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Persistent Pain and Gingival Swelling in a Middle-aged Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 59-year-old Hispanic woman presented with a 6-month history of intermittent pain in the right posterior mandibular gingiva. Her local dentist had prescribed an antibiotic and performed a tooth extraction in the area 6 months prior with no improvement in symptoms. Ultimately, her pain became persistent and radiated to the right lower lip. She had a history of stage IV endometrial serous adenocarcinoma (ESA) 4 years prior that was treated with total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and peritoneal lavage. She had developed a recurrence for which she had just completed 3 cycles of treatment with carboplatin. She also had a history of anxiety, hypertension, and pterygium, and she was taking gabapentin, lorazepam, prochlorperazine, metoprolol succinate, bromfenac and ketorolac ophthalmic solution, and aprepitant. Intraoral examination revealed a 1.5 × 1.0-cm firm, erythematous gingival mass in the area of missing right mandibular second bicuspid and first molar with buccal and lingual expansion (Figure 1A). The right mandibular first bicuspid was grade 3 mobile. A periapical radiograph was obtained, and results showed a diffuse, poorly demarcated radiolucency measuring approximately 1.2 × 0.8 cm (Figure 1B). Findings from an incisional biopsy of the mass showed an infiltrative tumor (Figure 1C). Tumor cells were positive for CK7, PAX8, and WT-1, and negative for CK20 and TTF-1 (Figure 1C, inset).

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C. Oral metastasis

The histopathological and immunohistochemical findings were consistent with the patient’s preexisting ESA. Oral metastases in the jaws and soft tissues are uncommon and account for only 1% to 8% of all malignancies in the oral cavity. Bony metastases, particularly in the mandible, are twice as common as those in the oral soft tissues of the gingiva and tongue.1,2 The most common cancer that metastasizes in the oral cavity in female patients is carcinoma of the breast (25.4%-36.6%), while metastatic cancers of the female genital tract in the oral cavity are rare and have a frequency of 3% to 9%.2,3 The clinical presentation of metastatic disease in the oral cavity may be nonspecific. Patients may have pain, swelling, and/or bleeding. These signs may lead a clinician to first consider odontogenic infection or inflammatory gingival nodules such as pyogenic granuloma.3,4 Because odontogenic infections often present in a similar fashion and metastatic tumors are rare, lesions are often treated with antibiotics, which leads to diagnostic delay like with this case.3 It is likely the metastatic ESA in this case had originated in the bone (as it does in approximately two-thirds of cases) with extension into the soft tissues that presented as a gingival mass.

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Article Information

Corresponding Author: Asma Almazyad, BDS, Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, 188 Longwood Ave, Boston, MA 02215 (asma_almazyad@hsdm.harvard.edu).

Published Online: April 25, 2019. doi:10.1001/jamaoto.2019.0606

Conflict of Interest Disclosures: Dr Villa reports grants from Bristol-Myers Squibb outside of the submitted work. No other disclosures are reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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