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Metastatic Pancreatic Adenocarcinoma to the Mandibular Condyle: A Rare Clinical Presentation

2013; Elsevier BV; Volume: 72; Issue: 1 Linguagem: Inglês

10.1016/j.joms.2013.06.207

1531-5053

Antonia Kolokythas, Michael Miloro, Alexis B. Olsson, Michael Miloro,

Oral and Maxillofacial Pathology

Metastatic disease to the oral cavity is rare, representing only 1-8% of oral malignancies, and involvement of the mandibular condyle is even less prevalent. In a recent literature review of 796 cases of metastatic disease to the oral cavity, only 39 (13.8%) involved the condyle. This report is a unique case of metastatic pancreatic adenocarcinoma to the condyle. There are only 5 documented cases of metastatic pancreatic adenocarcinoma to the oral cavity, one of which metastasized to the condyle. This is an important case because metastatic lesions to the condyle may mimic temporomandibular joint disorders making clinical diagnosis and decision-making extremely challenging for the oral and maxillofacial surgeon. The requirement for arrival at an appropriate and prompt diagnosis is crucial for determining the most appropriate treatment regimens and improved outcomes. Additionally, in approximately 33% of cases, the oral metastatic lesion may be the first indication of an undiscovered distant primary tumor, making timely evaluation and treatment critical from an oncologic perspective. Metastatic disease to the oral cavity is rare, representing only 1-8% of oral malignancies, and involvement of the mandibular condyle is even less prevalent. In a recent literature review of 796 cases of metastatic disease to the oral cavity, only 39 (13.8%) involved the condyle. This report is a unique case of metastatic pancreatic adenocarcinoma to the condyle. There are only 5 documented cases of metastatic pancreatic adenocarcinoma to the oral cavity, one of which metastasized to the condyle. This is an important case because metastatic lesions to the condyle may mimic temporomandibular joint disorders making clinical diagnosis and decision-making extremely challenging for the oral and maxillofacial surgeon. The requirement for arrival at an appropriate and prompt diagnosis is crucial for determining the most appropriate treatment regimens and improved outcomes. Additionally, in approximately 33% of cases, the oral metastatic lesion may be the first indication of an undiscovered distant primary tumor, making timely evaluation and treatment critical from an oncologic perspective. Metastatic disease to the oral cavity is rare, representing only 1-8% of oral malignancies,1Miles B.A. Schwartz-Dabney C. Sinn D.P. Kessler H.P. Bilateral metastatic breast adenocarcinoma within the temporomandibular joint: A case report.J Oral Maxillofac Surg. 2006; 64: 712Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 2Kruse A.L.D. Luebbers A. Obwegeser J.A. et al.Temporomandibular disorders associated with metastases to the temporomandibular joint: A review of the literature and 3 additional cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e21Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Vahatalo K. Ekfors T. Syrjanen S. Adenocarcinoma of the pancreas metastatic to the mandible.J Oral Maxillofac Surg. 2000; 58: 110Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 4Zachariades N. Neoplasms metastatic to the mouth, jaws, and surrounding tissues.J Craniomaxillofac Surg. 1989; 17: 283Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 5Aniceto G.S. Penin A.G. de la Mata Pages R. Moreno Montalvo J.J. Tumors metastatic to the mandible: Analysis of nine cases and review of the literature.J Oral Maxillofac Surg. 1990; 48: 246Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 6Muttagi S.S. Chaturvedi P. D'Cruz A. et al.Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center.Indian J Cancer. 2011; 48: 234Crossref PubMed Scopus (27) Google Scholar, 7Sari M. Serin G.M. Inali S. Kaya H. Condylar metastasis involving TMJ and TMJ dislocation presenting as the initial manifestation of squamous lung cancer.Oral Oncol Extra. 2006; 42: 224Crossref Scopus (6) Google Scholar, 8Jham B.C. Salama A.R. McClure S.A. Ord R.A. Metastatic tumors to the oral cavity: A clinical study of 18 cases.Head Neck Pathol. 2011; 5: 355Crossref PubMed Scopus (30) Google Scholar, 9Porter S.R. Chaudhry Z. Griffiths M.J. et al.Bilateral metastatic spread of testicular teratoma to the mandibular condyles.Eur J Cancer B Oral Oncol. 