mandible and a destructive lesion involving the left condyle (Figure 1). The MR ... Metastatic disease to the jaws simulates infection in many ways: pain, swelling, ...
Dentomaxillofac. Radiol., Vol. 25, No. 5, pp. 292-297, 1996 Copyright © 1996 Elsevier Science Ltd for the I A D M F R . All rights reserved Printed in Great Britain 0250-832X/96 $15.00 + 0.00 ELSEVIER
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Case report. Magnetic resonance features of metastatic melanoma of the temporomandibular joint and mandible C.J. Nortje*, LJ. van Rensburg*t and I.O.C. Thompson! 'Department of Maxillofacial Radiology and ^Department of Oral Pathology, Faculty of Dentistry, University of Stellenbosch, and tLouis Leipoldt MR Center, Bellville, Cape Town, Republic of South Africa
Received 30 August 1995 and in final form 30 April 1996 We report a case of histologically verified melanoma of the nose which presented 2 years after initial radiotherapy with left temporomandibular pain, dysfunction and dental sepsis. Conventional radiography revealed a partially dentate mandible with a destructive lesion involving the left condyle, an ill-defined lesion in the right retromolar region and chronic inflammatory apical root lesions. Since MRI of the nose was done at the initial presentation, it was postulated that MRI could be used to characterize the destructive jaw lesions. The MR features were similar to the original nasal lesion and accepted as proof of diagnosis of metastatic melanoma. A literature review reveals only 37 previous cases of metastasis to the temporomandibular joint with none of involvement by melanoma. The role of MRI in the diagnosis of this lesion is also described for the first time. Copyright © 1996 Elsevier Science Ltd for IADMFR. Keywords: melanoma; magnetic resonance imaging; temporomandibular joint; neoplasm, metastasis Dentomaxillofac. Radiol., 1996; 25: 292-297
Case report A 43-year-old man, who 2 years previously had received radiotherapy for a proven nasal melanoma, presented to the Department of Maxillofacial Surgery with left temporomandibular dysfunction, pain and dental sepsis. A pre-extraction panoramic radiograph revealed three remaining teeth in the maxilla and a partially dentate mandible in which there were a number of roots with chronic inflammatory apical lesions. Additionally, there was an ill-defined radiolucent lesion in the right retromolar region of the mandible and a destructive lesion involving the left condyle (Figure 1). The MR scan (Figure 2a, b, c) and nasal biopsy (Figure 3) undertaken at the initial presentation were retrieved and reviewed. Histological examination of sections of the nasal biopsy showed a tumour that consisted predominantly of epithelioid cells (Figure 3). Spindle-shaped tumour cells were also present, but in limited numbers. Many of the cells were pleomorphic with large nuclei and contained melanin, which was also present in the macrophages. Occasional multinucleated giant cells were observed and the mitotic activity varied in different areas of the tumour. The overlying epithelium was orthokeratinized and parakeratinized. Its continuity was interrupted by areas of ulceration but no necrosis or haemorrhage was present. The appear-
ance was considered consistent with a malignant melanoma. A mild chronic inflammatory cell infiltrate was present in the deeper part of the tumour. Due to the destructive nature of the lesions in the left condyle and the right ramus, a MR scan was conducted 0.5 Tesla, Gyroscan T5-11 (Philips, Best Holland). T1 Spin-Echo: TE = 20 ms, TR=500 ms; T2 = Fast SE: TE = 120 ms; TR = 3280 ms. Magnevist® Gadolinium-DTPA 0.1 mmol/kg (Schering, Berlin, Germany) was used as a contrast medium. The images displayed a well-demarcated mass causing destruction of part of the ramus and the left condyle. The condylar lesion extended medially into the lateral pterygoid muscle and laterally into the masseter (Figure 4). Both lesions were hyperintense on Tl-weighted coronal images and enhanced with contrast (Figure 6). A small central, hyperintense focus was present in the condylar lesion (Figure 5). This signal characteristic is similar to that frequently found in non-haemorrhagic melanoma and is consistent with necrosis or sub-acute haemorrhage39. The coronal Tl-weighted images of the right mandibular ramus showed an intramedullary mass that had eroded the cortex lingually (Figure 6). The lesion was hyperintense on T1 and isointense on T2 (not shown) to brain cortex and enhanced with contrast. The clinical history and similar imaging features of the nasal lesion and mandibular lesions were condi-
Metastatic melanoma
293
Figure 1 Panoramic radiograph illustrating an ill-defined radiolucent lesion at a right angle to the mandible and a destructive lesion of the left condyle (arrowed)
tionally accepted as proof of the diagnosis of melanoma in the mandible and condyle. The patient was referred back to the Oncology Department. Subsequent clinical evaluation lead to a final diagnosis of multi-organ metastatic disease. Despite chemotherapy, he died 6 months later.
