Introduction
Oral metastatic tumors are uncommon, representing
approximately 1% of oral tumors, and usually involve the bones;
their occurrence in the oral soft tissues is exceedingly rare. The
affected persons usually have widespread disease with a poor
prognosis, and the most commonly reported primary sites are the
breast, lung, kidney, bone and colon (1,2). Few
cases of transitional cell carcinoma of the urinary bladder
metastatic to the oral cavity have been reported. Most of these
cases occurred in the jawbones, and only three cases occurred in
the soft tissues (3). We report on
a patient who presented with a metastatic tumor confined to the
oral mucosa that originated from a transitional cell carcinoma of
the urinary bladder. The patient had widespread disease and a poor
prognosis.
The study was approved by the institutional review
board, and due to the retropective nature of the study, the
requirement to obtain informed consent was waived.
Case report
In December 2004, a 70-year-old man presented with
gross hematuria and dysuria. After being diagnosed with
transitional cell carcinoma of the urinary bladder following
transurethral resection, the patient underwent radical cystectomy
(pT3aN0M0, grade 2/3; Fig. 1) and
was then followed up regularly. In February 2006, he complained of
chest and back pain. Abdominal-pelvic computed tomography (CT) and
bone scintigraphy revealed multiple para-aortic lymph nodes and
numerous hot spots consistent with bone metastases. These nodes and
hots spots were located in the sternum, ribs, thoraco-lumbar spine,
left ilium and left femur. Palliative radiotherapy to the lumbar
spine, which was the most painful site, was administered to relieve
the pain. The patient then received two cycles of chemotherapy with
gemcitabine and carboplatin. In May 2006, the patient presented
with a painful polypoid mass, located in the vestibule of the mouth
and lateral to the lower right central incisor, which had an
irregular surface with a soft consistency and yellowish exudates
(Fig. 2). No bone involvement was
visible on panoramic or periapical X-rays, bone scintigraphy or CT.
A biopsy of the soft tissue mass showed metastatic transitional
cell carcinoma of the urinary bladder (Fig. 3). The chest X-ray and CT performed
at that time revealed multiple pulmonary metastases. Palliative
radiotherapy was planned, but was refused by the patient and his
guardians. The patient received supportive care and succumbed to
the disease one month after the detection of the oral
metastasis.
Discussion
The case described in this study draws attention to
the occurrence of oral mucosal metastasis and the consideration of
this phenomenon in the differential diagnosis in urinary bladder
cancer patients with an oral mass-like lesion. Metastases to the
oral soft tissues, including the oral mucosa, with no bone
involvement are exceedingly rare and are most frequently located in
the gingiva, followed by the tongue, tonsil, palate, lip, buccal
mucosa and floor of the mouth. The most common primary sites of
metastatic lesions to the oral mucosa were the breasts in females
and lungs in males (2,4). In urinary bladder cancer, metastatic
tumors in the oral cavity are uncommon and occur mostly in the
jawbones (3). Only three cases of
cancer confined to the oral soft tissues with no bone involvement
have been reported (Table I)
(5–7).
 | Table IReview of the literature regarding
clinical characteristics of oral soft tissue metastasis from
urinary bladder cancer. |
Table I
Review of the literature regarding
clinical characteristics of oral soft tissue metastasis from
urinary bladder cancer.
| Age | Gender | Site of soft tissue
metastasis | Other metastatic
lesion(s) | Treatment | Survivala | Ref |
|---|
| 62 | F | Tongue | None | CTX | 5 months | 5 |
| 75 | M | Submandibular
gland | Bone | Surgery | ND | 6 |
| 58 | M | Upper alveolus | Liver, bone, adrenal
gland | Noneb | ND | 7 |
The treatment of a metastatic oral lesion depends on
the tumor size, location and extent of metastatic lesions, as well
as the status of the patient. It is difficult to perform radical
treatment for a lesion on a patient in poor general condition,
particularly given the low probability of complete removal of the
primary and metastatic sites. Conversely, lack of treatment may
cause dietary disturbance due to pain and bleeding. Thus, the early
removal of the oral lesion may be desirable in terms of quality of
life (2,8). In our case, a painful polypoid mass
was confined to the oral mucosa with no bone involvement in a
patient who had been receiving chemotherapy for recurrent
transitional cell carcinoma of the urinary bladder with multiple
bone metastases. Initially, the lesion was considered to be a
benign gingival one such as an epulis, pyogenic granuloma or
peripheral fibroma, since it is extremely rare to encounter
transitional cell carcinoma of the urinary bladder metastatic to
the oral mucosa without bone involvement. However, a biopsy of the
lesion confirmed that it was metastatic transitional carcinoma of
the urinary bladder, and the chest X-ray and CT performed at that
time revealed multiple pulmonary metastases. The disease progressed
rapidly and the patient succumbed within a short period of time,
indicating extensive spread of the oral metastatic lesion and a
poor prognosis of the disease, as reported in other cases (9,10).
Clinicians should be aware that a metastatic tumor
confined to the oral mucosa is possible, particularly in the
advanced stages of cancer, and may provide evidence of widespread
disease with a poor prognosis, although such metastatic tumors are
exceedingly rare in patients with transitional cell carcinoma of
the urinary bladder.
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