1996; 32B: 359Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 10Stypulkowska J. Bartowski S. Panas M. Zaleska M. Metastatic tumors to the jaws and oral cavity.J Oral Surg. 1979; 37: 805PubMed Google Scholar, 11Zachariades N. Koumoura F. Vairaktaris E. Mezitis M. Metastatic tumors to the jaws: A report of seven cases.J Oral Maxillofac Surg. 1989; 47: 991Abstract Full Text PDF PubMed Scopus (26) Google Scholar and involvement of the mandibular condyle is even less prevalent.7Sari M. Serin G.M. Inali S. Kaya H. Condylar metastasis involving TMJ and TMJ dislocation presenting as the initial manifestation of squamous lung cancer.Oral Oncol Extra. 2006; 42: 224Crossref Scopus (6) Google Scholar In a recent literature review of 796 cases of metastatic disease to the oral cavity, only 39 (13.8%) involved the condyle.12Tabib R. Elias S. Tal Y. et al.Temporomandibular joint-related symptoms as initial presentation of lung carcinoma in a patient with Takayasu's arteritis.J Oral Maxillofac Surg. 2011; 69: 226Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar This report presents a unique case of metastatic pancreatic adenocarcinoma to the condyle, and this highlights the importance of accurate diagnosis when the presenting signs and symptoms are misleading or inconclusive. There are only 5 documented cases of metastatic pancreatic adenocarcinoma to the oral cavity, 1 of which metastasized to the condyle.3Vahatalo K. Ekfors T. Syrjanen S. Adenocarcinoma of the pancreas metastatic to the mandible.J Oral Maxillofac Surg. 2000; 58: 110Abstract Full Text PDF PubMed Scopus (12) Google Scholar This is an important case because metastatic lesions to the condyle may mimic temporomandibular joint (TMJ) disorders, making clinical diagnosis and decision making extremely challenging for the oral and maxillofacial surgeon.1Miles B.A. Schwartz-Dabney C. Sinn D.P. Kessler H.P. Bilateral metastatic breast adenocarcinoma within the temporomandibular joint: A case report.J Oral Maxillofac Surg. 2006; 64: 712Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 2Kruse A.L.D. Luebbers A. Obwegeser J.A. et al.Temporomandibular disorders associated with metastases to the temporomandibular joint: A review of the literature and 3 additional cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e21Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 5Aniceto G.S. Penin A.G. de la Mata Pages R. Moreno Montalvo J.J. Tumors metastatic to the mandible: Analysis of nine cases and review of the literature.J Oral Maxillofac Surg. 1990; 48: 246Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 13Johal A.S. Davies S.J. Franklin C.D. Condylar metastasis: A review and case report.Br J Oral Maxillofac Surg. 1994; 32: 180Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 14Adachi P. Kaba S.P. Trierveiler M. Shinohara E. Osteoblastic metastasis from breast affecting the condyle misinterpreted as temporomandibular joint disorder.Indian J Cancer. 2011; 48: 252Crossref PubMed Scopus (8) Google Scholar, 15Shintaku W.H. Venturin J.S. Yepes J.F. Application of advanced imaging modalities for the diagnosis of metastatic adenocarcinoma of the lungs in the temporomandibular joint.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: e37Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 16Glaser C. Lang S. Pruckmayer M. et al.Clinical manifestations and diagnostic approach to metastatic cancer of the mandible.Int J Oral Maxillofac Surg. 1997; 26: 365Abstract Full Text PDF PubMed Scopus (52) Google Scholar The requirement for arrival at an appropriate and prompt diagnosis is crucial for determining the most appropriate treatment regimens and improved outcomes. In addition, in approximately 33% of cases, the oral metastatic lesion may be the first indication of an undiscovered distant primary tumor, making timely evaluation and treatment critical from an oncologic perspective.4Zachariades N. Neoplasms metastatic to the mouth, jaws, and surrounding tissues.J Craniomaxillofac Surg. 1989; 17: 283Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 6Muttagi S.S. Chaturvedi P. D'Cruz A. et al.Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center.Indian J Cancer. 2011; 48: 234Crossref PubMed Scopus (27) Google Scholar, 8Jham B.C. Salama A.R. McClure S.A. Ord R.A. Metastatic tumors to the oral cavity: A clinical study of 18 cases.Head Neck Pathol. 