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\begin{document}

\title{Metastasis of a prostate adenocarcinoma to mandible: a case report and
review of literature}



\author[1]{Mahboube Hasheminasab}%
\author[1]{Abbas  Karimi}%
\author[1]{Mehdi Kardoust}%
\author[2]{Farid Kosari}%
\author[2]{Amirali Asadi}%
\affil[1]{Affiliation not available}%
\affil[2]{Tehran University of Medical Sciences}%


\vspace{-1em}



  
  \date{June 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Bones, lymph nodes, lungs, or liver, are the common metastatic sites for
prostate cancer. However, prostate adenocarcinoma metastasis to the
mandible is very rare. In this case report we present a case of a
64-year-old man with poorly differentiated prostate cancer and
metastasis to the mandible.%
\end{abstract}%



\sloppy




\textbf{Key Clinical Message:}

Dentists should include oral metastases originating from prostate
adenocarcinoma as a rare differential diagnosis of jaw lesions that can
produce periosteal reactions in the Radiographic features.

\par\null

INTRODUCTION

Carcinoma of prostate accounts for 25\% of all malignancies in men that
tends to metastasize to bone. Ribs, ilium of pelvis, the vertebral
column and skull are often involved, whereas less than 1\% of malignant
tumors metastasize to maxillofacial region.(1) Bone metastasis in oral
cavity is extremely rare, and represents 1\% of all malignant oral
neoplasia. The incidence is 80 to 90\% in mandible, mainly in molar
region and is always a sign of spreading of the cancer.(2)

In this paper we present the details of a 64-year old male patient with
mandibular metastasis from advanced prostate adenocarcinoma. In
Addition, we have reviewed 10 case reports of metastatic prostate
adenocarcinoma to mandible in the literature.

CASE PRESENTATION

A 64-year old man was referred to the department of oral and
maxillofacial surgery complaining of a mass on the right side of
mandible associated with paresthesia of the right side of lower lip.

Intraoral examination revealed little expansion of right mandible with
bony hard consistency measuring about 5 cm, which caused facial
asymmetry. CT scan images showed a lesion with periosteal reaction along
with bone destruction and bone formation in the ramus of right mandible
without perforation of cortical table and mandibular canal destruction.
He has undergone incisional biopsy of the right jaw lesion and the
result reported ``Clear Cell Carcinoma''. According to elevated serum
prostate specific antigen (PSA) levels, needle biopsy was obtained from
prostate. Histopathologic analysis of prostate biopsy confirmed prostate
adenocarcinoma of Gleason grade 5 + 5 = 10. IHC staining was positive
for CK (AE1/AE3) and PSA. The patient had also elevated level of serum
alkaline phosphatase, which suggested escalated bone metabolism. After
revision of jaw specimen, the diagnosis of metastatic adenocarcinoma was
confirmed. The patient underwent bilateral orchiectomy as a palliative
management with dramatic primary response.

DISCUSSION

Prostate cancer typically metastasizes to bones, such as lumbar
vertebrae, thoracic vertebrae, and the pelvis. Metastasis of prostate
cancer to the maxillofacial region is relatively rare(3).

Because metastatic lesions to the jaw mimic other oral lesions,
diagnosis is a dilemma for dentists. These lesions may cause
paresthesia, pain, ulcers, swelling, pathologic fracture and these
symptoms may be mistaken with other oral lesions. Imaging,
histopathologic examination and patient's history of cancer would help
the diagnosis. Also for the definitive diagnosis Scintigraphy and IHC
panel may help the clinician(4, 5). However, most patients with oral
metastasis generally have the primary cancer well diagnosed. In one
article, in the reported case the primary tumor was treated years before
by radical prostatectomy and the patient was still on medical care
during the jaw metastasis (2). Metastatic tumors of the head and neck
are most commonly located in the mandibular molar region(3). The
posterior mandible is the most susceptible metastasis site because of
its rich blood supply(6).

Metastasis cases of mandible reported in the literature were mostly in
angle and body region and rarely in condylar area. Most frequently,
patients were in their 7\textsuperscript{th} and
8\textsuperscript{th}decades of life (7-10). The most common chief
complaints of the patients were pain and swelling, other manifestations
such as paresthesia, limited mouth opening, preauricular pain were also
reported(3, 8, 11).

Radiographic feature showing periosteal reactions can be classified as
single layer, multilayered, solid, speculated, perpendicular, sloping,
complex, Codman triangle and sunburst(12). The appearance of a
`sunburst' periosteal reaction is suggestive of rapid onset pathology(6)
and in this case, it highly suggests a malignant bone forming tumor,
such as an osteosarcoma. Metastatic prostate lesions usually secrete
osteoprotegrin as a RANK-L inhibitor. Thereby they are proposed to be
osteoblastic or sclerotic(13).

Table1 reviews previous cases of metastasis to mandible in the
literature.

In Conclusion, dentists and general physicians should include oral
metastases originating from prostate adenocarcinoma as a rare
differential diagnosis of jaw lesions that can produce periosteal
reactions. Metastasis are more common in elderly people and more common
in posterior of mandible. The patient's chief complaint is usually pain
and swelling with paresthesia.

