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images occur because of the air trapped between the synthetic fibers. The spongy quality can be persistent, observable even after 6 months.6,7 Ultrasonography is also a useful method for diagnosis; a surgical sponge causes strong posterior ghosting and has an irregular hyperechoic center surrounded by a hypoechoic mass.10 If the gauze contains iodoform or a radiopaque filament, a gossypiboma diagnosis can be more easily determined. Radiopaque gauze tissues are not best displayed with magnetic resonance imaging.11 The definitive diagnosis can be confirmed by histopathologic examination of removed pathological tissue. Two types of foreign object reactions pathologically occur. The most common reaction is the exudative type that leads to abscess formation. More rarely, an aseptic fibrous response has been observed that leads to granuloma formation and results in adhesion or encapsulation.12 Surgery should be planned as soon as possible after diagnosis. In the literature, the mortality rate for cases of gossypiboma is reported as 10% to 17.6% and is associated with delayed diagnosis and treatment.13 In the present case, the patient underwent the original surgery, during which the sponge was forgotten, at another center with a prediagnosis of thyroglossal duct cyst. Pathology results indicated thyroid papillary carcinoma. Therefore, the patient underwent total thyroidectomy surgery at the same center. Likely, the specimen reported as papillary carcinoma after the first surgery belonged to the thyroid pyramidal lobe and was not, in actuality, a thyroglossal duct cyst or other mass. We hypothesize that, because of extensive bleeding from perfusion of the thyroid during the first surgery, it was necessary to control bleeding for an unexpectedly long period, and the sponge was left in the field at this time. Thus, the uncontrolled excessive bleeding in the neck was not observed in the neck area, but only in the thyroid and great vessels within the neck. Another difference between abdominal surgeries, during which sponges are most commonly forgotten, and head and neck surgeries is that the head and neck surgical area is small and more superficial compared with the abdominal area. During neck surgery, with an adequate field of vision of the anatomy, this problem does not occur often if all necessary materials are counted and given the requisite level of attention. For these reasons, head and neck surgeries are rare operations that have complication of forgetting a sponge. The present case, to our knowledge, is the first in the literature. Surgeons should pay special attention to forgotten surgical textile materials and tools because of the associated risks of medicolegal problems and of unnecessary invasive diagnostic tests and therapies. Forgotten surgical textiles can cause misinterpretations, falsely suggesting recurrence after tumor surgeries or various postoperative complications. Therefore, once during the operation and twice after surgery, the number of surgical sponges should be confirmed.2 The risk factors for forgotten gauze packs during surgery are the use of sponges to prevent bleeding for long periods, transitioning to using temporary tampon instead of providing hemostasis immediately, and placing sponges divided into smaller pieces.

SUMMARY In conclusion, forgetting a sponge during surgery is difficult medicolegally for a surgeon to explain to a patient, as doctors are increasingly blamed for any complications. Informing patients of risks before operations and receiving signed consent forms are important steps to avoid medicolegal problems. Consent forms must include postoperative infections and clarify that postoperative improvement may be delayed. The present case also shows that controlling all materials used during surgery after surgery is basic but necessary.

Correspondence

Fulya Ozer, MD Isilay Oz, MD Cem Ozer, MD Department of Otorhinolaryngology Head and Neck Surgery Baskent University Faculty of Medicine Ankara, Turkey [email protected]

REFERENCES 1. Akbulut S, Arikanoglu Z, Yagmur Y, et al. Gossypibomas mimicking a splenic hydatid cyst and ileal tumor: a case report and literature review [published online ahead of print]. 2011 2. Dux M, Ganten M, Lubienski A, et al. Retained surgical sponge with migration into the doudenum and persistent doudenal fistula. Eur Radiol 2002;12:74Y77 3. Ozer C, Ozer F, Sener M, et al. A forgotten gauze pack in the nasopharynx: an unfortunate complication of adenoidectomy. Am J Otolaryngol 2007;28:191Y193 4. Amr AE. Submandibular gossypiboma mimicking a salivary fistula: a case report. Cases J 2009;2:6413 5. Pons Y, Schouman T. Maxillary sinus textiloma: a case report. J Med Case Report 2010;4:288 6. Sigron GR, Locher MC. A gossypiboma (foreign body granuloma) mimicking a residual odontogenic cyst in the mandible: a case report. J Med Case Rep 2011;5:211 7. Song SY, Hong JW, Yoo WM, et al. Gossypiboma after mandibular contouring surgery. J Craniofac Surg 2009;20:1607Y1610 8. Kaiser CW, Friedman S, Spurling KP, et al. The retained surgical sponge. Ann Surg 1996;224:79Y84 9. Yildirim S, Tarim A, Nursal TZ, et al. Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center, Langenbecks Arch. Surg 2006;391:390Y395 10. Cevik I, Dillioglugil O, Ozveri H, et al. Asymptomatic retained surgical gauze towel diagnosed 32 years after nephrectomy. Int Urol Nephrol 2008;40:885Y888 11. Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained surgical sponges (gossypiboma). Asian J Surg 2005;28:109Y115 12. Jham BC, Nikitakis NG, Scheper MA, et al. Granulomatous foreign-body reaction involving oral and perioral tissues after injection of biomaterials: a series of 7 cases and review of the literature. J Oral Maxillofac Surg 2009;67:280Y285 13. Zantvoord Y, van der Weiden RM, van Hooff MH. Transmural migration of retained surgical sponges: a systematic review. Obstet Gynecol Surv 2008;63:465Y471

