawbones, the common location of the metastatic lesion is the mandible; the molar area is the most frequently involved site.
• In its early manifestation, gingival metastasis resembles hyperplastic or reactive lesions (eg, pyogenic granuloma, peripheral giant cell granuloma, fibrous epulis),^[19] as shown in the images below. A large pedunculated mass on the gingiva resembles a pyogenic granuloma and peripheral giant cell granuloma in a 44-year-old woman with metastatic breast carcinoma. A large soft-tissue mass on the gingiva resembles pyogenic granuloma and peripheral giant cell granuloma in a 51-year-old man with metastatic renal cell carcinoma.
• In other oral soft tissue locations, especially in the tongue, the metastatic lesion manifests as a submucosal mass.
• In the jawbones, physical examination reveals a bony swelling with tenderness over the affected area.
• Sometimes, tooth mobility and trismus are present.

The oral region is an uncommon site for metastatic lesions. However, several factors can enhance metastatic colonization in the oral region. Note the following:

• In dentulous patients, 80% of the metastatic tumors to the oral soft mucosa are found in the attached gingiva, whereas in edentulous patients, metastatic lesions are equally distributed between the tongue and the alveolar mucosa. The rich capillary network of chronically inflamed gingiva has been suggested as a mechanism that entraps malignant cells.
• The jawbones have little active marrow, which is a preferred site for metastatic deposits in the skeleton. However, in some cases, active marrow can be found in the posterior area of the mandible. In addition, remnants of hematopoietic marrow can be found in an edentulous jaw in cases of focal osteoporotic bone marrow defects. These hematopoietically active sites may attract metastatic tumor cells.