Int. J. Oral Surg. 1983; 12; 56--59

(Key words: melanoma; malignancy: metastases; tnandibte: surgery, ora!)

Melanoma metastatic to the mandibleReport 0 f a case

ROBERT W. T. MYALL, THOMAS H. MORTON AND PHILIP WORTHINGTON

Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Washington, Seattle, USA

ABSTRACT - Metastasis of a tumor to the jaws can simulate an infection, but thepresence of paraesthesia and loose teeth or inadequate response to treatmentshould alert the clinician to a more serious cause. A malignant melanomametastatic to the jaws illustrates these points.

(Received for publication 21 June, accepted 10 October 1982)

Table I. The nine most common primary sites ofneoplasms metastasising to the jaws

* Mainly melanomas.Seven other primary sites were included in the originallist, but each made up less than 1% of the total cases(after BATSAKIS').

used by CLAUSEN & PAULSEN' to classify alesion as metastatic; to be classified as ametastatic melanoma, the lesion had to be a truemetastasis localised to the bone tissue, his­tologically verified, from a known non-

Only 1% of malignant oral tumors representmetastases' and hence they are rarely en­countered in the practice of oral and maxillofa­cial surgery. The majority of tumor embolibecome lodged in the red bone marrow of themandible posterior to the cuspids in the manynarrow vascular channels. Here they pro­liferate". The metastatic foci are initiallylocated centrally and later produce such non­specific signs and symptoms as pain, swelling,dysaethesia, and eventually loosening of teeth.Unless the clinician has his wits about him, hemay misinterpret these findings, since radio­graphic evidence of malignancy may postdatethe initial signs and symptoms by more than ayear',

About 4.4% of the neoplasms that mestas­tasize to the jaws are melanomas (Table 1);metastasis of a melanoma to other bones isfound more often, though still infrequently.When SAMIT ' O reviewed the literature onmetastatic melanomas, he found only a fewreports that satisfied the oft-quoted criteria

Primary site of neoplasm

BreastKidneyLungColon and rectumProstateThyroidStomachSkin*Testes

%of eases

30.415.614.87.87.06.15.24.42.6

MYALL, MORTON AND WORTHINGTON 57

contiguous site. Our case history, illustrating

the natural history of a jaw metastasis, high­lights the trap into which the clinician may fall.It also underlines the behavior of a melanoma.

Case reportThe patient was a 30-year-old white woman whocame to the University of Washington Dental Schoolin early September 1977with paraesthesia of the rightside of her lower lip. She had first noticed a discretealteration in sensation 4 months previously, whichhad gradually changed to a deep-seated discomfort.Eventually it seemed to involve the whole of the sideof her face and neck. By the end of May, she couldstand the discomfort no longer and saw her dentist,who removed an impacted wisdom tooth.Considerable pain followed the extraction and shewas unable to open her mouth. She was referred to anoral surgeon and then to a neurologist. Theneurologist gave a presumptive diagnosis of multiplesclerosis and placed her on cortisone. She wasdischarged 1 week later.

After 3 further weeks of recurrent symptoms, shearrived at the Dental School's Emergency Clinic witha swollen right lower jaw which was painful topalpation, paraesthesia of the lower lip, and atemperature of 38°C. Intraoral and occlusal X-rayfilms of the jaws suggested that she had a malignantlesion in the right mandibular body (Figs. 1 and 2).She was consequently admitted to the hospital forevaluation and biopsy.

When questioned, she said that a malignantmelanoma (Fig. 3) had been removed from the leftside ofher anterior chest wall in 1974. A benign lump

Fig. 1. Intraoral radiograph showing, especiallyapically of the second mandibular molar, small areasof bone destruction with irregular margins suggestinga malignancy. The third molar has been removed.

Fig. 2. Occlusal radiograph showing irregular bonedestruction emanating from several sites and extru­sion of the second mandibular molar.

had been removed from her right breast in 1976. Forthe 8 weeks prior to the current admission, she hadhad a cold with a green discharge draining from theright side of her nose. At the same time that theparaesthesia of the lip returned, she noticed someweakness of the whole right side of her body.

