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 Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology 28 (2016) 197–201

Contents lists available at ScienceDirect

 Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology

 journal homepage: www.elsevier .com/ locate / jomsmp

Case Report

A rare case of mucous adenocarcinoma with gingival metastasis:

A case report and review of literature

Sumit Majumdar 1, Divya Uppala2, Rajyalakshmi Boddepalli3, Ayyagari Kameswara Rao∗

Department of Oral Pathology andMicrobiology, GITAMDentalCollege and Hospital, Rushikonda, Visakhapatnam530045, India

a r t i c l e i n f o

 Article history:

Received 25March 2015

Received in revised form 27 August 2015Accepted 2 September 2015

Available online21October 2015

Keywords:

Metastasis

Mucous adenocarcinoma

Stomach

Immunohistochemistry

a b s t r a c t

Oral cavity metastatic tumors are considered rare and represent approximately 1% of all oral malignan-

cies. Because they are rare and due to atypical clinical and radiographic presentation, metastatic lesions

are considered a diagnostic challenge. Primary tumors which metastasize to the oral cavity are most

commonly from lung, breast, and kidney and colon. Oral cavity metastases represent distant spread

and are associated with poor prognosis. The purpose of  this report is to present a rare case of mucous

adenocarcinomaof stomach whichmetastasized to mandibular gingiva.

©2015AsianAOMS,ASOMP, JSOP, JSOMS, JSOM, and JAMI. PublishedbyElsevier Ltd. All rights reserved.

1. Introduction

Oral region is an uncommon site for metastatic tumor. Itaccounts foronly1%ofalloralmalignantneoplasms andmostcom-

monly involve theposteriorregion ofmandible[1]. Primarytumors

frombreast, lung,kidney, boneandcolonaccountsfor 70%ofalloral

metastatic cases [1], while stomach accounts for only for 2.2%of all

cases [8]. Several types of carcinomas arise from thestomach,with

adenocarcinoma being the most common and is the second most

common cancer worldwide accounting for 3% to 10% of all can-

cer related deaths [3]. Gastric carcinomacan spreadby direct local

invasionof adjacent organs, peritonealspread, lymphaticspread or

by haematogenous dissemination [4,5]. Gastric carcinomasmetas-

tasize most commonly to liver, lung, and pancreas [4]. The oral

cavity is an uncommon site formetastatic spreadof gastric adeno-

carcinoma very few cases are reported in literature and according

AsianAOMS:AsianAssociationofOralandMaxillofacialSurgeons;ASOMP:Asian

Society of Oral andMaxillofacial Pathology; JSOP: Japanese Society of Oral Pathol-

ogy; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese

Society of OralMedicine; JAMI: Japanese Academy of Maxillofacial Implants.∗ Correspondingauthor. Tel.: +91 9440074890.

E-mail addresses:drsumitmajumdar1971@gmail.com(S.Majumdar),

uppala.divya@gmail.com(D. Uppala), drrajii@gmail.com (R. Boddepalli),

calmua@gmail.com(A.K. Rao).1 Tel.: +91 9831132632.2 Tel.: +91 9966413710.3 Tel.: +91 9611129360.

toSauerbornDetal. [4] only18 caseswere reported includingtheir

case and our search revealed only 2 more such cases [5,6] of which

only 10 cases are reported in the mandible (Table 1).

2. Casereport

A 60-year-old female patient reported to the hospital with

the chief complaint of non-healing socket and painless growth of 

gums since 1 month (Fig. 1A). Her Medical history revealed that

she had gastritis and using proton pump inhibitors for the past

2 years and was anemic. Past dental history reveals an extrac-

tion of mobile mandibular right first molar. She was a chronic

reverse smoker, quit the habit recently. On intra oral examina-

tion a pinkish soft tissue growth surrounding the extracted socket

wasnotedmeasuringabout 2cm×1cmwhich bleededonprobing

and the extracted socket was dry (Fig. 1B). Extraoral examina-tion revealed a painful, fixed right submandibular lymph node.

