OtolaryngologyHead and Neck Surgery (2007) 137, 169-170

CASE REPORT

Gingival metastasis from gastric adenocarcinoma

Kyung-Gyun Hwang, DDS, PhD, Chang-Joo Park, DDS, PhD, Seung-Sam Paik, MD, PhD, and Kwang-Sup Shim, DDS, PhD, Seoul, South Korea
he oral cavity is a rare but occasional target for metastases, which may masquerade as various benign and inammatory lesions. Also, occult cancer may metastasize to the oral cavity as a rst and exclusive manifestation.1 It is important to bear these possibilities in mind because such situations may be encountered during a routine examination of the head and neck region. A 58-year-old man was referred to the Department of Dentistry/Oral and Maxillofacial Surgery because of a 2-month history of a painful swelling of upper right rst molar area. Past medical history was signicant for subtotal gastrectomy for adenocarcinoma of the stomach (stage IIIa: T3 N1 M0) at the age of 54. Following surgery, he received six cycles of chemotherapy with 5-uorouracil, adriamycin, and mitomycin-C. At that time, no metastasis was found on abdominal computed tomography (CT) scan. Six months later, abdominal CT and endoscopic examination showed no recurrence or metastasis. However, 4 years later, pulmonary and hepatic metastases appeared, and whole body bone scan detected multiple metastatic rib, pelvis, and femoral bone lesions. Consequently, the patient was admitted for chemotherapy and referred to our department during the chemotherapy. Clinically, intraoral examination revealed soft tissue swelling, resembling periodontal pyogenic abscess of granuloma-like hyperplastic lesions. The lesion was located on the buccal gingiva and vestibule and measured approximately 3.0 2.0 cm (Fig 1A). The exophytic growth, in the rst and second molar region, was associated with pain, foul odor, and a bloody and necrotic tag. The extraoral head and neck examination showed no evidence of lymphadenopathy or other pathology. Radiographic examination demonstrated horizontal bone loss in the rst and second molar region. Facial CT showed a 2.0 1.5-cm soft tissue mass on the lateral right maxilla near the second molar. The bony defect was found on the inferior-lateral wall of the right maxillary sinus. However, there was no change on the sinus mucosa (Fig 1B). After the patient was provided written informed consent, the incisional biopsy was performed to conrm clinical diagnosis of this gingival mass. Histopathologically, biopsy
Received September 2, 2006; accepted January 11, 2007.

material consisted of a fragment covered by normal gingival epithelium. Microscopic examination revealed moderately differentiated adenocarcinoma with desmoplastic stromal changes (Fig. 2). It should be noted that microscopic ndings of the previous specimen of stomach showed the same histological features. Finally, immunohistochemical analysis was consistent with metastatic adenocarcinoma from the stomach.

DISCUSSION
Metastatic involvement of the oral region, as a manifestation of generalized metastasis, has rarely been reported, and the incidence is approximately 1-3% of all oral malignancies.2 The oral sites of metastasis include the mandible, maxilla, upper gingiva, lower gingiva, and tongue; primary sites of neoplasms include the breast, lung, adrenal gland, kidney, bone, colo-rectum, skin, and prostate. Gastric cancer, especially gastric adenocarcinoma, is the most common malignancy among men in Korea and is responsible for 20% of cancer deaths among this population. A high salt intake and Helicobacter pylori infection have been considered as two major risk factors for the higher incidence of gastric cancer in Koreans.4 Metastasis of primary gastric cancer to the oral cavity is quite unusual. About 10 cases of such metastasis have been reported in the last 100 years. Shimoyama et al4 reported one case and cited nine cases of distant metastasis to the oral cavity since 1968. Abrams et al5 reviewed 119 autopsy cases of gastric cancer and concluded that the liver, lung, and peritoneum were frequent distant metastatic sites. However, no case of metastasis to the oral region was found, and they concluded that oral metastasis from gastric cancer is very rare. Oral mucosa and jawbone involvement could be more frequent than reported because these regions are not always included in metastatic evaluation or autopsies. Therefore, oral examination should be included in evaluation of distant metastasis of gastric carcinoma and other cancers. The clinical ndings that gingival lesions resemble benign lesions, such as pyogenic granulomas, periodontal abscess, or inammatory hyperplastic lesion, make it

0194-5998/$32.00 2007 American Academy of OtolaryngologyHead and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2007.01.014
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OtolaryngologyHead and Neck Surgery, Vol 137, No 1, July 2007

Figure 1 Clinical and radiographic presentation. (A) Clinical appearance of the soft tissue swelling resembled periodontal abscess. Marked exophytic growth on the buccal vestibule, in the right upper rst and second molar region, associated with pain and a bloody and necrotic tag. (B) Facial CT scan showed 2.0 1.5-cm sized soft tissue mass labeled on the lateral right maxilla near the second molar. Bony defect was found on the inferior-lateral wall of the right maxillary sinus.

imperative that metastatic cancer be included in the differential diagnosis of gingival masses. Most patients complain of swelling, pain, or paresthesia that develops in a relatively short time.2 The main symptoms are bleeding and a rapidly growing ulcerated mass. Diagnosis requires careful history taking, particularly of previous surgical operations. Oral metastasis is usually evidence of widespread disease. Because the prognosis is poor, treatment is palliative in most cases. Surgery is usually undertaken when the primary tumor is controlled and there is no evidence of other metastasis. Most patients die within 1 year after

the diagnosis of metastasis. Therefore, clinicians should be aware of clinical and prognostic implications of oral metastasis from gastric cancer or other malignancy.3

AUTHOR INFORMATION
From the Departments of Dentistry/Oral and Maxillofacial Surgery (Drs Hwang, Park, and Shim) and Pathology (Dr Paik), College of Medicine, Hanyang University, Seoul, Korea. Corresponding author: Kyung-Gyun Hwang, DDS, PhD, Department of Dentistry/Oral and Maxillofacial Surgery, College of Medicine, Hanyang University, No. 17 Haengdang-Dong, Seongdong-Ku, Seoul 133-792, Korea. E-mail address: hkg@hanyang.ac.kr.

FINANCIAL DISCLOSURE
None.

REFERENCES
1. Colombo P, Tondulli L, Masci G, et al. Oral ulcer as an exclusive sign of gastic cancer: report of a rare case. BMC Cancer 2005;5:11721. 2. Meyer I, Shklar G. Malignant tumors metastatic to mouth and jaw. Oral Surg Oral Med Oral Pathol 1965;20:350 62. 3. Choi S, Lim YJ, Park SK. Risk factor analysis for metaplastic gastritis in Koreans. World J Gastroenterol 2006;12:2584 7. 4. Shimoyama S, Seto Y, Aoki F, et al. Gastric cancer with metastasis to the gingiva. J Gastroenterol Hepatol 2004;19:8315. 5. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma. Analysis of 1000 autopsied cases. Cancer 1950;3:74 85.

Figure 2 Histopathological aspects. The gingival biopsy showed moderately differentiated adenocarcinoma with desmoplastic stromal changes (hematoxylin and eosin stain, original magnication 200).

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