J Clin Exp Dent. 2010;2(1):e47-50.

Oral metastasis of colon adenocarcinoma.

Journal section: Oral Medicine and Pathology doi:10.4317/jced.2.e47

Publication Types: Case Report

Gingival and submandibular lymph node metastasis

of sigmoid colon adenocarcinoma

J Landeyro 1, A Ravents 1, J Mommsen 3, A Elguezabal 1, M Gen 1, L Boutayed 1, MS Martnez 2

1
M.D., Department of Pathology. Hospital Universitari Joan XXIII . Tarragona. Spain
2
Ph.D. M.D., Department of Pathology. Hospital Universitari Joan XXIII . Tarragona. Spain
3
Ph.D. M.D., Department of Maxillofacial Surgery. Hospital Universitari Joan XXIII. Tarragona. Spain

Correspondence:
Julieta Landeyro
Department of Pathology
Hospital Universitari Joan XXIII
C/ Mallafr i Guasch 4
43007 Tarragona, Spain
e-mail julietalandeyro@yahoo.com.ar

Received: 06/01/2009
Accepted: 15/02/2010

Landeyro J, Ravents A, Mommsen J, Elguezabal A, Gen M, Boutayed

L, Martnez MS. Gingival and submandibular lymph node metastasis
of sigmoid colon adenocarcinoma. J Clin Exp Dent. 2010;2(1):e47-50.
http://www.medicinaoral.com/odo/volumenes/v2i1/jcedv2i1p47.pdf

Article Number: 678937 http://www.medicinaoral.com/odo/indice.htm

Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: jced@jced.es

Abstract
Introduction: Metastatic tumors of oral and maxillofacial region compromise 1% of all malignant oral neoplasms.
Most commonly affect the jaw bone and less commonly intraoral soft tissues. They originate mainly from primary
tumors of lung, breast, colon-rectum, prostate and kidney. Case report: a 77 years old man with history of sigmoid
colon adenocarcinoma and liver metastasis. Two years later of being free of disease, he presented with submandi-
bular lymphadenopathy and a gingival mass in right upper jaw. Fine needle aspiration of the node and biopsy of
the gingival mass were performed. The cytological smears showed cohesive cell groups on a necrotic background.
Biopsy examination showed subepithelial infiltration by neoplasm of glandular pattern with immunoreactivity for
keratin 20 and carcinoembryonic antigen. A definitive diagnosis of node and oral metastases of colon adenocar-
cinoma was made. Discussion: Metastases in the oral and maxillofacial region are very uncommon and usually
represent an advanced stage and disseminated disease. They present non specific radiologic and clinical features
so it is imperative to reach a definitive diagnosis the cytological/histological examination. Because of its rarity, the
diagnosis of metastases in the oral region are a challenging, both to the clinician and to the pathologist, in recogni-
sing that a lesion is metastasic and in determining the site of origin.

Key words: Gingiva, metastasis, colon adenocarcinoma, nodal metastasis.

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J Clin Exp Dent. 2010;2(1):e47-50. Oral metastasis of colon adenocarcinoma.

Introduction clinical outcome. Two years later being free of disease,

The metastasis of oral and maxillofacial region are rare, com- he was referred by his dentist to the department of maxi-
promise 1% of all oral malignancies (1). They originate from llofacial surgery due a gingival tumor of 3 x 4 cm in
malignant neoplasms of lung, breast, kidney, colon and prosta- diameter of one month of evolution with no response to
te, and occur more frequently in the jaw bone (2-4). With this antibiotic treatment. The lesion was located at the level
presentation, we report a case of an oral (gingival and bone) of teeth 1.5-2.1 (right upper jaw) and the radiological
and submandibular lymph node metastasis of colon adenocar- examination showed the destruction of the outer cortical
cinoma, and discuss the incidence, clinical features and mana- bone displacing the roots (Fig.1). The rest of the clini-
gement of metastatic lesions in this location. cal examination, included submandibular lymphadeno-
pathy, painless, firm and slightly adherent to deep tis-
Case Report sues of 1 and 1.5 cm in diameter. Fine needle aspiration
A 77 year old male diagnosed in 2005 in another center (FNA) of one of the nodes and then an incisional biopsy
of sigmoid colon adenocarcinoma with liver metastases. of the gingival lesion were performed. In the cytologic
He was treated with FOLFOX (oxaliplatin-5fluoroura- smears were observed a background of abundant ne-
cilo-leucovorin) and subsequently underwent surgical crotic material and three-dimensional groups of cohesi-
resection of hepatic segments V, VI and VII with a good ve columnar cells with elongated hipercromatic nuclei

Fig. 1. Orthopantography. Lesion in rigth upper jaw which destroys the outer cortical bone and displaces roots. (arrows)