The radiological findings were insignificant to the clinical find-

ings (Fig. 2). Clinical diagnosis was made as pyogenic granuloma

and an incisional biopsy of the soft tissue growth was done under

local anesthesia. The Hematoxylin and Eosin stained soft tissue

section revealed cells with a peripherally located crescent shaped

nucleus and intracytoplasmic mucin, the cells are discohesive in

the connective tissue with few tubulo ductal areas (Fig. 3A and

B). Histochemical stains were performed in an attempt to local-

ize and characterize the tumor cells. Histochemical studies using

Periodic acid–Schiff staining revealed the strong positivity in the

http://dx.doi.org/10.1016/j.ajoms.2015.09.002

2212-5558/© 2015 AsianAOMS, ASOMP,JSOP, JSOMS,JSOM, and JAMI. Publishedby Elsevier Ltd. All rightsreserved.

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 Table 1

S. no Sex/age Site of soft tissue in oral cavity Author/year

1. F/63 Mandible Lund et al. (1968) [4]

2. M/58 Mandible Astacio and Alfaro (1969) [4]

3. M/51 Mandible Ohba et al. (1974) [4]

4. F/65 Maxilla Lopez and Loboz (1976) [4]

5. M/59 Maxilla Osaki et al. (1978) [4]

6. M/65 Soft palate Arjona et al. (1989) [4]

7. M/69 Mandible Tojo et al. (1989) [4]8. M/56 Mandible Hamakawa et al. (1993) [4]

9. M/66 Maxilla Florio and Hurd (1995) [4]

10. M/60 Mandible Makino et al. (1997) [4]

11. M/65 Maxilla Yajima and Miyazaki (1999) [4]

12. M/65 Tongue Yasumoto et al. (1999) [4]

13. M/56 Mandible Shimoyama et al. (2004) [4]

14. F/61 Maxilla Colombo et al. (2005) [4]

15. M/65 Mandible Kwon et al. (2006) [4]

16. F/82 Mandible Nishide and Kanamura (2006) [4]

17. M/58 Maxilla Hwang et al. (2007) [4]

18. M/70 Mandible Sauerborn et al. (2011) [4]

19. M/50 Maxilla Umashankar et al. (2013) [5]

20. M/50 Maxilla Manjunath et al. (2013) [6]

21. F/60 Mandible Present case

Fig. 1. (A) Extra oral and (B) Intra oral picture of 60 year old female patient.

cytoplasmof tumorcells,whichwasinterpreted asmucin (Fig. 4A).

Immunohistochemically tumor cellsshowedintra cytoplasmic and

luminal positivity for MUC1 (Fig. 4B). Based on this a diagnosis of 

mucousadenocarcinomawasmade. Thepossibility of a metastatic

Fig. 2. Orthopantomogram.

lesion was considered because mucous adenocarcinoma may not

develop in thegingiva as theprimary site. An immunohistochemi-

calstudywas done to identify themostprobablesite of theprimary

tumor. As the most common metastatic tumors are from breast

and lungs immuno profiling was started with Cytokeratins 7 and

20 (CK7/20). The tumor cells are widely immunopostive for CK7.

Though the tumor cells were widely positive for CK7, they werenegative for Estrogen Receptor (ER), Napsin, TTF1 and focally pos-

itive for CK20. The tumor cells are strongly positive for Carcino

Embryonic Antigen (CEA) (Fig. 5). Based on the above immuno-

histochemical studies final diagnosis of mucous adenocarcinoma

from stomach was confirmed and the patient was referred to an

oncologist for further treatment. Endoscopic examination showed

an ulceroproliferative growth of the gastric mucosa and thehisto-

logical features of the endoscopic biopsy specimen demonstrated

the same histological pattern of the metastatic tumor (Fig. 6A and

B).Patientwasnot able toretain inany formsolid or liquiddietdue

to frequent regurgitationevenunderconstantcare andsupervision.

Patient expired dueto poor nutrition, beforeany further investiga-

tions could be performed to diagnose metastatic deposits in other

organs.