Prostate Adenocarcinoma Metastasis to the Oral Cavity To the Editor: Prostate cancer is the second leading cause of cancer death in many countries, including Brazil, where it accounts for 23.3% of all cancers affecting males.1Y3 It is primarily a disease of older men that commonly causes bone metastases, but it only rarely involves the gnathic bones.4 We herein report 2 cases of prostate cancer metastases to the oral cavity. In the first case, a 55-year-old man was referred to our service, with complaints of a painful swelling and paresthesia on the right side of the face for approximately 3 months. The patient did not report any contributory past medical information. Results of a clinical examination revealed facial asymmetry, with enlargement of the right posterior region of the mandible. Intraorally, there was a large, hard, fixed, and telangiectatic nodule on the posterior right alveolar ridge of the mandible (Fig. 1A). The

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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The Journal of Craniofacial Surgery

FIGURE 1. Clinical, radiographic, and microscopic features of prostate cancer oral metastasis of case 1. A, Presence of an intraoral nodule covered by a telangiectatic mucosa, affecting the posterior region of the mandible. B, An extensive osteolytic lesion with ill-defined borders affecting the posterior region of the mandibular body and ascending ramus can be found in the panoramic radiograph. C, Small nests of atypical epithelial cells forming ductal structures in a prominent fibrous stroma (hematoxylin-eosin, original magnification 100). D, Higher magnification of the ductal structures and epithelial cells with round nuclei, central nucleoli, and scarce cytoplasm (hematoxylin-eosin, original magnification 400).

FIGURE 2. Bone scintigraph of case 1 reveals multiple metastases, including the extensive neoplastic infiltration of the mandible and the primary prostate cancer.

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panoramic radiograph revealed an extensive osteolytic lesion with ill-defined borders, involving the posterior region of the mandible and ascending ramus (Fig. 1B). Results of a microscopic analysis displayed solid nests of atypical epithelial cells forming ductal structures in a fibrotic stroma (Figs. 1C, D). Immunohistochemical analysis was positive for findings of prostatic-specific antigen (PSA) and prostatic-specific acid phosphatase, leading to the final diagnosis of an oral metastasis of a prostatic adenocarcinoma. An elevated serum PSA was found (25.3 ng/mL; normal range form, 0Y4 ng/dL), and results of bone scintigraphy revealed multiple metastases, including an extensive neoplastic infiltration in the mandible and the primary prostate cancer (Fig. 2). The patient was referred for palliative treatment and died 2 months after the diagnosis. In the second case, a 69-year-old man was referred for an evaluation of a swelling in the lower posterior left alveolar ridge of the mandible, with approximately 5 months of duration. The patient reported a medical history of a primary prostate cancer that was being treated palliatively. Results of an intraoral examination revealed a large lesion necrotic on the surface, involving the posterior region of the left alveolar ridge of the mandible. A second asymptomatic nodule in the molar gingival area of the right maxilla (Figs. 3A, B) was also found. A panoramic radiograph showed ill-defined bone destructions in the mandible and maxilla (Fig. 3C). Results of a microscopic examination of both lesions depicted solid nests of atypical neoplastic epithelial cells forming a palisade at the periphery and showing abundant

FIGURE 3. Clinical, radiographic, and microscopic features of case 2. A, Extensive lesion involving the posterior region of the left alveolar ridge of the mandible. B, A second asymptomatic nodule in the molar gingival area on the right side of the maxilla was also seen. C, Panoramic radiograph showing diffuse multifocal bone destruction with ill-defined limits in both sides of the mandible and in the right alveolar ridge of the maxilla. In both the mandible and the maxilla, floating teeth could be found. D, Well-organized and delimited solid nests of epithelial neoplastic cells separated by scarce fibrous stroma (hematoxylin-eosin, original magnification 200). E, Higher magnification of the neoplastic islands separated by a thin fibrous stroma, showing peripheral cells forming a palisade, and central cells with abundant clear granular cytoplasm (hematoxylin-eosin, original magnification 400).