Fig. 2. FNA of submandibular lymphadenopathy. a) and b) necrotic Fig. 3. Gingival tumor biopsy. a) submucosal infiltration by adeno-
background smear. Diff-Quick and Papanicolau 40x; c) three-di- carcinoma. H&E 40x; b) glandular proliferation with cribriform
mensional groups of cohesive cells with hipercromatic oval nuclei. pattern and central necrosis. H&E 40x; c) positivity of tumor cells
Diff-Quick 100x to CK20. 100x.
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J Clin Exp Dent. 2010;2(1):e47-50. Oral metastasis of colon adenocarcinoma.

and ample cytoplasm (Fig. 2). A diagnosis of metastatic The history, location, growth rate, age, sex and radiological
carcinoma compatible with nodal metastasis from colon findings are often indicative of metastasis but to reach a de-
adenocarcinoma was made. The histological examina- finitive diagnosis is imperative the cytological/histopatologi-
tion of the gingival lesion showed surface of squamous cal examination (12). The differential diagnosis of gingival
epithelium and subepithelial level, an epithelial neoplas- masses should be considered inflammatory, reactives and
tic infiltration of cribriform glands lined by columnar neoplastic processes. Among benign lesions include: pyoge-
cells with elongated nuclei and extensive areas of necro- nic granuloma, reparative granuloma of the midline, fibroma,
sis. Immunohistochemistry showed positivity of tumor hemangioma and epulis. Among malignant lesions, squamous
cells to carcinoembryonic antigen (CEA) and keratin 20 cell carcinoma of oral cavity versus squamous cell carcinoma
(CK20) and negativity to keratin 7 (CK7) (Fig. 3). Final of lung, salivary gland ductal carcinoma versus ductal breast
diagnosis was metastatic adenocarcinoma of colon. It is carcinoma and primary clear cell tumor of salivary gland ver-
currently unknown patients clinical course. sus conventional type renal cell carcinoma (2,5). Some rela-
tively specific immunohistochemical markers can help us to
identify the lesion as metastatic and the origin of it, including
Discussion
estrogen and progesterone receptors (breast); andro-
The metastasis of oral and maxillofacial region are rare, cons-
gen receptors and prostate-specific antigen (prostate); CK7
tituting between 1-3% of all oral malignancies (1). Occur bet-
and thyroid transcription factor-1 (lung); CK 20 and CEA (co-
ween the 5th and 7th decade of life without sex predilection
lon rectum); CD10 and vimentin (kidney). In our case, the
(2,5,6). The primary neoplasm is known in most cases, but
morphological and immunohistochemical findings allowed us
25% is the first sign of metastatic disease and between 22%
to recognize as metastatic gingival lesion and determine the
and 30% indicates the existence of an unknown primary tumor
site of origin. Considering that this patient already had liver
(2,5,6). The average time between diagnosis of primary tumor
metastases, probably the route of spread was hematogenous
and detection of oral metastasis is 40 months, however some
and lymph node involvement is secondary to neoplastic infil-
may take more than 10 years (5). Most oral metastases are of
tration of lymphatic vessels of the area.
epithelial origin, although metastatic sarcomas, melanoma and
The presence of metastases in the oral/maxillofacial region
neuroblastoma have been reported (7). The most frequent si-
usually represents an advanced stage and multiple-organ dis-
tes of origin are lung, colo-rectum, kidney and prostate cancer
seminated disease with poor prognosis. Most of patients die
in men and breast, genital tract and kidney in women, tumors
within the first year of diagnosis with a survival rate at 4 years
more prevalent in the general population (5,7-10).Other sour-
of 10% (3,7). The treatment modalities are limited to conserva-
ces uncommon are pancreas, thyroid, adrenal gland and liver
tive and palliative therapies intended to improve the quality of
(2,5).
life of these patients, and include local resection, radiotherapy
Bone involvement is the most common presentation of oral
or chemotherapy (5).
and maxillofacial metastasis, most commonly involving the
In conclusion, because of its rarity, the diagnosis of metastatic
jawbone, and especially the molar region (5,6). The intraoral
lesions of the oral and maxillofacial region are a challenge for
soft tissue metastases are rare and correspond to 0.1% of all
the clinician to the pathologist. We illustrate with this presen-
cancers in the area, the oral mucosa being the most affected
tation, a case of oral and nodal metastasis of colon adenocarci-
site followed by the tongue (2,3,7). Seoane et al. (7) have
noma and we emphasize that the cytological /histopathological
reported that no prognostic distinction between soft tissue or
examination is mandatory and with the help of immunohisto-
bone metastasis.
chemical techniques to determine the origin site.
The pathogenesis of oral metastasis is unclear. As the case
presented, have also been documented oral metastasis in the
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