Discussion Although metastatic tumours are the most common malignancies that affect the skeleton, they comprise only 1% of malignant oral tumours, and are, therefore, infrequently encountered in the practice of oral and maxillofacial radiology. In one series of 408 patients with malignant tumours, only 3.2% had oral metastases1. Adenocarcinoma is the most common of all the metastases to the jaws, accounting for 70% of these lesions2. Carcinoma of the breast is responsible for the higher prevalence of jaw metastases in females3. Other common primary sites are lung followed by prostate. Metastases to the temporomandibular joint are uncommon, and in our extensive review of the literature only 37 cases were found 4-36 (Table I). Condylar metastases result in symptoms that may present as temporomandibular joint pain dysfunction syndrome while lesions that occur in the molar region of the mandible present as a swelling or mass with pain35. Thirty-two of the 37 cases were carcinomas and the most common clinical symptom was TMJ dysfunction. Metastatic disease to the jaws simulates infection in many ways: pain, swelling, lymphadenopathy and diffuse radiographic changes occur in both. Symptoms of TMJ dysfunction, such as pain, trismus, limited mandibular opening, deviation, swelling and radiographic evidence of an underlying lesion may be the first indication of either a primary or metastatic
malignant process. This is particularly true when the patient has known metastases or when the primary malignant disease has a propensity to metastasize to bone25. Most malignant tumours involving the temporomandibular joint are usually a result of direct extension from neoplasms of the skin, ear, parotid and nasopharynx23. An unusual occurence is bilateral condylar metastases from prostatic carcinoma27. The rarity of condylar metastases may be the result of the isolated nature of its blood supply7'25. Another possible explanation relates to the lack of the red marrow in the jaws. Most of the red marrow is found in the mandibular third molar region, and this is the region most often involved in metastases to the jaws. MRI is now recognized as the modality of choice for the radiological diagnosis of most malignant conditions involving the jaws33. This report supports this view. In our study, MRI was able to demonstrate superior contrast and soft-tissue visualization, as well as the extra-osseous extention of this lesion. In cases where metastases are present in the temporomandibular joint, MRI can suggest the possibility of a metastatic lesion if the signal characteristics are identical to those of the primary. This is well demonstrated in our case where the TMJ metastases had identical T1 signal characteristics to the original lesion in the nose. MRI provides some specificity as to the melanotic nature of the lesions. The MR imaging features of both the original nasal lesion and metastatic lesions were in accordance with the accepted signal characteristics of a non-haemorrhagic melanotic tumour. Both exhibited T1 and T2 signal shortening. Melanin in tumours of the brain is seen as high intensity on T1 and is also of intermediate signal intensity compared with the cortex on T2-weighted images37. The decrease in T2 is believed to be partly due to free radicals and binding of metal ions by melanin38. Absence of T2 shortening is indicative of tumour
294 necrosis and or haemorrhage, both of which are well recognized complications of melanotic tumours39. The small area of necrosis/haemorrhage in the centre of the TM joint lesion did not distract from the overall appearance of a non-haemorrhagic melanotic tumour. T2 hyperintensity in malignant non-haemorrhagic melanoma of the palate is a recently reported but unexplained MRI pitfall40.
C.J. Nortje et al. The presence of T1 shortening in an extracranial head and neck lesion is thus a very important clue as to the presence of a melanotic tumour. Metastatic deposits that are regularly haemorrhagic include melanoma, renal cell carcinoma and choriocarcinoma. Early subacute bleeding/blood (intracellular methemoglobin) and late subacute bleeding/blood (extracellular methemoglobin) will both exhibit T1
Figure 2 (a) Axial Tl-weighted SE MR image of the nose reveals a linear, hyperintense soft-tissue lesion in the right middle ethmoidal sinus with bone destruction, (b) Axial T2-weighted SE MR image shows characteristic T2-shortening of the lesion due to the paramagnetic effect of melanin. Note the mucosal hyperintensity. (c) Axial Tl-weighted SE MR image: Post-gadolinium DTPA. The lesion exhibits moderate differential enhancement
295
Metastatic melanoma
Figure 3 Nasal biopsy (H&E χ 400) shows foci of heavily pigmented and non-pigmented cells with no necrosis or haemorrhage in the specimen, consistent with malignant melanoma
shortening. On first principles, the T2 signal intensities will differ, being shortened in the early phase and prolonged in the late phase. To our knowledge, this is the first report of the use of MRI in the diagnosis of metastatic melanoma to the condyle, involving the temporomandibular joint. Based on the MR appearance, the distinctive signal characteristics similar to the original tumour combined with careful clinical work up, obviated the need for an invasive procedure to obtain further histological diagnosis in this case.