2011; 5: 355Crossref PubMed Scopus (30) Google Scholar, 13Johal A.S. Davies S.J. Franklin C.D. Condylar metastasis: A review and case report.Br J Oral Maxillofac Surg. 1994; 32: 180Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 17Hayes R.L. Pinson T.J. Leffall L.D. Adenocarcinoma of the pancreas metastatic to the mandible.Oral Surg Oral Med Oral Pathol. 1966; 21: 61Abstract Full Text PDF PubMed Scopus (7) Google Scholar, 18Castigliano S.G. Rominger C.J. Metastatic malignancy of the jaws.Am J Surg. 1954; 87: 496Abstract Full Text PDF PubMed Scopus (63) Google Scholar A 66-year-old woman presented to Northwestern Memorial Hospital, Chicago, Illinois, for evaluation of a diagnosis of right mandibular osteomyelitis and a right TMJ abscess. The patient reported right preauricular pain of approximately 3 months' duration, which began after sustaining a crown fracture of a right maxillary molar tooth. After extraction of the remaining tooth roots, the pain in the area of the right maxilla and right preauricular region worsened. The origin of the patient's pain was thought at the time to be related to TMJ dysfunction and potential injury from the extraction procedure, with iatrogenic torsion injury to the right TMJ, and therefore nonsurgical TMJ treatment was offered that included physical therapy and acupuncture, with no improvement. Subsequently, the patient was hospitalized with shortness of breath that was thought to be due to an unrelated episode of pneumonia. The severity of the pain from the right TMJ prompted a computed tomography (CT) scan; this showed a fluid collection around the right joint space. A percutaneous CT-guided aspiration of the right TMJ retrieved 1.5 mL of serosanguineous fluid, and cultures showed no bacterial growth. Empiric antibiotic therapy was initiated, and the patient was transferred to Northwestern Memorial Hospital for evaluation and management. At presentation, the patient's complaints remained the same, with constant, sharp pain over the right TMJ radiating to the right temporal region that had not improved since the aspiration procedure. The medical history was noteworthy for coronary artery disease status post percutaneous transluminal coronary angioplasty, atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, peripheral vascular disease, and end-stage renal disease (ESRD) due to glomerulonephritis, for which the patient required hemodialysis 3 times per week. Her medications included metoprolol 25 mg orally twice daily; atorvastatin 20 mg orally daily; lansoprazole 30 mg orally daily; epoetin alpha 10,000 u subcutaneously after dialysis; and Nephrocaps (Fleming Pharmaceuticals, Fenton, MO). She had no known drug allergies. Her social history was noteworthy for a 100 pack-year smoking history and social ethanol consumption. Her family history was negative for malignancy. On physical examination, the patient was found to be lethargic and in mild distress. She was afebrile, and her vital signs were within normal limits. The head and neck examination showed moderate firm facial edema over the right preauricular region that was tender to palpation. The oropharynx was clear, the tongue and floor of the mouth were not elevated, and the uvula was normal. The area of previous percutaneous aspiration was evident over the right TMJ region (Fig 1). No cervicofacial lymphadenopathy or cranial nerve VII or VIII hypoesthesia was noted. Cranial nerve VII was intact. The findings of the remainder of the extraoral examination were within normal limits. Intraorally, the patient presented with a partial complement of moderately restored teeth in fair repair. There was no vestibular edema, floor-of-the-mouth edema, or tenderness, and the patient's tongue was non-elevated and freely movable. The uvula was in the midline, and the patient's airway was patent. Maximum incisal opening was 1 to 1.5 cm, with guarding present because of pain. No other abnormalities were evident. A laboratory evaluation showed a normal complete blood cell count without leukocytosis, except for mild anemia. The blood urea nitrogen and creatinine levels were elevated. In addition, the serum amylase and carcinoembryonic antigen levels were elevated. Radiographic examination included a panoramic radiograph that showed osteolytic changes of the right condyle, as well as widening of the right joint space suggestive