Int J Gynecol Obsret, 1991, 35: 79-82 international Federation of Gynecology
79 and Obstetrics
Oral cavity metastasis from carcinoma N.G.P.
Davidsona
Departments
of the cervix
and C. Moyob
of'Radiotherapyand ‘Gynaecology,
Poole General Hospital. Poole. Dorset (UK)
(Received September 2lst, 1989) (Revised and accepted February 5th, 1990)
Abstract
A case report of a patient with carcinoma of the cervix with metastasis to the oral cavity clinically mimicking a primary oral cavity neoplasm is described. The patient presented one year after completing radiotherapy followed by radical hysterectomy and pelvic lymphadenectomy for carcinoma of the cervix. Excellent palliation was produced with radiotherapy. We are not aware of any reported case of oral cavity metastasis from carcinoma of the cervix. Keywords: Oral cavity; Metastasis; Carcinoma
of the cervix. Introduction
Carcinoma of the cervix is the fourth most common malignant neoplasm in women. It spreads mainly by direct extension and via the lymphatics. Many patients who have later stage disease do not have hematogenous metastasis. However, if hematogenous pathways are altered by surgery and/or irradiation, hematogenous spread could occur. In this paper, a case of oral cavity metastasis from squamous carcinoma of the cervix is described. Case report
In November 1984, a 44-year-old woman presented with a 3-month history of irregular inter-menstrual bleeding. A cervical smear show-
Case Report
0020-7292/91/%03.50 @ 1991 International Federation Published and Printed in Ireland
ed malignant cells. An examination under anesthesia revealed tumor replacing the cervix and extending into the anterior fomix and right parametrium FIG0 stage IIb. Cystoscopy was normal. A cervical biopsy showed invasive squamous carcinoma of the cervix. Urea and electrolytes were normal. Chest X-ray was clear. Intravenous urogram showed prompt excretion with no evidence of obstructive uropathy. Lymphangiogram was within normal limits. Intracavitary cesium insertion was attempted, but failed as the cervical OScould not be identified. She was commenced on a course of external beam irradiation to the pelvis, and received a total tumor dose of 45 Gy in 25 fractions over 38 days on a 5 MeV linear accelerator. Six weeks later she underwent a radical hysterectomy and pelvic lymphadenectomy and made an uneventful recovery. Para-aortic nodes were not sampled. Histology of the specimen showed necrosis of the cervix with no residual tumor. Nine lymph nodes removed were all clear. She attended follow up clinic regularly and remained asymptomatic. Full blood count, urea and electrolytes, chest X-ray, CT scan of the abdomen and pelvis done at regular intervals were normal. In December 1985, she was referred to the oral surgery department with an ulcerating lesion in the oral cavity. Examination of the mouth revealed a large ulcerating lesion involving the anterior gingiva of the upper jaw (Fig. 1). X-ray of the maxilla did not show any abnormality of the bone. General examination revealed the presence of four cutaneous nodules
of Gynecology
and Obstetrics
80
Davidson and Mayo
Fig. 1. Proliferating
metastatic
lesion in the upper gingiva
on the scalp, and a further nodule on the anterior abdominal wall. Biopsy of the oral cavity and scalp lesions were done. Histology revealed metastatic squamous carcinoma similar to the original cervical primary. The oral metastasis was treated with a course of external beam irradiation. A palliative total tumor dose of 30 Gy in 10 fractions was given on a Cobalt-60 machine. Good local control was achieved, and the metastasis regressed completely (Fig. 2). She was commenced on combination chemotherapy with vincristine, bleomycin and methotrexate to control her systemic disease, but her disease progressed rapidly and she died in June 1986. A request for a postmortem was declined. Inr J Gynecol Ohsrrt 35
Discussion The commonest sites of recurrent cervical disease are the pelvis and abdomen [14]. Less common sites include bone [l] and lungs [IO]. Rarely metastases have been found in skin [5], small intestine [I 11, thyroid [13], brain [6], kidney [2], umbilicus [4], scalp [12], ovary [3], labia [2] and eye 191.Oral cavity is occasionally the site for distant metastases from primary malignant neoplasm. Most metastases involve the soft tissue of the oral cavity secondarily, spreading from an initial deposit in the underlying bone, but primary oral soft tissue metastases do occur [8]. The most common sites for primary lesions metastasing to the oral cavity
Oral cavity metastasis from carcinoma of the cervix
Fig. 2.
