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TMJ metastasis: A unusual case report

TMJ metastasis: A unusual case report The metastases to the TMJ from a primary lung tumour is a very rare occurrence. This case is unusual in several aspects, as the non-reducible dislocation of the TMJ was the first clinical manifestation of the tumour. CT staging showed that this secondary tumour in the condyle was the only bone metastasis. Introduction reduced mouth opening, inability to perform lateral Metastases involving the TMJ are rare, and only 40 cases movements, right crossbite and edge-to-edge occlusion. have been reported in the international literature [1]. The The oral examination revealed Class III malocclusion and primary site of the carcinoma was the breast in 9 cases, the left mandibular deviation. (Fig. 1) On palpation the gle- lung in 9, the prostate in 5 and the rectum in 3 [2], fol- noid cavity was found to be empty. lowed by the liver, cardia [3], uterus and pancreas (1 case each). In 2 cases the primary tumour was a melanoma [4], An orthopanoramic X-ray showed dislocation of the right the nose being the primary site in one case and the hallux condyle. in the other. In 6 cases, the primary site was not identified. As a rule, TMJ metastases manifest clinically even years After unsuccessful attempts to reduce the dislocation on after the onset of the primary tumour. In this study, we an outpatient basis, it was decided to perform manual present a very unusual case, unique in the literature, in reduction under general anaesthesia, without positive which the non-reducible dislocation of the mandible was result. Consequently an open reduction under general the first clinical manifestation of pulmonary adenocarci- anaesthesia was performed. noma. During routine preoperative exams, the chest X-ray showed an opaque area with microcalcifications. Given Case presentation The patient, a 60-year-old male, underwent extraction of the high level of significance of the temporomandibular the lower first right molar. From that moment he suffered symptoms and the fact that the patient's cardiorespiratory from right TMJ pain. At first his symptoms were associated parameters and blood tests were normal, after consulting to the intervention. Following this episode, the patient with pulmonologists we decided to perform surgery on reported limitation of mandibular movements, with the condylar area and to postpone diagnosis and treat- Page 1 of 3 (page number not for citation purposes) Head & Face Medicine 2008, 4:8 http://www.head-face-med.com/content/4/1/8 Th m Figure 1 ae ora ndibular l ex deviation amination revealed Class III malocclusion and left The oral examination revealed Class III malocclusion and left mandibular deviation. The hi ma Figure 3 ligna stol nt an ogidc al ha exami d meta nati stas on sho ised fr w oed m a p that the l rimary lu esion was ng tumour The histological examination showed that the lesion ment decisions involving the lung until immediately after was malignant and had metastasised from a primary surgery lung tumour. The joint capsule was accessed through a pretragal inci- sion, observing that the condyle was displaced past the eminence. An unsuccessful attempt was made to perform The histological examination showed that the lesion was bimanual reduction. It was finally observed that there was malignant and had metastasised from a primary lung a mass that completely occupied the intra-articular space. tumour. (Fig. 3) The tumour was thus circumscribed and resected, after which the dislocation was successfully reduced manually; A post-operatory chest X-ray appeared within the normal Deutrey's procedure was then performed to constrict the range, and only a post-operatory spiral CT scan succeeded condyle. (Fig. 2) in identifying the primary tumour The patient was referred to the pulmonary and oncology departments. Based on bronchoscopy and biopsy results, pulmonary adenocarcinoma was diagnosed. Given the presence of distant metastases, the patient was classified as Stage IV (TNM) [5]. However, a total-body CT scan revealed that the condylar lesion was the only distant metastasis. The patient underwent a cycle of radiotherapy, but died 6 months later. Discussion Tumours of the TMJ – both benign and malignant – are rare but difficult to diagnose [6]. In view of the fact that, at onset, they resemble common temporomandibular dis- orders, they can often mislead the specialist in formulat- ing correct diagnostic suspicions. Therefore, in patients who do not respond to treatment it is appropriate to reconsider the diagnosis and include the suspicion of can- cer in the differential diagnosis. Intraoperative view Figure 2 This case is particularly interesting because it not only Intraoperative view. The condyle was displaced past the eminence. The mass occupied the intra-articular space. involves an uncommon secondary site, but onset was extremely atypical, as the clinical manifestation of bone Page 2 of 3 (page number not for citation purposes) Head & Face Medicine 2008, 4:8 http://www.head-face-med.com/content/4/1/8 7. Rubin MM, Jui V, Cozzi GM: Metastatic carcinoma of the man- metastasis preceded that of the primary carcinoma. What dibular condyle presenting as temporomandibular joint syn- is even more significant is that the nature of the tumour drome. J Oral Maxillofac Surg 1989, 47:507-510. involved was a non-small-cell carcinoma. 8. Berrettoni BA, Carter JR: Mechanisms of cancer metastasis to bone. J Bone Joint Surg Am 1986, 68:308-312. The mandible and thus the condyle are unusual sites for metastases. Metastases to the entire maxillomandibular complex represent just 1% of metastatic cancers and 1% of all tumours in this area [7]. Metastases seem to prefer the marrow of haematopoietically active bone tissue, as this red marrow is richer in sinusoids that allow neoplastic clones to colonize and proliferate [8]. However, the man- dible is not a haematopoietic site, particularly in older patients. Conclusion Therefore, the case described here is a very significant example of the diagnostic challenges that TMJ lesions can represent. The authors underline the need to include con- dylar tumours in the differential diagnosis when the symptoms do not respond to treatment. A CT or MRI scan of the TMJ should be part of the diagnostic procedure. The case presented is the first example in literature of the clinical onset of lung cancer with a non-reducible disloca- tion of the temporomandibular joint. Competing interests The authors declare that they have no competing interests. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Authors' contributions All the authors were involved in examination of the patient as well as in writing and reviewing the manuscript. References 1. DeBoom GW, Jensen JL, Siegel W, Bloom C: Metastatic tumors of the mandibular condyle. Review of the literature and report of a case. Oral Surg Oral Med Oral Pathol 1985, 60:512-516. 2. Balestreri L, Canzonieri V, Innocente R, Cattelan A, Perin T: Tempo- romandibular joint metastasis from rectal carcinoma: CT findings before and after radiotherapy. A case report. Tumori Publish with Bio Med Central and every 1997, 83:718-720. scientist can read your work free of charge 3. Smolka W, Brekenfeld C, Buchel P, Lizukan T: Metastatic adeno- "BioMed Central will be the most significant development for carcinoma of the temporomanbibular joint from the cardia of the stomach: a case report. Int J Oral Maxillofac Surg 2004, disseminating the results of biomedical researc h in our lifetime." 33:713-5. Sir Paul Nurse, Cancer Research UK 4. Nortje CJ, van Rensburg LJ, Thompson IOC: Case report. Mag- netic resonance features of metastatic melanoma of the Your research papers will be: temporomandibular joint and mandible. Dentomaxillofac Radiol available free of charge to the entire biomedical community 1996, 25:292-297. 5. Webster K: Adenocarcinoma metastatic to the mandibular peer reviewed and published immediately upon acceptance condyle. J CraniomaxillofacSurg 1988, 16:230-232. cited in PubMed and archived on PubMed Central 6. Owen DG, Stelling CB: Condylar metastasis with initial presen- yours — you keep the copyright tation as TMJ syndrome. J Oral Med 1985, 40:198-201. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 3 of 3 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Head & Face Medicine Springer Journals