Conflict of interests

None

Authorship List:

1.Mahboube Hasheminasab: Oral and Maxillofacial Surgeon,
Craniomaxillofacial Research Center, Tehran University of Medical
Sciences, Tehran, Iran; Department of Oral and Maxillofacial Surgery,
School of Dentistry, Tehran University of Medical Sciences, Tehran,
Iran.

2.Abbas Karimi: Oral and Maxillofacial Surgeon, Craniomaxillofacial
Research Center, Tehran University of Medical Sciences, Tehran, Iran;
Department of Oral and Maxillofacial Surgery, School of Dentistry,
Tehran University of Medical Sciences, Tehran, Iran.

3. Mehdi Kardoust Parizi: Department of Urology, Shariati Hospital,
Tehran University of Medical Sciences, Tehran, Iran.

4.Farid Kosari: Department of Pathology, Shariati Hospital, Tehran
University of Medical Sciences, Tehran, Iran.

5.Amirali Asadi: Resident of Oral and Maxillofacial Surgery, School of
Dentistry, Tehran University of Medical Sciences, Tehran, Iran.

References:

1. Bubendorf L, Schopfer A, Wagner U, Sauter G, Moch H, Willi N, et al.
Metastatic patterns of prostate cancer: an autopsy study of 1,589
patients. Human pathology. 2000;31(5):578-83.

2. Menezes JD, Cappellari PF, Capelari MM, Goncalves PZ, Toledo GL,
Toledo Filho JL, et al. Mandibular metastasis of adenocarcinoma from
prostate cancer: case report according to epidemiology and current
therapeutical trends of the advanced prostate cancer. Journal of applied
oral science : revista FOB. 2013;21(5):490-5.

3. Saijo H, Chikazu D, Mori Y, Hikiji H, Yonehara Y, Takato T.
Metastasis of prostate cancer to the mandibular condyle. Asian Journal
of Oral and Maxillofacial Surgery. 2008;20(2):86-8.

4. Xu Y, Wang Y, Zhou R, Li H, Cheng H, Wang Z, et al. The benign
mimickers of prostatic acinar adenocarcinoma. Chinese Journal of Cancer
Research. 2016;28(1):72.

5. Pruckmayer M, Glaser C, Nasel C, Lang S, Rasse M, Leitha T. Bone
metastasis with superimposed osteomyelitis in prostate cancer. Journal
of Nuclear Medicine. 1996;37:999-1000.

6. Tchan MC, George M, Thomas M. Metastatic prostate cancer mimicking
primary osteosarcoma of the jaw: an infrequent clinical case. Southern
medical journal. 2008;101(6):657-9.

7. Kim I-K, Lee D-H, Cho H-Y, Seo J-H, Park S-H, Kim J-M. Prostate
adenocarcinoma mandibular metastasis associated with numb chin syndrome:
a case report. Journal of the Korean Association of Oral and
Maxillofacial Surgeons. 2016;42(5):301-6.

8. Aksoy S, Orhan K, Kursun S, Kolsuz ME, Celikten B. Metastasis of
prostate carcinoma in the mandible manifesting as numb chin syndrome.
World journal of surgical oncology. 2014;12(1):401.

9. Menezes JDdSd, Cappellari PFM, Capelari MM, Goncalves PZ, Toledo GL,
Sales-Peres A, et al. Mandibular metastasis of adenocarcinoma from
prostate cancer: case report according to epidemiology and current
therapeutical trends of the advanced prostate cancer. Journal of Applied
Oral Science. 2013;21(5):490-5.

10. Iga H, Azuma M, Harada K, Yoshida H, Sato M, Hayashi H, et al.
Metastatic Prostate Carcinoma to the Mandible: Report of a case. Oral
Medicine \& Pathology. 1998;3(2):85-8.

11. Van der Waal R, Buter J, Van der Waal I. Oral metastases: report of
24 cases. British Journal of Oral and Maxillofacial Surgery.
2003;41(1):3-6.

12. Wenaden A, Szyszko T, Saifuddin A. Imaging of periosteal reactions
associated with focal lesions of bone. Clinical radiology.
2005;60(4):439-56.

13. Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic
tumours to the oral cavity--pathogenesis and analysis of 673 cases. Oral
oncology. 2008;44(8):743-52.

Figure Legends:

Figure 1(A, B): Axial and Coronal view show a sunray spicules/sunburst
appearance of periosteal reaction in the right posterior body, angle and
ramus of mandible mimicking Osteosarcoma variable with both bone
destruction and bone formation. (C) Panoramic view

Figure 2: (A) low power view of the tumor showing fibro-connective
tissue with dense infiltration by nests of tumor cells (H\&E x 40) - (B)
The tumor cells form solid nests and glandular structures, separated by
thin fibrous septa (H\&E x 100) - (C) The Individual tumor cells in the
nests have small round to medium sized oval hyper chromatic nuclei and
moderate amount of clear cytoplasm Mitotic figures are infrequent. No
necrosis is seen (H\%E x 400)\selectlanguage{english}
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