of joint effusion (Fig 2). A CT scan confirmed the osteolytic changes of the right condyle with surrounding reactive periosteal bone growth characterized as an aggressive-appearing sunburst "hair-on-end" periosteal reaction of the right mandibular condyle and ramus, with mild associated lytic destruction. A CT scan showed right preauricular edema as well as bony destruction of the right condylar head, with reactive periosteal proliferation of the condyle and sigmoid notch region (Fig 3).Figure 3A, A soft tissue specimen from the right TMJ showed tumor cells forming glands and containing intracellular mucin (hematoxylin-eosin stain, original magnification ×200). B, A high-power soft tissue specimen from the right TMJ showed tumor cells and intracellular mucin (hematoxylin-eosin stain, original magnification ×400).View Large Image Figure ViewerDownload Hi-res image Download (PPT) On the basis of a working diagnosis of right TMJ abscess, an open biopsy of the right TMJ was performed with the patient under general anesthesia. Upon entrance to the right superior joint space, purulent discharge was encountered; this was submitted for culture and sensitivity testing. Hard and soft tissue specimens were also obtained from the right condylar head and adjacent soft tissues and submitted for culture, sensitivity testing, and histopathologic examination. In addition, acid fast, fungal, aerobic, and anaerobic cultures were submitted and returned as negative, and no organisms were identified on the gram stains. The TMJ biopsy results identified an adenocarcinoma with mucinous features, along with fragments of necrotic bone (Figure 3, Figure 4). A standard series of immunohistochemical stains was performed in an attempt to establish the origin of the primary tumor. Immunostaining performed to rule out metastasis from other sites was negative, including estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2/neu (breast); thyroid transcription factor-1 (lung); and homeobox protein 2 and cytokeratin 20 (colon).19Zhao X.Q. Dong J.H. Zhang W.Z. Liu Z. Prognosis of ampullary cancer based on immunohistochemical type and expression of osteopontin.Diag Pathol. 2011; 98: 1Google Scholar The tumor cells were positive for cytokeratin 7 and 19, confirming the pancreatic metastasis. Digital diagnostic mammography and breast ultrasonography were conducted, with normal findings ruling out a primary breast carcinoma. A CT scan of the chest showed widely metastatic disease, with multiple pulmonary nodules, pretracheal and right subcarinal lymphadenopathy, and an ill-defined soft tissue mass in the splenic hilum and along the pancreatic tail, with surrounding inflammation and fluid collection (Fig 5). A consultation with the gastroenterology and general surgery services, as well as clinical correlation, established a diagnosis of a pancreatobiliary tumor of the tail of the pancreas. Palliative radiotherapy (3,000 cGy in 10 fractions) to the right TMJ was delivered to alleviate the patient's persistent right facial pain. Once adequate pain control was achieved with oral medications, the patient was discharged home, and she died of her disease within a period of 6 months. Metastatic malignancies to the mandibular condyle are rare and diagnostically challenging.9Porter S.R. Chaudhry Z. Griffiths M.J. et al.Bilateral metastatic spread of testicular teratoma to the mandibular condyles.Eur J Cancer B Oral Oncol. 1996; 32B: 359Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 16Glaser C. Lang S. Pruckmayer M. et al.Clinical manifestations and diagnostic approach to metastatic cancer of the mandible.Int J Oral Maxillofac Surg. 1997; 26: 365Abstract Full Text PDF PubMed Scopus (52) Google Scholar They are often indicative of an undiagnosed distant primary tumor, typically widely metastatic at presentation and bearing a poor prognosis.2Kruse A.L.D. Luebbers A. Obwegeser J.A. et al.Temporomandibular disorders associated with metastases to the temporomandibular joint: A review of the literature and 3 additional cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e21Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 6Muttagi S.S. Chaturvedi P. D'Cruz A. et al.Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center.Indian J Cancer. 2011; 48: 234Crossref PubMed Scopus (27) Google Scholar, 7Sari M. Serin G.M. Inali S. Kaya H. Condylar metastasis involving TMJ and TMJ dislocation presenting as the initial manifestation of squamous lung cancer.Oral Oncol Extra. 