Acknowledgements The authors wish to thank Drs Schnetler, Corbett and Partners for providing CT and MRI facilities free to The Oral and Dental Teaching Hospital, Faculty of
Figure 4 Coronal Tl-weighted MR image reveals a lobulated destructive mass involving the temporomandibular joint. The lesion is mildly hyperintense compared with muscle and brain cortex
Figure 5 Coronal T2-Fast SE MR image shows that the mass in the left TMJ is hyperintense to muscle and isointense to brain. It extends medially into the muscles of mastication. The central hyperintense focus presumably represents necrosis or haemorrhage
Dentistry, University of Stellenbosch, Miss K. Louw for preparing the manuscript and Mr M. Jooste for the photography. Berlimed Schering (South Africa) generously supplied us with Magnevist.
Figure 6 Coronal Tl-weighted SE MR demarcated intramedullary soft-tissue mass lar ramus with similar signal characteristics Figure 4 and lingual cortical interruption. lesion seen on the panoramic radiograph
image shows a well in the right mandibuto the TMJ lesion in It corresponds to the
C.J. Nortji et al.
296 Table I
Metastatic neoplasms to the mandibular condyle. Review of literature
Authors
Age
Sex
Previous malignancy
Presenting symptoms
Primary site
1 2
De Cholnoky 4 Thoma et al?
Unknown 51
Unknown F
Yes No
Not specified TMJ dysfunction
Toe Unknown
3 4
Thoma et al? Salman and Langel''
49 54
Μ F
No Yes, diagnosed 1 month earlier
Unknown Uterus
5
Blackwood 7
24
F
Breast
Adenocarcinoma
6 7
Worth" Ameli and Capaccia1'
Elderly Unknown
Μ Μ
Yes, diagnosed 3 months earlier No No
TMJ dysfunction Hard mass in right preauricular region involving zygoma and parotid glands Numbness of left face and stiffness in the jaw TMJ dysfunction Unknown
Melanoma Transitional cell carcinoma Adenocarcinoma Squamous carcinoma
Rectum Lung
8
Epker et al."'
45
F
Biederman and Winker-Blanck" Hartman et al.'2
Unknown
Unknown
Pain and swelling, left face Pain TMJ
Breast
9
Yes, diagnosed 5 years earlier
Adenocarcinoma Bronchogenic carcinoma Adenocarcinoma
52
F
46
F
12
Agerberg and Söderström 13 Butler 14
49
F
Yes, diagnosed 5 months earlier Yes, diagnosed 2 years earlier Yes, 2 years previously
13
Mace 15
54
F
Yes, diagnosed 3 years earlier
14
Wolujewicz"'
74
Μ
No
15
Mizukawa et al.'7
32
F
16
Compere et al.'*
48
Μ
Yes, diagnosed 3 years previously No
Pain and trismus, inability to masticate Left maxillary and preauricular pain Pain, headache right side Limitation in opening and occasional left mental nerve paresthesia Swelling in preauricular region Pain right TMJ
17
Compere et al.'"
73
F
No
18
Compere et al.'K
65
F
No.