8
Complete regression of the lesion following radiotherapy.
soft tissues are lung, kidney, stomach and liver [7]. On rare occasions, tumors from other sites have metastasized to the oral cavity soft tissues, but we are not aware of any reported case of oral cavity metastasis from carcinoma of the cervix. Carlson et al. [2], reviewed 2200 patients treated for carcinoma of the cervix, and found that the frequency of distant metastases was low for early cervical lesions, but it increased significantly as the clinical stage of the disease became more advanced. They also found that most distant metastases occurred within 1 year of initial treatment. The prognosis of patients with distant metastasis was very poor. Metastatic tumors of the oral cavity could easily be misdiagnosed, as they may mimic a dental
pathology such as gingivitis, periodontal abscess pyogenic granuloma or a primary tumor of the oral cavity. A good history and biopsy is necessary to establish the diagnosis. Palliative treatment aimed at controlling oral cavity metastasis is needed to relieve distressing symptoms and improve the quality of life. A short course of external beam radiotherapy could give excellent palliation. References Barmeir E. Langer 0, Levy JI, Nissenbaum M, DeMoor NG, Blumenthal NJ: Unusual skeletal metastases in carcinoma of the cervix. Gynaecol Oncol 20: 307, 1985. Carlson V. Delclos L, Fletcher GH: Distant metastases in squamous cell carcinoma of the uterine cervix. Radiology 88: 961. 1967. Case Report
x2
3
4
5
6
7
8
9
IO
Davidson and Mo),o
Cassidy LJ. Kennedy JH: Ovarian metastasis from stage Ib squamous carcinoma of the cervix. Case report. Br J Obstet Gynaecol 93: 1169, 1986. Daw E and Riley S: Umbilical metastasis from squamous
Mathur SK, Pandya GP Solitary metastatic malignant stricture of the ileum. A rare cause of small bowel obstruction. A case report. J Postgrad Med 30: 186, 1984. Shimizu I, Hayashi S, Uehara M, Nakayama S: Cutaneous
carcinoma of the cervix. Case report. Br J Obstet Gynaecol 89: 1982. Freeman CR, Rosenfield M, Schopflocher P: Cutaneous metastases from carcinoma of the cervix. Arch Dermatol
metastases to the scalp from carcinoma of the uterine cervix. Arch Dennatol 119: 275, 1983. Toongsuwan S, Vardthananusara C, Charoenpanich P. Suvonnakote, Damrogvadha P: Thyroid metastases from
118. 40, 1982. Friedman M, Nissenbaum M, Lakier R, Browde S: Brain metastases in early cancer of the uterine cervix. S Afr Med J 64: 498. 1983.
primary carcinoma of the cervix. J Med Ass Thailand 65. 618, 1982. Webb JM, Symmonds RE: Site of recurrence of cervical cancer after radical hysterectomy. Am J Obstet Gynaecol
Hatziotis JC, Constantinidou H, Papanayotou PH: Metastatic tumours of the oral soft tissue. Oral Surg 36. 544. 1973. Henk JM, Lnagdon JD: Malignant tumours of the oral cavi-
138: 813, 1980.
ty. In: Management of Malignant Disease, p 211. Edward Arnold, London, 1985. Hertzanu Y. Vellet AD, Fain BA, Ferreira MMV, Ninin DT: Eye metastases in carcinoma of the cervix. A case report. S Afr Med J 7I: 53, 1987. Imachi M. Tsukamoto N, Matsuyama T, Nakano H: Pulmonary metastasis from carcinoma of the uterine cervix. Gynaecol Oncol 33: 189, 1989.
Int J Gynecol Obstet 35
Address for reprints: N.G.P. Davidson Department of Radiotherapy and Oncology Leicester Royal Infirmary Infirmary Square Leicester LEl JWW, UK
79 and Obstetrics
Oral cavity metastasis from carcinoma N.G.P.