2006; 42: 224Crossref Scopus (6) Google Scholar, 8Jham B.C. Salama A.R. McClure S.A. Ord R.A. Metastatic tumors to the oral cavity: A clinical study of 18 cases.Head Neck Pathol. 2011; 5: 355Crossref PubMed Scopus (30) Google Scholar, 10Stypulkowska J. Bartowski S. Panas M. Zaleska M. Metastatic tumors to the jaws and oral cavity.J Oral Surg. 1979; 37: 805PubMed Google Scholar, 16Glaser C. Lang S. Pruckmayer M. et al.Clinical manifestations and diagnostic approach to metastatic cancer of the mandible.Int J Oral Maxillofac Surg. 1997; 26: 365Abstract Full Text PDF PubMed Scopus (52) Google Scholar, 17Hayes R.L. Pinson T.J. Leffall L.D. Adenocarcinoma of the pancreas metastatic to the mandible.Oral Surg Oral Med Oral Pathol. 1966; 21: 61Abstract Full Text PDF PubMed Scopus (7) Google Scholar, 18Castigliano S.G. Rominger C.J. Metastatic malignancy of the jaws.Am J Surg. 1954; 87: 496Abstract Full Text PDF PubMed Scopus (63) Google Scholar The mechanism of metastasis is believed to be hematogenous spread because the mandible lacks a lymphatic system.3Vahatalo K. Ekfors T. Syrjanen S. Adenocarcinoma of the pancreas metastatic to the mandible.J Oral Maxillofac Surg. 2000; 58: 110Abstract Full Text PDF PubMed Scopus (12) Google Scholar Consideration has been given to the Batson plexus, which supplies arterial blood in an area extending from the skull to the sacrum and undergoes anastomosis at the circle of Willis with the internal carotid artery.4Zachariades N. Neoplasms metastatic to the mouth, jaws, and surrounding tissues.J Craniomaxillofac Surg. 1989; 17: 283Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 11Zachariades N. Koumoura F. Vairaktaris E. Mezitis M. Metastatic tumors to the jaws: A report of seven cases.J Oral Maxillofac Surg. 1989; 47: 991Abstract Full Text PDF PubMed Scopus (26) Google Scholar Oral metastasis usually occurs between the fourth and seventh decades of life. The mandible is more commonly affected than the maxilla, with the area of the premolars and molars being the most prevalent sites.1Miles B.A. Schwartz-Dabney C. Sinn D.P. Kessler H.P. Bilateral metastatic breast adenocarcinoma within the temporomandibular joint: A case report.J Oral Maxillofac Surg. 2006; 64: 712Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 2Kruse A.L.D. Luebbers A. Obwegeser J.A. et al.Temporomandibular disorders associated with metastases to the temporomandibular joint: A review of the literature and 3 additional cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e21Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Vahatalo K. Ekfors T. Syrjanen S. Adenocarcinoma of the pancreas metastatic to the mandible.J Oral Maxillofac Surg. 2000; 58: 110Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 4Zachariades N. Neoplasms metastatic to the mouth, jaws, and surrounding tissues.J Craniomaxillofac Surg. 1989; 17: 283Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 5Aniceto G.S. Penin A.G. de la Mata Pages R. Moreno Montalvo J.J. Tumors metastatic to the mandible: Analysis of nine cases and review of the literature.J Oral Maxillofac Surg. 1990; 48: 246Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 6Muttagi S.S. Chaturvedi P. D'Cruz A. et al.Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center.Indian J Cancer. 2011; 48: 234Crossref PubMed Scopus (27) Google Scholar, 8Jham B.C. Salama A.R. McClure S.A. Ord R.A. Metastatic tumors to the oral cavity: A clinical study of 18 cases.Head Neck Pathol. 2011; 5: 355Crossref PubMed Scopus (30) Google Scholar, 9Porter S.R. Chaudhry Z. Griffiths M.J. et al.Bilateral metastatic spread of testicular teratoma to the mandibular condyles.Eur J Cancer B Oral Oncol. 1996; 32B: 359Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 13Johal A.S. Davies S.J. Franklin C.D. Condylar metastasis: A review and case report.Br J Oral Maxillofac Surg. 1994; 32: 180Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 20D'Silva N.J. Summerlin D.J. Cordell K.G. et al.Metastatic tumors in the jaws: A retrospective study of 114 cases.J Am Dent Assoc. 2006; 137: 1667PubMed Google Scholar, 21Rubin M.M. Jui V. Cozzi G.M. Metastatic carcinoma of the mandibular condyle presenting as temporomandibular joint syndrome.J Oral Maxillofac Surg. 1989; 47: 507Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 22Linkous C.M. Welch J.T. Metastatic malignant tumors of the jaws.Oral Surg Oral Med Oral Pathol. 