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INTERESTING IMAGE
Year : 2020  |  Volume : 35  |  Issue : 2  |  Page : 178-180  

Isolated mandibular metastasis detected on staging18FDG PET/CT scan in a case of carcinoma urinary bladder


1 Department of Nuclear Medicine, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Nuclear Medicine and PET/CT, Platinum Imaging Centre, New Delhi, India

Date of Submission01-Feb-2020
Date of Acceptance10-Feb-2020
Date of Web Publication12-Mar-2020

Correspondence Address:
Dr. Nitin Gupta
Department of Nuclear Medicine, Sir Ganga Ram Hospital, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_18_20

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   Abstract 


Isolated mandibular metastasis is very rare from carcinoma urinary bladder with no locoregional lymph node involvement. Here, we present a case where staging fluorodeoxyglucose - positron emission tomography - computed tomography (FDG PET-CT) scan showed an FDG avid primary lesion in carcinoma urinary bladder with FDG avid erosion in the right mandibular condyle. However, since no pelvic lymph nodes were involved, the mandibular lesion was kept on follow-up and cystoprostatectomy was performed. Follow-up FDG PET-CT scan after 6 months revealed an osteolytic destructive lesion in the mandible with associated soft tissue component and the biopsy confirmed this as metastatic lesion.

Keywords: Carcinoma urinary bladder, FDG PET/CT scan, mandibular metastasis


How to cite this article:
Gupta N, Khare A. Isolated mandibular metastasis detected on staging18FDG PET/CT scan in a case of carcinoma urinary bladder. Indian J Nucl Med 2020;35:178-80

How to cite this URL:
Gupta N, Khare A. Isolated mandibular metastasis detected on staging18FDG PET/CT scan in a case of carcinoma urinary bladder. Indian J Nucl Med [serial online] 2020 [cited 2020 Mar 29];35:178-80. Available from: http://www.ijnm.in/text.asp?2020/35/2/178/280444



A 54-year-old male patient presented with a history of hematuria for 6 months. Contrast enhanced computed tomography (CECT) scan showed a lesion in the anterior wall of the urinary bladder and subsequent Transurethral resection of bladder tumour (TURBT) and histopathological report of the lesion confirmed high-grade invasive urothelial carcinoma with muscle invasion. The patient was referred for staging whole-body PET-CT scan. MIP [Figure 1]a image showed FDG uptake in the urinary bladder and axial PET, CT, and fused PET-CT images [Figure 1]h, [Figure 1]i, [Figure 1]j confirmed an FDG avid lesion in the anterior wall of the urinary bladder corresponding to the known primary site. Another FDG uptake was noted in the right mandible and corresponding axial and coronal PET, CT, and fused PET-CT images [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g revealed FDG avid erosion of condylar process of the right mandible. However, since no FDG avid locoregional lesion was seen, thus the chances of isolated metastasis to mandible were rare and the patient was planned for cystoprostatectomy. After 6 months, the patient presented with pain and swelling in the right side of the face. MIP image of the whole-body PET-CT scan for restaging revealed FDG avid lesion in the right side of the face and lumbar vertebrae [Figure 2]a and corresponding axial and coronal [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f, [Figure 2]g PET, CT and fused PET-CT images were suggestive of a large FDG avid osteolytic destructive lesion with associated soft tissue component involving ramus, condyle and coronoid process of the right mandible. Another FDG avid lesion was also noted in L2 vertebra [Figure 2]h, [Figure 2]i, [Figure 2]j. Subsequent biopsy from the mandible lesion confirmed metastatic carcinoma.
Figure 1: MIP (a) image of staging whole-body PET-CT scan, showing primary FDG avid lesions. Axial (h-j) PET, CT, and fused PET images showing FDG avid lesions involving anterior wall of urinary bladder. Apart from primary lesion, FDG avid erosion of condylar process of the right mandible was seen in axial and coronal (b-g) PET, CT, and fused images

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Figure 2: MIP (a) image of postoperative carcinoma urinary bladder patient showing FDG avid lesion in the right mandibular region, lumbar vertebrae, and ileal conduit. Axial and coronal (b-g) PET, CT, and fused PET-CT images showing FDG avid osteolytic destructive lesion involving ramus and condyle of the right mandible and FDG avid osteolytic lesion in L2 vertebra in axial (h-j) PET, CT, and fused PET-CT images