On examination, she had marked tenderness overthe right maxillary sinus, but no swelling. The lowerright side of her facewas slightly swollen. Intraorally,she had a 5 x 1 em firm, yet compressible buccalexpansion alongside the first and second right lowermolars, both ofwhichwere mobile.The second molarwas partly extruded lingually but with no purulentdischarge from thegingival sulcus.The right lower lipand chin were anaesthetic, but there were no otherneurological deficits.Her right submandibular lymphnodes were enlarged and tender. Shehad a small scarabove her left breast, but no breast lumps or axillarylymphadenopathy. Results of cardiovascular, ab­dominal, and musculoskeletal examinations werewithin normal limits.

Laboratory tests, including CBC with differentialwhite count, urinalysis, and liver function tests werewithin normal limits,as wereher chest radiographs. AWater's view of her maxillary sinuses showedopacification in the right sinus which was later foundto be due to infection.

58 MYALL, MORTON AND WORTHINGTON

Fig. 3. Melanoma cells in a section from the originalexcisional biopsy specimen from the left chest wall(H&E, x 100).

The patient appeared to have symptoms suggestingmultiple sclerosis together with anaesthesia of themandibular division of the trigeminal nerve, expan­sion of the buccal plate of the right mandible andloosening of its molar teeth , these latter signssuggesting the possibility ofa tumor. The radiograph­ic findings supported this contention (Figs . land 2).The patient was taken to the operating room the dayafter admission ; an exploratory biopsy was per­fanned, and the 2 loose molars were removed; thebuccal and lingual cortical plates were found to beeroded.

A frozen section of the biopsy specimen showedonly what were called "epithelioid-like cells." Thepatient had no post-operative complications and wasdischarged after a 4-day stay in the hospital.

The final histopathological diagnosis was of ametastatic melanoma invading the right mandible.The tumour, which stained positively for melanin,was seen to have eroded and invaded the bone (Fig. 4).Ultrastructural examination revealed premelano­somes together with partly pigmented melanosomeswithin the tumour cells, which further substantiatedthe diagnosis. A histological section from the initialmelanoma removed from the left breast was reviewedby the pathologist, who noted that the surgicalmargins were free of tumour but that there wasinvasion to level 34

•

After discussions with the medical oncology andradiation oncology services, it was thought unlikelythat surgical treatment of this apparently isolatedmetastatic lesion was appropriate, and the patient'sjaw was subjected to radio-therapy. She survived a

Fig. 4. Metastatic melanoma cells invading themandibular bone. (H&E, x 100).

few months before succumbing to what appearedclinically to be Widespread metastases. The family didnot wish an autopsy to be performed.

DiscussionMetastatic disease simulates infection in manyways - pain, swelling, lymphadenopathy, anddiffuse radiographic changes - but there arecertain warning signs that should be heeded.Alteration in sensation in the distribution of asensory nerve is suggestive of malignancy.Occasionally, patients with acute osteomyelitisnotice dysaesthesia, as do those with recenttrauma to the jaw bones, but in the absence ofobvious signs of trauma and osteomyelitis, thepresence of malignancy, primary or secondary,should be entertained. Accelerated loosening ofteeth in the absence of trauma is also a firm

reason for suspecting a malignant process. In asubstantial number of cases, infection can besuperimposed on the malignancy, thus disguis­ing its true nature. Only careful observation willenable the oral surgeon to recognize thoseuncharacteristic aspects in the natural history ofthe disease which will make him rethink hisdiagnosis. BATSAKIS' makes the startling obser­vation that "pain may precede radiographicevidence of the lesion by as much as IS months"(p. 241).

This patient had been treated by severaldental and medical practitioners over a period

MELANOMA METASTASES 59

of 3 months. She had been offered differingopinions about the cause of her symptoms andconsequently several different forms of treat­ment. This is quite commonplace, followingmisdiagnosis of malignancy of the jaw". It is notthat anyone person overlooked the obvious,but more the slow indefinite evolution of signsand symptoms that is characteristic of meta­stasis to the jaw. The key evidence in hermedical history was, however, the fact that shehad had a melanoma removed from her leftbreast. The later radiographic evidence (Figs. Iand 2) eloquently demonstrated metastaticdisease in her jaw.