1974; 48: 703Abstract Full Text PDF Scopus (10) Google Scholar Metastases to the condyle are infrequent because of the limited local blood supply, the lack of substantial hematopoietic marrow, and the presence of an osseous plate that limits spread of malignancy into the marrow space of the condyle.2Kruse A.L.D. Luebbers A. Obwegeser J.A. et al.Temporomandibular disorders associated with metastases to the temporomandibular joint: A review of the literature and 3 additional cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e21Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Vahatalo K. Ekfors T. Syrjanen S. Adenocarcinoma of the pancreas metastatic to the mandible.J Oral Maxillofac Surg. 2000; 58: 110Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 4Zachariades N. Neoplasms metastatic to the mouth, jaws, and surrounding tissues.J Craniomaxillofac Surg. 1989; 17: 283Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 5Aniceto G.S. Penin A.G. de la Mata Pages R. Moreno Montalvo J.J. Tumors metastatic to the mandible: Analysis of nine cases and review of the literature.J Oral Maxillofac Surg. 1990; 48: 246Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 7Sari M. Serin G.M. Inali S. Kaya H. Condylar metastasis involving TMJ and TMJ dislocation presenting as the initial manifestation of squamous lung cancer.Oral Oncol Extra. 2006; 42: 224Crossref Scopus (6) Google Scholar, 9Porter S.R. Chaudhry Z. Griffiths M.J. et al.Bilateral metastatic spread of testicular teratoma to the mandibular condyles.Eur J Cancer B Oral Oncol. 1996; 32B: 359Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 11Zachariades N. Koumoura F. Vairaktaris E. Mezitis M. Metastatic tumors to the jaws: A report of seven cases.J Oral Maxillofac Surg. 1989; 47: 991Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 13Johal A.S. Davies S.J. Franklin C.D. Condylar metastasis: A review and case report.Br J Oral Maxillofac Surg. 1994; 32: 180Abstract Full Text PDF PubMed Scopus (18) Google Scholar Diagnosis is challenging because there is no pathognomonic radiographic appearance for mandibular metastases, although radiolucency is common.1Miles B.A. Schwartz-Dabney C. Sinn D.P. Kessler H.P. Bilateral metastatic breast adenocarcinoma within the temporomandibular joint: A case report.J Oral Maxillofac Surg. 2006; 64: 712Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 5Aniceto G.S. Penin A.G. de la Mata Pages R. Moreno Montalvo J.J. Tumors metastatic to the mandible: Analysis of nine cases and review of the literature.J Oral Maxillofac Surg. 1990; 48: 246Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 11Zachariades N. Koumoura F. Vairaktaris E. Mezitis M. Metastatic tumors to the jaws: A report of seven cases.J Oral Maxillofac Surg. 1989; 47: 991Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 14Adachi P. Kaba S.P. Trierveiler M. Shinohara E. Osteoblastic metastasis from breast affecting the condyle misinterpreted as temporomandibular joint disorder.Indian J Cancer. 2011; 48: 252Crossref PubMed Scopus (8) Google Scholar, 20D'Silva N.J. Summerlin D.J. Cordell K.G. et al.Metastatic tumors in the jaws: A retrospective study of 114 cases.J Am Dent Assoc. 2006; 137: 1667PubMed Google Scholar Clinical symptoms are usually nonspecific, mimicking odontogenic infections or TMJ disorders.2Kruse A.L.D. Luebbers A. Obwegeser J.A. et al.Temporomandibular disorders associated with metastases to the temporomandibular joint: A review of the literature and 3 additional cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e21Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 8Jham B.C. Salama A.R. McClure S.A. Ord R.A. Metastatic tumors to the oral cavity: A clinical study of 18 cases.Head Neck Pathol. 2011; 5: 355Crossref PubMed Scopus (30) Google Scholar, 10Stypulkowska J. Bartowski S. Panas M. Zaleska M. Metastatic tumors to the jaws and oral cavity.J Oral Surg. 1979; 37: 805PubMed Google Scholar, 15Shintaku W.H. Venturin J.S. Yepes J.F. Application of advanced imaging modalities for the diagnosis of metastatic adenocarcinoma of the lungs in the temporomandibular joint.