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This case is particularly interesting because it not only involves an uncommon secondary site but being the only site of metastasis without even locoregional lymph nodes involvement. Metastasis to the oral cavity rarely occurs and constitutes 1% of all oral cavity malignancies[1] and has mostly been found in the jaws compared to the soft tissues.[2] The majority of jaw metastasis appears to occur in the mandible with most jaw metastatic disease associated with additional distant metastases (both to bone and soft tissue).[3] Metastasis to the jawbones mainly occurs in the posterior region of the mandible, the ramus and the condyle, which are rich in red bone marrow. In a recent review of 453 cases of metastasis to the jaw bone, the lung was the most common primary site in men and breast in women.[4] The differential diagnosis for mandibular metastatic carcinoma includes temporomandibular joint disorders, ameloblastoma, primary intraosseous squamous carcinoma and osteosarcoma. The most common reported sites of metastasis for urinary bladder carcinoma are liver (47%), lung (45%), or bone (32%).[5] Few case reports have been published previously describing mandibular metastasis from carcinoma urinary bladder[6],[7] and from other cancers including lung cancer,[8],[9] breast cancer,[10] and pancreas,[11] and a study has been published describing six patients with mandibular metastasis with primary in prostate in 2, lung in 2, breast in 1, and thyroid in 1.[12] Oral metastasis means poor prognosis in patients and signs of advanced disease. Our case highlights the importance of FDG avid lesions seen on the whole-body PET-CT scan and there can be metastatic lesion in jaw without involvement of locoregional lymph nodes. Thus, mandibular lesions should be further evaluated for correct staging and management should be changed accordingly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zachariades N. Neoplasms metastatic to the mouth, jaws and surrounding tissues. J Craniomaxillofac Surg 1989;17:283-90.  Back to cited text no. 1
    
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Irani S. Metastasis to the oral soft tissues: A review of 412 cases. J Int Soc Prev Community Dent 2016;6:393-401.  Back to cited text no. 2
    
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Cardona F, Bagán JV, Pérez A. Mandibular metastasis of bladder transitional cell carcinoma. J Oral Maxillofac Surg 2000;58:1154-8.  Back to cited text no. 3
    
4.
Irani S. Metastasis to the jawbones: A review of 453 cases. J Int Soc Prev Community Dent 2017;7:71-81.  Back to cited text no. 4
    
5.
Teyssonneau D, Daste A, Dousset V, Hoepffner JL, Ravaud A, Gross-Goupil M. Metastatic non-muscle invasive bladder cancer with meningeal carcinomatosis: Case report of an unexpected response. BMC Cancer 2017;17:323.  Back to cited text no. 5
    
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de Courten A, Irle C, Samson J, Lombardi T. Metastatic transitional cell carcinoma of the urinary bladder presenting as a mandibular gingival swelling. J Periodontol 2001;72:688-90.  Back to cited text no. 6
    
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Frydenlund N, Zakharia Y, Garje R, Dahmoush L, O'Donnell MA. Non-muscle invasive papillary urothelial carcinoma metastatic to the mandible. J Investig Med High Impact Case Rep 2018;6:2324709618806332.  Back to cited text no. 7
    
8.
Boniello R, Gasparini G, D'Amato G, di Petrillo A, Pelo S. TMJ metastasis: A unusual case report. Head Face Med 2008;4:8.  Back to cited text no. 8
    
9.
Raja Lakshmi C, Sudhakara Rao M, Bhavana SM, Sathish S. Primary squamous cell carcinoma of lung leading to metastatic jaw tumor. Case Rep Pulmonol 2014;2014:392616.  Back to cited text no. 9
    
10.
Dodo M, Kumagai M, Kato Y, Hirakawa H, Koseki T. Metastasis in the mandibular condyle: A case report. J Med Case Rep 2017;11:323.  Back to cited text no. 10
    
11.
Kolokythas A, Miloro MB, Olsson AB, Miloro M. Metastatic pancreatic adenocarcinoma to the mandibular condyle: A rare clinical presentation. J Oral Maxillofac Surg 2014;72:83-8.  Back to cited text no. 11
    
12.
Cai Z, Zhu C, Wang L, Zhu L, Zhang Z, Zhu H, et al. A retrospective study of six patients with mandibular metastatic carcinoma. Oncol Lett 2016;11:3650-4.  Back to cited text no. 12
    


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