Davidsona
Departments
of the cervix
and C. Moyob
of'Radiotherapyand ‘Gynaecology,
Poole General Hospital. Poole. Dorset (UK)
(Received September 2lst, 1989) (Revised and accepted February 5th, 1990)
Abstract
A case report of a patient with carcinoma of the cervix with metastasis to the oral cavity clinically mimicking a primary oral cavity neoplasm is described. The patient presented one year after completing radiotherapy followed by radical hysterectomy and pelvic lymphadenectomy for carcinoma of the cervix. Excellent palliation was produced with radiotherapy. We are not aware of any reported case of oral cavity metastasis from carcinoma of the cervix. Keywords: Oral cavity; Metastasis; Carcinoma
of the cervix. Introduction
Carcinoma of the cervix is the fourth most common malignant neoplasm in women. It spreads mainly by direct extension and via the lymphatics. Many patients who have later stage disease do not have hematogenous metastasis. However, if hematogenous pathways are altered by surgery and/or irradiation, hematogenous spread could occur. In this paper, a case of oral cavity metastasis from squamous carcinoma of the cervix is described. Case report
In November 1984, a 44-year-old woman presented with a 3-month history of irregular inter-menstrual bleeding. A cervical smear show-
Case Report
0020-7292/91/%03.50 @ 1991 International Federation Published and Printed in Ireland
ed malignant cells. An examination under anesthesia revealed tumor replacing the cervix and extending into the anterior fomix and right parametrium FIG0 stage IIb. Cystoscopy was normal. A cervical biopsy showed invasive squamous carcinoma of the cervix. Urea and electrolytes were normal. Chest X-ray was clear. Intravenous urogram showed prompt excretion with no evidence of obstructive uropathy. Lymphangiogram was within normal limits. Intracavitary cesium insertion was attempted, but failed as the cervical OScould not be identified. She was commenced on a course of external beam irradiation to the pelvis, and received a total tumor dose of 45 Gy in 25 fractions over 38 days on a 5 MeV linear accelerator. Six weeks later she underwent a radical hysterectomy and pelvic lymphadenectomy and made an uneventful recovery. Para-aortic nodes were not sampled. Histology of the specimen showed necrosis of the cervix with no residual tumor. Nine lymph nodes removed were all clear. She attended follow up clinic regularly and remained asymptomatic. Full blood count, urea and electrolytes, chest X-ray, CT scan of the abdomen and pelvis done at regular intervals were normal. In December 1985, she was referred to the oral surgery department with an ulcerating lesion in the oral cavity. Examination of the mouth revealed a large ulcerating lesion involving the anterior gingiva of the upper jaw (Fig. 1). X-ray of the maxilla did not show any abnormality of the bone. General examination revealed the presence of four cutaneous nodules
of Gynecology
and Obstetrics
80
Davidson and Mayo
Fig. 1. Proliferating
metastatic
lesion in the upper gingiva
on the scalp, and a further nodule on the anterior abdominal wall. Biopsy of the oral cavity and scalp lesions were done. Histology revealed metastatic squamous carcinoma similar to the original cervical primary. The oral metastasis was treated with a course of external beam irradiation. A palliative total tumor dose of 30 Gy in 10 fractions was given on a Cobalt-60 machine. Good local control was achieved, and the metastasis regressed completely (Fig. 2). She was commenced on combination chemotherapy with vincristine, bleomycin and methotrexate to control her systemic disease, but her disease progressed rapidly and she died in June 1986. A request for a postmortem was declined. Inr J Gynecol Ohsrrt 35
Discussion The commonest sites of recurrent cervical disease are the pelvis and abdomen [14]. Less common sites include bone [l] and lungs [IO]. Rarely metastases have been found in skin [5], small intestine [I 11, thyroid [13], brain [6], kidney [2], umbilicus [4], scalp [12], ovary [3], labia [2] and eye 191.Oral cavity is occasionally the site for distant metastases from primary malignant neoplasm. Most metastases involve the soft tissue of the oral cavity secondarily, spreading from an initial deposit in the underlying bone, but primary oral soft tissue metastases do occur [8]. The most common sites for primary lesions metastasing to the oral cavity
Oral cavity metastasis from carcinoma of the cervix
Fig. 2.