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

Correspondence

important to improve life quality and pain relief.10 In conclusion, oral metastasis of prostatic cancer is uncommon, but it may lead to the diagnosis of an unknown primary cancer. He´lder Antoˆnio Rebelo Pontes, DDS, PhD Fla´via Sirotheau Correˆa Pontes, DDS, PhD Joa˜o de Barros Barreto University Hospital Federal University of Para´ Para´, Brazil Felipe Paiva Fonseca, DDS, MSc Piracicaba Dental School State University of Campinas Sao Paulo, Brazil [email protected] Marcondes Sena-Filho, DDS, MSc Piracicaba Dental School State University of Campinas Sao Paulo, Brazil De´cio dos Santos Pinto Jr, DDS, PhD Dental School University of Sao Paulo Sao Paulo, Brazil Patrı´cia Timbo´ Soares, DDS Sek Hyun Kim, DDS Joa˜o de Barros Barreto University Hospital Federal University of Para´ Para´, Brazil Oslei Paes de Almeida, DDS, PhD Piracicaba Dental School State University of Campinas Sao Paulo, Brazil

REFERENCES

FIGURE 4. Bone scintigraph of case 2 reveals the extensive primary prostate cancer and the multifocal metastatic involvement of the gnathic bones.

clear granular cytoplasm in the central parts of the nests (Figs. 3D, E). Both lesions were positive for PSA findings by immunohistochemistry, confirming metastases of a prostatic adenocarcinoma. Serum PSA was elevated (10.3 ng/mL), and findings of bone scintigraphy revealed multifocal neoplastic infiltration of the jaw bones and the extensive primary prostate cancer (Fig. 4). The patient died 3 months after the oral metastases diagnosis. Although the incidence of prostate cancer metastases have decreased in the previous years, it still occurs in approximately 3.5% of the patients on initial diagnosis, most commonly affecting bones, especially the vertebrae, pelvis, ribs, and skull.5,6 Most patients with prostate cancer oral metastasis are in the seventh and eighth decades of life, and the metastatic focus usually involves the mandibular posterior region.7Y9 No case affecting more than 1 oral site simultaneously, as described here in the second case, has been reported. In most cases, the primary tumor had already been diagnosed before oral manifestations; however, as in our first case, more than 15% of the cases may be initially diagnosed through oral biopsies. Clinical manifestations are unspecific, causing pain, swelling, bleeding, dysphagia, trismus, paresthesia, and tooth mobility.7 Oral metastases usually indicate poor prognosis, but treatment, although palliative, is

1. ACS. American Cancer Society. Cancer facts and figures 2012. Atlanta: American Cancer Society, 2012 2. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10Y29 3. Brasil. Ministerio da Sau´de. Estimativa 2013: Incideˆncia de Caˆncer no Brasil/Instituto Nacional do Caˆncer. Rio de Janeiro: INCA; 2011 [cited 2012]; Available at: http://www.inca.gov.br/estimativa/2010/ estimativa20091201.pdf. 12/27/2012 4. Freudlsperger C, Kurth R, Werner MK, et al. Condylar metastasis from prostatic carcinoma mimicking temporomandibular disorder: a case report. Oral Maxillofac Surg 2012;16:79Y82 5. Logothetis CJ, Lin SH. Osteoblasts in prostate cancer metastasis to bone. Nat Rev Cancer 2005;5:21Y28 6. Ryan CJ, Elkin EP, Small EJ, et al. Reduced incidence of bony metastasis at initial prostate cancer diagnosis: data from CaPSURE. Urol Oncol 2006;24:396Y402 7. Shen ML, Kang J, Wen YL, et al. Metastatic tumors to the oral and maxillofacial region: a retrospective study of 19 cases in West China and review of the Chinese and English literature. J Oral Maxillofac Surg 2009;67:718Y737 8. Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, et al. Metastatic tumours to the oral cavityVpathogenesis and analysis of 673 cases. Oral Oncol 2008;44:743Y752 9. Hirshberg A, Leibovich P, Buchner A. Metastatic tumors to the jawbones: analysis of 390 cases. J Oral Pathol Med 1994;23: 337Y341 10. Reyes Court D, Encina S, Levy I. Prostatic adenocarcinoma with mandibular metastatic lesion: case report. Med Oral Patol Oral Cir Bucal 2007;12:E424YE427

* 2014 Mutaz B. Habal, MD

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Prostate adenocarcinoma metastasis to the oral cavity.

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