10 11
9
19
Donazzan et al,'
20
Gerlach et al.2"
42
Yes, diagnosed 6 months earlier F Yes, diagnosed 21 years earlier Unknown Unknown
55
F
60
21
21
Giles and McDonald
22
Peacock and Fleet 22
53
Μ
23 24 25
Owen and Stelling 23 Hecker et al.24 De Boom et al.25
68 63 68
Μ F Μ
26
Thatcher and Dye 26
68
Μ
Unknown 52
Μ F
21
27 28
Gormann et al. Webster 28
29 30
Webster 2 " Rubin et al.2"
54 67
F F
31
Cantrambone and Pfeffer 1 0 Rutsatz et al?' Karr et al?2
78
Μ
Unknown 63
Unknown F
55
Μ
35
Van Rensburg and Nortje 3 3 Lalaikos et al?4
15
F
36
Macafee et al.3*
49
Μ
37
Johal et al.™
65
F
32 33 34
Swelling in preauricular region, trismus Swelling in preauricular region, trismus Presented with pain and TMJ dysfunction Pain, TMJ
Swelling, pain right TMJ Yes, diagnosed 6 years Difficult to occlude the earlier teeth and difficult opening No Right facial swelling, pain, and limitation of jaw movements No Pain left TMJ No Trismus pain (5 weeks) Pathologic fracture, No mandibular condyle Unknown Swelling left TMJ (1 month) Pain, TMJ right side No Yes, diagnosed 2 years Right pre-auricular region right TMJ earlier Yes Left TMJ pain No Left facial pain, dislocation (2 months) Pre-auricular swelling Yes (6 weeks) Yes Left TMJ Yes, diagnosed 21 Pain pre-auricular region months earlier Yes, diagnosed 2 years Pain left TMJ joint previously Yes Swelling right TMJ joint Swelling right side of Unknown face. Paresthesia of lip No Pain, limited movement right TMJ
Lung
Tumor type
Breast
Bronchogenic carcinoma Intraductal carcinoma
Breast
Intraductal carcinoma
Breast
Melanoma
Breast
Adenocarcinoma
Prostate
Adenocarcinoma
Breast
Ductal carcinoma
Lung
Squamous cell carcinoma
Pancreas
Not specified
Breast
Adenocarcinoma
Lung
Bronchial epithelioma
Lung
Carcinoma
Rectum
Adenocarcinoma
Lung
Squamous cell carcinoma
Lung Unknown Prostate
Adenocarcinoma Adenocarcinoma Adenocarcinoma
Prostate
Carcinoma
Prostate Lung
Carcinoma Carcinoma
Breast Unknown
Carcinoma Adenocarcinoma
Prostate
Carcinoma
Lung Left foot
Squamous carcinoma Synovial sarcoma
Unknown
Adenocarcinoma
Liver
Carcinoma
Colon
Adenocarcinoma
Unknown
Clear cell tumour
Metastatic melanoma References 1. Stypulkowska J, Bartkowski S, Panas M, Zaleska M. Metastatic Tumors to the jaws and oral cavity. J Oral Surg 1979; 37: 805-89. 2. Mejer I, Shklar G. Malignant tumors metastatic to the jaws. Oral Surg 1965; 20: 350-62. 3. Moss M, Shapiro DN. Mandibular metastasis of breast cancer. J Am Dent Assoc 1969; 78: 756-60. 4. De Cholnoky T. Malignant melanoma. Am Surg 1941; 113: 392-410. 5. Thoma KH, Holland DJ, Rounds CE et al. Tumor of mandibular condyle: report of two cases. Am J Orthod Oral Surg 1947; 33: 344. 6. Salman I, Langel I. Metastatic tumor of the oral cavity. Oral Surg 1954; 7: 1141-9. 7. Blackwood HJ. Metastatic carcinoma of madibular condyle. Oral Surg 1956; 9: 1318-23. 8. Worth HM: Principles and Practice of oral radiologic interpretation Chicago, IL: Year Book Medical, 1963: pp 562-7. 9. Ameli M, Capaccia A. Locolizzozione metastatica isolata del condilo mandibolare da carcinoma bronchogeno. Arch Ital Laring 1965; 78: 165. 10. Epker BN, Merrill RG, Henny FA. Breast adenocarcinoma metastatic to the mandible. Oral Surg 1969; 28: 471-9. 11. Biederman F, Winker-Blanck E. Unterkieferkopfchenmetastase als erstes Symptom eines Bronchialkarzinomas. Fortschr Rontgenstr 1969; 110: 417. 12. Hartman GL, Robertson G R , Sugg W E et al. Metastatic carcinoma of mandibular condyle. J Oral Surg 1973; 31: 716-7. 13. Agerberg G, Söderström U. Metastasis of mammary carcinoma to the mandibular condyle. Int J Oral Surg 1974; 3: 34-40. 14. Butler JH. Myofacial pain dysfunction syndrome involving tumor metastasis: Case report. J Periodontal 1975 ; 46: 309-11. 15. Mace M. Condylar metastasis from mammary adenocarcinoma. Br J Oral Surg 1977; 15: 227-230. 16. Wolujcwicz MA. Condylar metastasis from a carcinoma of the prostate gland. Br J Oral Surg 1980; 18: 175-82. 17. Mizukawa JH, Dolwick MF, Johnson RP. Metastatic breast adenocarcinoma of mandibular condyle. J Oral Surg 1980; 38: 448-51. 18. Compere TF, Deboise A, Bertrand TCH et al. Trois metastases condyliennes. Reve Stomato Chir Maxillofac 1981; 32: 357-60. 19. Donazzan M, Pellerin P, Seak JP, Lectercq A. Lacunes condyliennes mandibulaires. Rev Stomatol Chir Maxillofac 1981; 82: 113-20. 20. Gerlach KL, Horch HH, Lacroix WF. Condylar metastasis from bronchial carcinoma. J Maxillofac Surg 1982; 10: 250-2. 21. Giles DL, McDonald PJ. Pathologic fracture of mandibular condyle due to carcinoma of the rectum .Oral Surg Oral Med Oral Pathol 1982; 53: 247-9. 22. Peacock TR, Fleet JD. Condylar metastasis from a bronchogenic carcinoma. Br J Oral Surg 1982; 20: 39-44. 23. Owen GO, Stelling CB: Condylar metastasis with initial presentation TMJ syndrome. J Oral Med 1985; 40: 198-201.