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: e37Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 16Glaser C. Lang S. Pruckmayer M. et al.Clinical manifestations and diagnostic approach to metastatic cancer of the mandible.Int J Oral Maxillofac Surg. 1997; 26: 365Abstract Full Text PDF PubMed Scopus (52) Google Scholar, 20D'Silva N.J. Summerlin D.J. Cordell K.G. et al.Metastatic tumors in the jaws: A retrospective study of 114 cases.J Am Dent Assoc. 2006; 137: 1667PubMed Google Scholar, 23Cash C.D. Royer R.Q. Dahlin D.C. Metastatic tumors of the jaws.Oral Surg Oral Med Oral Pathol. 1961; 14: 897Abstract Full Text PDF PubMed Scopus (68) Google Scholar Approximately 50% of reported cases of metastatic lesions involving the condyle present with symptoms similar to TMJ disorders, thereby delaying diagnosis and appropriate treatment.13Johal A.S. Davies S.J. Franklin C.D. Condylar metastasis: A review and case report.Br J Oral Maxillofac Surg. 1994; 32: 180Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 14Adachi P. Kaba S.P. Trierveiler M. Shinohara E. Osteoblastic metastasis from breast affecting the condyle misinterpreted as temporomandibular joint disorder.Indian J Cancer. 2011; 48: 252Crossref PubMed Scopus (8) Google Scholar, 15Shintaku W.H. Venturin J.S. Yepes J.F. Application of advanced imaging modalities for the diagnosis of metastatic adenocarcinoma of the lungs in the temporomandibular joint.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: e37Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 21Rubin M.M. Jui V. Cozzi G.M. Metastatic carcinoma of the mandibular condyle presenting as temporomandibular joint syndrome.J Oral Maxillofac Surg. 1989; 47: 507Abstract Full Text PDF PubMed Scopus (27) Google Scholar Detailed radiographic investigation is warranted, and the differential diagnosis should include the possibility of a metastatic lesion.9Porter S.R. Chaudhry Z. Griffiths M.J. et al.Bilateral metastatic spread of testicular teratoma to the mandibular condyles.Eur J Cancer B Oral Oncol. 1996; 32B: 359Abstract Full Text PDF PubMed Scopus (15) Google Scholar Commonly reported signs and symptoms include pain, paresthesia, malocclusion, pathologic fracture, swelling, trismus, and TMJ discomfort. However, in many cases the lesion may be asymptomatic.2Kruse A.L.D. Luebbers A. Obwegeser J.A. et al.Temporomandibular disorders associated with metastases to the temporomandibular joint: A review of the literature and 3 additional cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e21Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 4Zachariades N. Neoplasms metastatic to the mouth, jaws, and surrounding tissues.J Craniomaxillofac Surg. 1989; 17: 283Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 8Jham B.C. Salama A.R. McClure S.A. Ord R.A. Metastatic tumors to the oral cavity: A clinical study of 18 cases.Head Neck Pathol. 2011; 5: 355Crossref PubMed Scopus (30) Google Scholar, 11Zachariades N. Koumoura F. Vairaktaris E. Mezitis M. Metastatic tumors to the jaws: A report of seven cases.J Oral Maxillofac Surg. 1989; 47: 991Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 13Johal A.S. Davies S.J. Franklin C.D. Condylar metastasis: A review and case report.Br J Oral Maxillofac Surg. 1994; 32: 180Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 21Rubin M.M. Jui V. Cozzi G.M. Metastatic carcinoma of the mandibular condyle presenting as temporomandibular joint syndrome.J Oral Maxillofac Surg. 1989; 47: 507Abstract Full Text PDF PubMed Scopus (27) Google Scholar Carcinomas that commonly metastasize to the oral cavity include breast, prostate, kidney, lung, thyroid, and gastrointestinal malignancies.1Miles B.A. Schwartz-Dabney C. Sinn D.P. Kessler H.P. Bilateral metastatic breast adenocarcinoma within the temporomandibular joint: A case report.J Oral Maxillofac Surg. 2006; 64: 712Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 4Zachariades N. Neoplasms metastatic to the mouth, jaws, and surrounding tissues.J Craniomaxillofac Surg. 1989; 17: 283Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 5Aniceto G.S. Penin A.G. de la Mata Pages R. Moreno Montalvo J.J. Tumors metastatic to the mandible: Analysis of nine cases and review of the literature.J Oral Maxillofac Surg. 1990; 48: 246Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 6Muttagi S.S. Chaturvedi P. D'Cruz A. et al.Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center.Indian J Cancer. 2011; 48: 234Crossref PubMed Scopus (27) Google Scholar, 7Sari M. Serin G.M. Inali S. Kaya H. 