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Publisher
Springer Journals
Copyright
Copyright © 2008 by Boniello et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Otorhinolaryngology; Oral and Maxillofacial Surgery; Dentistry
eISSN
1746-160X
DOI
10.1186/1746-160X-4-8
pmid
18533016
Publisher site
See Article on Publisher Site

Abstract

The metastases to the TMJ from a primary lung tumour is a very rare occurrence. This case is unusual in several aspects, as the non-reducible dislocation of the TMJ was the first clinical manifestation of the tumour. CT staging showed that this secondary tumour in the condyle was the only bone metastasis. Introduction reduced mouth opening, inability to perform lateral Metastases involving the TMJ are rare, and only 40 cases movements, right crossbite and edge-to-edge occlusion. have been reported in the international literature [1]. The The oral examination revealed Class III malocclusion and primary site of the carcinoma was the breast in 9 cases, the left mandibular deviation. (Fig. 1) On palpation the gle- lung in 9, the prostate in 5 and the rectum in 3 [2], fol- noid cavity was found to be empty. lowed by the liver, cardia [3], uterus and pancreas (1 case each). In 2 cases the primary tumour was a melanoma [4], An orthopanoramic X-ray showed dislocation of the right the nose being the primary site in one case and the hallux condyle. in the other. In 6 cases, the primary site was not identified. As a rule, TMJ metastases manifest clinically even years After unsuccessful attempts to reduce the dislocation on after the onset of the primary tumour. In this study, we an outpatient basis, it was decided to perform manual present a very unusual case, unique in the literature, in reduction under general anaesthesia, without positive which the non-reducible dislocation of the mandible was result. Consequently an open reduction under general the first clinical manifestation of pulmonary adenocarci- anaesthesia was performed. noma. During routine preoperative exams, the chest X-ray showed an opaque area with microcalcifications. Given Case presentation The patient, a 60-year-old male, underwent extraction of the high level of significance of the temporomandibular the lower first right molar. From that moment he suffered symptoms and the fact that the patient's cardiorespiratory from right TMJ pain. At first his symptoms were associated parameters and blood tests were normal, after consulting to the intervention. Following this episode, the patient with pulmonologists we decided to perform surgery on reported limitation of mandibular movements, with the condylar area and to postpone diagnosis and treat- Page 1 of 3 (page number not for citation purposes) Head & Face Medicine 2008, 4:8 http://www.head-face-med.com/content/4/1/8 Th m Figure 1 ae ora ndibular l ex deviation amination revealed Class III malocclusion and left The oral examination revealed Class III malocclusion and left mandibular deviation. The hi ma Figure 3 ligna stol nt an ogidc al ha exami d meta nati stas on sho ised fr w oed m a p that the l rimary lu esion was ng tumour The histological examination showed that the lesion ment decisions involving the lung until immediately after was malignant and had metastasised from a primary surgery lung tumour. The joint capsule was accessed through a pretragal inci- sion, observing that the condyle was displaced past the eminence. An unsuccessful attempt was made to perform The histological examination showed that the lesion was bimanual reduction. It was finally observed that there was malignant and had metastasised from a primary lung a mass that completely occupied the intra-articular space. tumour. (Fig. 3) The tumour was thus circumscribed and resected, after which the dislocation was successfully reduced manually; A post-operatory chest X-ray appeared within the normal Deutrey's procedure was then performed to constrict the range, and only a post-operatory spiral CT scan succeeded condyle. (Fig. 2) in identifying the primary tumour The patient was referred to the pulmonary and oncology departments. Based on bronchoscopy and biopsy results, pulmonary adenocarcinoma was diagnosed. Given the presence of distant metastases, the patient was classified as Stage IV (TNM) [5]. However, a total-body CT scan revealed that the condylar lesion was the