8
Complete regression of the lesion following radiotherapy.
soft tissues are lung, kidney, stomach and liver [7]. On rare occasions, tumors from other sites have metastasized to the oral cavity soft tissues, but we are not aware of any reported case of oral cavity metastasis from carcinoma of the cervix. Carlson et al. [2], reviewed 2200 patients treated for carcinoma of the cervix, and found that the frequency of distant metastases was low for early cervical lesions, but it increased significantly as the clinical stage of the disease became more advanced. They also found that most distant metastases occurred within 1 year of initial treatment. The prognosis of patients with distant metastasis was very poor. Metastatic tumors of the oral cavity could easily be misdiagnosed, as they may mimic a dental
pathology such as gingivitis, periodontal abscess pyogenic granuloma or a primary tumor of the oral cavity. A good history and biopsy is necessary to establish the diagnosis. Palliative treatment aimed at controlling oral cavity metastasis is needed to relieve distressing symptoms and improve the quality of life. A short course of external beam radiotherapy could give excellent palliation. References Barmeir E. Langer 0, Levy JI, Nissenbaum M, DeMoor NG, Blumenthal NJ: Unusual skeletal metastases in carcinoma of the cervix. Gynaecol Oncol 20: 307, 1985. Carlson V. Delclos L, Fletcher GH: Distant metastases in squamous cell carcinoma of the uterine cervix. Radiology 88: 961. 1967. Case Report
x2
3
4
5
6
7
8
9
IO
Davidson and Mo),o
Cassidy LJ. Kennedy JH: Ovarian metastasis from stage Ib squamous carcinoma of the cervix. Case report. Br J Obstet Gynaecol 93: 1169, 1986. Daw E and Riley S: Umbilical metastasis from squamous
Mathur SK, Pandya GP Solitary metastatic malignant stricture of the ileum. A rare cause of small bowel obstruction. A case report. J Postgrad Med 30: 186, 1984. Shimizu I, Hayashi S, Uehara M, Nakayama S: Cutaneous
carcinoma of the cervix. Case report. Br J Obstet Gynaecol 89: 1982. Freeman CR, Rosenfield M, Schopflocher P: Cutaneous metastases from carcinoma of the cervix. Arch Dermatol
metastases to the scalp from carcinoma of the uterine cervix. Arch Dennatol 119: 275, 1983. Toongsuwan S, Vardthananusara C, Charoenpanich P. Suvonnakote, Damrogvadha P: Thyroid metastases from
118. 40, 1982. Friedman M, Nissenbaum M, Lakier R, Browde S: Brain metastases in early cancer of the uterine cervix. S Afr Med J 64: 498. 1983.
primary carcinoma of the cervix. J Med Ass Thailand 65. 618, 1982. Webb JM, Symmonds RE: Site of recurrence of cervical cancer after radical hysterectomy. Am J Obstet Gynaecol
Hatziotis JC, Constantinidou H, Papanayotou PH: Metastatic tumours of the oral soft tissue. Oral Surg 36. 544. 1973. Henk JM, Lnagdon JD: Malignant tumours of the oral cavi-
138: 813, 1980.
ty. In: Management of Malignant Disease, p 211. Edward Arnold, London, 1985. Hertzanu Y. Vellet AD, Fain BA, Ferreira MMV, Ninin DT: Eye metastases in carcinoma of the cervix. A case report. S Afr Med J 7I: 53, 1987. Imachi M. Tsukamoto N, Matsuyama T, Nakano H: Pulmonary metastasis from carcinoma of the uterine cervix. Gynaecol Oncol 33: 189, 1989.
Int J Gynecol Obstet 35
Address for reprints: N.G.P. Davidson Department of Radiotherapy and Oncology Leicester Royal Infirmary Infirmary Square Leicester LEl JWW, UK