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In this unique case the patient's primary tumor was located in the tail of the pancreas. These tumors are often asymptomatic and tend to be metastatic at the time of diagnosis.17Hayes R.L. Pinson T.J. Leffall L.D. Adenocarcinoma of the pancreas metastatic to the mandible.Oral Surg Oral Med Oral Pathol. 1966; 21: 61Abstract Full Text PDF PubMed Scopus (7) Google Scholar In this case oral metastasis was the first indication of a pancreatic primary with widely metastatic disease. Delayed diagnosis and misdirected treatment modalities often prolong the time from initial presentation to diagnosis of metastatic disease.23Cash C.D. Royer R.Q. Dahlin D.C. Metastatic tumors of the jaws.Oral Surg Oral Med Oral Pathol. 1961; 14: 897Abstract Full Text PDF PubMed Scopus (68) Google Scholar An accurate history of the present illness, medical history, family history, review of systems, complete physical examination, and adequate laboratory studies and tissue biopsy facilitate proper and prompt diagnosis.6Muttagi S.S. Chaturvedi P. D'Cruz A. et al.Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center.Indian J Cancer. 2011; 48: 234Crossref PubMed Scopus (27) Google Scholar, 18Castigliano S.G. Rominger C.J. Metastatic malignancy of the jaws.Am J Surg. 1954; 87: 496Abstract Full Text PDF PubMed Scopus (63) Google Scholar Our patient's medical history included a history of smoking and type 2 diabetes, which are both risk factors for pancreatic cancer.3Vahatalo K. Ekfors T. Syrjanen S. Adenocarcinoma of the pancreas metastatic to the mandible.J Oral Maxillofac Surg. 2000; 58: 110Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 25Duell E.J. Epidemiology and potential mechanisms of tobacco smoking and heavy alcohol consumption in pancreatic cancer.Mol Carcinog. 2012; 51: 40Crossref PubMed Scopus (80) Google Scholar, 26Li D. Diabetes and pancreatic cancer.Mol Carcinog. 2012; 51: 64Crossref PubMed Scopus (203) Google Scholar, 27Chen N. Unnikrishnan R.I. Anjana R.M. et al.The complex exocrine-endocrine relationship and secondary diabetes in exocrine pancreatic disorders.J Clin Gastroenterol. 2011; 45: 850Crossref PubMed Scopus (34) Google Scholar In addition, although not pathognomonic for pancreatic cancer, the serum amylase and carcinoembryonic antigen levels were elevated; moreover, measurement of the carbohydrate antigen (CA) 19-9 level could have been obtained, but it is also elevated in other disorders of the biliary tract. Metastatic lesions should always be included in the differential diagnosis to prevent delay in diagnosis and treatment.21Rubin M.M. Jui V. Cozzi G.M. Metastatic carcinoma of the mandibular condyle presenting as temporomandibular joint syndrome.J Oral Maxillofac Surg. 1989; 47: 507Abstract Full Text PDF PubMed Scopus (27) Google Scholar Typical treatment modalities include palliative radiotherapy and chemotherapy.5Aniceto G.S. Penin A.G. de la Mata Pages R. Moreno Montalvo J.J. Tumors metastatic to the mandible: Analysis of nine cases and review of the literature.J Oral Maxillofac Surg. 1990; 48: 246Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 7Sari M. Serin G.M. Inali S. Kaya H. Condylar metastasis involving TMJ and TMJ dislocation presenting as the initial manifestation of squamous lung cancer.Oral Oncol Extra. 2006; 42: 224Crossref Scopus (6) Google Scholar, 11Zachariades N. Koumoura F. Vairaktaris E. Mezitis M. Metastatic tumors to the jaws: A report of seven cases.J Oral Maxillofac Surg. 1989; 47: 991Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 22Linkous C.M. Welch J.T. Metastatic malignant tumors of the jaws.Oral Surg Oral Med Oral Pathol. 1974; 48: 703Abstract Full Text PDF Scopus (10) Google Scholar The goals of treatment are pain relief and the prevention of secondary infections, pathologic fracture, hemorrhage, and malnutrition.10Stypulkowska J. Bartowski S. Panas M. Zaleska M. Metastatic tumors to the jaws and oral cavity.J Oral Surg. 1979; 37: 805PubMed Google Scholar, 18Castigliano S.G. Rominger C.J. Metastatic malignancy of the jaws.Am J Surg. 1954; 87: 496Abstract Full Text PDF PubMed Scopus (63) Google Scholar, 21Rubin M.M. Jui V. Cozzi G.M. Metastatic carcinoma of the mandibular condyle presenting as temporomandibular joint syndrome.J Oral Maxillofac Surg. 1989; 47: 507Abstract Full Text PDF PubMed Scopus (27) Google Scholar Unfortunately, as in this case, the prognosis for metastatic disease remains dismal.