For many years, malignant melanoma wasdescribed as 'the Black Cancer', with theimplication that its prognosis was uniformlydismal". Current evidence suggests that earlyisolated lesions can be cured with conservativesurgery", The incidence of and mortality fromepidermal malignant melanoma among light­skinned persons appear, however, to be increas­ing in all countries in which it has been studied".Dissemination occurs by direct invasion, vialymphatics or via blood vessels. Metastaseslimited to one location are usually lymphatic inorigin, whereas contralateral, bilateral andgeneralised metastases are the result of blooddispersion, which pathway is sometimes as­sociated with metastasis to the heart'". It iscommon for many years to elapse between thetime a primary melanoma is treated and theappearance of metastases. No way is known ofcontrolling widely disseminated malignant me­lanoma'. The presence of metastatic melanomawithout a demonstrable primary cutaneousgrowth is a well-known phenomenon andevidence suggests that in some cases, if not inthe majority, the primary growth regressesafterhaving metastasized". Another interestingaspect ofmetastatic melanoma is its associationwith paraneoplastic syndromes (effects uponthe host at sites distant from both primary andmetastatic sites of involvement). We mightconjecture that our patient's neurological de­ficits could be explained on this basis rather

than that of multiple sclerosis. On the otherhand, it could have been caused by metastaticdeposits in the central nervous system.

Acknowledgment - The authors thank Ms. AlisonRoss for her editorial help.

ReferencesI. BATSAKIS, J. G.: Tumors ofthehead andneck, 2nd

edition. Williams & Wilkins, Baltimore 1979, pp.240--251.

2. BRESLOW, A. & MACHT, S. D.: Optimal size ofresection margin for thin cutaneous melanomas.Surg, Gynecol. Obstet. 1977: 145: 691-692.

3. CASH, C. D., ROYER, R. Q. & DAHLIN, D. c..Metastatic tumors of the jaws. Oral Surg, 1961:14: 897-905.

4. CLARK, W. H. JR.: A classification of malignantmelanoma in man-correlated histogenesis andbiologic behavior. In: MONTAGNA W. & Hu, F.(eds.): Advances in biology of skin (VIII). Thepigmentary system. Pergamon, Oxford and NewYork 1967, pp. 621-647.

5. CLAUSEN, F. & PAULSEN, H.: Metastatic tumorsof the jaws. Oral Surg, 1961: 14: 897-905.

6. ELWOOD, J. M. & LEE, J. A. H.: Recent data onthe epidemiology of malignant melanoma. In:CLARK, W. H., JR., GOLDMAN, L. I. &MASTRANGELO, J. J. (eds.): Human malignantmelanoma. Grune & Stratton, New York 1978,pp. 263-272.

7. HARRIS, M. N., ROSES, D. E, CuLLlFORD, A. T. &GUMPORT, S. L. : Melanoma of the head and neck.Ann Surg, 1975: 182: 86-91.

8. MCGOVERN, V. J.: Spontaneous regression ofmelanoma. Pathology 1975: 7: 91-99.

9. SAGEBIEL, R. W.: Therapeutic implications of thehistopathology ofprimary malignant melanoma.What's Nell' in Cancer Care. 1980: 4: 1-6.

10. SAMIT, A. M., FALK, H. J., OHANIAN, M., LEBAN.S. G. & MASHBERG, A.: Malignant melanomametastatic to the mandible. J. Oral Surg, 1978:36: 816-821.

11. STOCKDALE, C. R.: Metastatic carcinomas of thejaws secondary to primary carcinoma of thebreast. Oral Surg, 1959: 12: 1095-1101.

Address:

Robert W. T. MyallDepartment of Oral and Maxillofacial SurgerySchool of Dentistry. SB-24University of WashingtonSeattle. WA 98195USA