297 24. Hecker R, Noon W, Elliot M. Adenocarcinoma metastatic to the temporo mandibular joint. J Oral Surg 1985; 43: 629-31. 25. de Boom GW, Jensen JL, Siegel W, Bloom C: Metastatic tumors of the mandibular condyle. J Oral Surg Oral Med Oral Path 1985; 60: 512-6. 26. Thatcher SL, Dye CG. Carcinoma of the prostate metastatic to the mandibular condyle mimicking parotid tumor. J Oral Surg 1986; 44: 394. 27. Gormann R, Meindl G, Bongarty R. Bilateral mandibular metastases of a prostatic carcinoma ROFO 1987; 146: 729 (in German). 28. Webster K. Adenocarcinoma metastatic to the mandibular condyle. J Cranio Maxillofac Surg 1988; 16: 230. 29. Rubin MM, Vivian J and Cozzi GM. Metastatic carcinoma of the mandibular condyle presenting as Temporomandibular joint syndrome. J Oral Surg 1989; 47: 507-10 30. Cantrambone RJ, Pfeffer RC. Significant post operative hemorrhage following biopsy of prostate tumour metastatic to the mandibular condyle. J Oral Surg 1990; 48: 858-61. 31. Rutsatz K, Peter U, Beust M, Hingst V. Metastase eines bronchial karzinomas in kiefergeleukbereich. Kasuistik. Deutch Stomatol 1990; 40: 477. 32. Karr RA, Best CG, Salem PA, Toth BB: Synovial sarcoma metastatic to the mandible: Report of two cases. J Oral Surg 1991; 49: 1341-6. 33. van Rensburg LJ, Nortje CJ. Magnetic resonance imaging and computed tomography of malignant disease of the jaws. Oral Maxillofac Surg Clin Ν Am 1992; 4: 75-101. 34. Lalaikos JF, Sotereanos GC, Nauwtockits, Tzakis AG. Isolated mandibular metastasis of hepotocellular carcinoma. J Oral Surg 1992; 50: 754-9 35. Macafee KA, Quinn PD, Abaza NA. Adenocarcinoma of the colon metastatic to temporomandibular joint: Case report. J Oral Surg 1993; 51: 793-7. 36. Johal AS, Davies SJ, Franklin CD. Condylar metastasis: a review and case report. Br J Oral Maxillofac Surg 1994; 32: 180-2. 37. Atlas SW:. Intraaxial brain tumors. In: Atlas SW, ed. Magnetic resonance imaging of the brain and spine. New York: Raven Press, 1991: 307-10. 38. Atlas SW, Grossman RI, Gouson JM et al. MR imaging of intracranial metastatic melanoma. J Comput Assist Tomogr 1987; 11: 577-82. 39. Rutherfoord GS, Hewlett RH. Supratentorial parenchymal and intraventricular mass lesions. In: G. Austin Gresham, Ed. Atlas of correlative surgical neuropathology imaging Current Histopathology, Vol. 24. 1994, pp 136-143. 40. Kubal WS, McGuire HH. Absent T2 shortening in malignant melanoma of the palate. A potential M R Pitfall. Poster 18, Scientific Poster Exhibits, 1994. International Congress of Head an Neck Radiology, Washington, DC, June 15-19,1994. Address: Professor CJ Nortje, Dept. of Maxillofacial Radiology, Oral and Dental Teaching Hospital, Faculty of Dentistry, Private Bag XI, Tygerberg 7505, Republic of South Africa