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S.Majumdar et al. / Journal of Oral andMaxillofacial Surgery,Medicine, andPathology 28 (2016) 197–201 199

Fig. 3. demonstrating mucous cells having a peripherally placed crescent shapednucleus with intracytoplasmic mucin (A); with few tubulo ductal areas (B) (Hematoxylin

and eosin Stain); Originalmagnification 25× and 10×, respectively.

3. Discussion

The primary metastases to soft tissues are extremely rare,

accounts only 1% of oral malignancies with a predilection for the

gingiva, tongue and post extraction socket [1]. The breast is the

most common site for tumors that metastasize to the jawbones,

whereas lung is common site for cancers that metastasize to the

oral soft tissues [2]. Most cancers areusually diagnosedat their ini-

tial site, because of thesymptoms that areproducedby theprimary

tumor. Some 10–15% of them, however, present as metastases in

solidorgans, body cavitiesor lymphnodes.Mostof thesesecondary

tumors are adenocarcinomas for which the commonest primarysites are pancreas, hepatobiliary system, and lungs [7]. The most

commonmetastaticmalignancies inwomenarefromprimary can-

cers in the breasts, genital organs, lungs and kidneys and in men

they arefromthelungs,kidneys andprostrate. In25% of such cases,

oral metastases were found to be the first sign of the metastatic

spread. There was almost equal gender distribution in jawbone

metastases anda male to femaleratioof 2:1in oral soft tissues [10].

Possible routes of metastasis to oral cavity are by hematogenous

and lymphaticroutes.Mandible is consideredsusceptibletometas-

tasis because of the presence of red bone marrow, local blood

vessels branching and slowing of blood flow [1,2]. Probable rea-

son formetastases to the headand neckareabypassing the lungs is

byBatson’splexuswhichisa valvelessvertebral venousplexus that

might allow for the retrograde spread of tumor cells [1,4,5,9]. Hir-

shberg also suggested that inflammation plays an important role

in attracting metastatic cells to the gingiva [2]. According to Hir-

shberg in 55 cases, tooth extraction preceded the discovery of the

metastases [1] both of which are correlative to the present case.

A wide range of non specific clinical signs and symptoms may beseen in association with oral metastatic lesions including rapidity

ingrowth,pain,difficulty inchewing, intermittentbleeding,altered

sensation, gumirritation, tooth loosening, exophyticmasses of the

softtissues, trismusandrarely pathologic fracturesultimately lead-

ing to poor quality of life [10]. Radiographic examination is rarely

considered diagnostically importantas the lesionmaynot produce

a radiographicappearance initsinitial stages.Hirshberget al.found

Fig. 4. (A) The strongpositivity in the cytoplasmof tumor cells,which was interpreted as mucin (Periodic acid–Schiff staining); (B) Tumor cells with intracytoplasmic and

luminal positivity forMUC1;Originalmagnification 10×.

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200 S.Majumdar et al. / Journal of Oral andMaxillofacial Surgery, Medicine, andPathology 28 (2016) 197–201

Fig. 5. (A)Tumor cells positivity forCK7; (B)focalpositivity forCK 20;(C) negativity forER; (D)negativity forTTF-1; (E)negativityfor Napsin; (F)positivity forCEA.Original

magnification 10×.

Fig. 6. (A)Ulceroproliferativegrowth of the gastricmucosa; (B) the samehistological features of themetastatic tumor (Hematoxylin and eosin stain, Originalmagnification

10×)

that out of 390 cases, 5.4%cases did not showany important radio-

graphic change [2]. So, early detection of jaw metastasis can be

challengingandthe delay indiagnosismay turn fatal to thepatient.

4. Conclusion

The discovery of an oral metastasis is extremely important for

betterpatient carebyappropriate applicationofadvanceddiagnos-

tictools, startingwithimmunohistochemistrywhichplaysapivotal

role in developing countries as it is cost–effective.

Conflict of interest

No conflict of interest.

References

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