only distant metastasis. The patient underwent a cycle of radiotherapy, but died 6 months later. Discussion Tumours of the TMJ – both benign and malignant – are rare but difficult to diagnose [6]. In view of the fact that, at onset, they resemble common temporomandibular dis- orders, they can often mislead the specialist in formulat- ing correct diagnostic suspicions. Therefore, in patients who do not respond to treatment it is appropriate to reconsider the diagnosis and include the suspicion of can- cer in the differential diagnosis. Intraoperative view Figure 2 This case is particularly interesting because it not only Intraoperative view. The condyle was displaced past the eminence. The mass occupied the intra-articular space. involves an uncommon secondary site, but onset was extremely atypical, as the clinical manifestation of bone Page 2 of 3 (page number not for citation purposes) Head & Face Medicine 2008, 4:8 http://www.head-face-med.com/content/4/1/8 7. Rubin MM, Jui V, Cozzi GM: Metastatic carcinoma of the man- metastasis preceded that of the primary carcinoma. What dibular condyle presenting as temporomandibular joint syn- is even more significant is that the nature of the tumour drome. J Oral Maxillofac Surg 1989, 47:507-510. involved was a non-small-cell carcinoma. 8. Berrettoni BA, Carter JR: Mechanisms of cancer metastasis to bone. J Bone Joint Surg Am 1986, 68:308-312. The mandible and thus the condyle are unusual sites for metastases. Metastases to the entire maxillomandibular complex represent just 1% of metastatic cancers and 1% of all tumours in this area [7]. Metastases seem to prefer the marrow of haematopoietically active bone tissue, as this red marrow is richer in sinusoids that allow neoplastic clones to colonize and proliferate [8]. However, the man- dible is not a haematopoietic site, particularly in older patients. Conclusion Therefore, the case described here is a very significant example of the diagnostic challenges that TMJ lesions can represent. The authors underline the need to include con- dylar tumours in the differential diagnosis when the symptoms do not respond to treatment. A CT or MRI scan of the TMJ should be part of the diagnostic procedure. The case presented is the first example in literature of the clinical onset of lung cancer with a non-reducible disloca- tion of the temporomandibular joint. Competing interests The authors declare that they have no competing interests. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Authors' contributions All the authors were involved in examination of the patient as well as in writing and reviewing the manuscript. References 1. DeBoom GW, Jensen JL, Siegel W, Bloom C: Metastatic tumors of the mandibular condyle. Review of the literature and report of a case. Oral Surg Oral Med Oral Pathol 1985, 60:512-516. 2. Balestreri L, Canzonieri V, Innocente R, Cattelan A, Perin T: Tempo- romandibular joint metastasis from rectal carcinoma: CT findings before and after radiotherapy. A case report. Tumori Publish with Bio Med Central and every 1997, 83:718-720. scientist can read your work free of charge 3. Smolka W, Brekenfeld C, Buchel P, Lizukan T: Metastatic adeno- "BioMed Central will be the most significant development for carcinoma of the temporomanbibular joint from the cardia of the stomach: a case report. Int J Oral Maxillofac Surg 2004, disseminating the results of biomedical researc h in our lifetime." 33:713-5. Sir Paul Nurse, Cancer Research UK 4. Nortje CJ, van Rensburg LJ, Thompson IOC: Case report. Mag- netic resonance features of metastatic melanoma of the Your research papers will be: temporomandibular joint and mandible. Dentomaxillofac Radiol available free of charge to the entire biomedical community 1996, 25:292-297. 5. Webster K: Adenocarcinoma metastatic to the mandibular peer reviewed and published immediately upon acceptance condyle. J CraniomaxillofacSurg 1988, 16:230-232. cited in PubMed and archived on PubMed Central 6. Owen DG, Stelling CB: Condylar metastasis with initial presen- yours — you keep the copyright tation as TMJ syndrome. J Oral Med 1985, 40:198-201. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 3 of 3 (page number not for citation purposes)

Journal

Head & Face MedicineSpringer Journals

Published: Jun 4, 2008

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