Late Metastasis from Breast Cancer Mimicking Primary Chronic Osteomyelitis of Jaw: A Case Report

Case Report

Austin ENT Open Access. 2018; 2(1): 1007.

Late Metastasis from Breast Cancer Mimicking Primary Chronic Osteomyelitis of Jaw: A Case Report

Hanc D¹*, Altun A² and Dinç S³

¹Department of Otolaryngology, Okmeydani Training and Research Hospital, Istanbul, Turkey

²Department of ENT clinics, Yunus Emre Hospital, Istanbul, Turkey

³Department of Radiology Department, Memorial Hospital, Istanbul, Turkey

*Corresponding author: Hanc D, Department of Otolaryngology, Okmeydani Training and Research Hospital, Istanbul, Turkey

Received: January 08, 2018; Accepted: February 12, 2018; Published: February 22, 2018


Breast cancer is the most frequently diagnosed cancer in females. Even in early stage breast cancer, probability of local recurrence and metastasis in long period should be considered. We present a case CT and MRI findings were identified as an unusual presentation of late metastases of breast cancer. An 80-year-old female with previous history of breast cancer 16 years ago presented with vertigo and malnutrition. She had swelling, paresthesia on the right side of the cheek and difficulty in chewing. There wasn’t any sign of infection. Diffuse osteosclerosis without lysis and adjacent soft tissue swelling was seen on the right side of the mandible on CT scans. No fistula tract was identified. Cortical thickening, low signal intensity on T1 weighted images and high signal intensity on T2 weighted images of bone marrow was identified on MRI scan. Buccal, gingival and masetter muscle swelling were noted. These radiologic findings are more compatible with primary chronic osteomyelitis rather than breast cancer metastasis. Biopsy is needed for diagnosis.

The purpose of this report is to describe late metastases of breast cancer mimicking primary chronic osteomyelitis and its differential diagnosis in the mandible.

Keywords: Breast Carsinoma; Mandible; Metastasis; Osteomyelitis


Metastatic tumors to the oral region are not common. Metastatic lesions may occur in the oral soft tissues, in the jawbones or in both osseous and soft tissue. Oral cavity metastases are considered rare and represent approximately 1% of all oral malignansies. Because of their rarity and atypical clinical and radiographic apperance, metastatic lesions are consider a diagnostic challenge. Because the most common jaw symptom is pain, these lesions could be misdiagnosed as pathologic entities with dental origin. Brest canser is one the most frequent canser in women worldwide. Brest canser is also the most frequent neoplasm that can metastasise to the head and neck region. In women the most common metastatic malignancies arise from primary cancers in from the breasts (42%), adrenals (8.5%), genital organs (7.5%) and thyroid glands (6%), but in men they arise from the lungs (22.3%), prostate (12%), kidneys(10.3%), bone (9.2%) and adrenals (9.2%). The lung cancer is the most common cancer that metastases to the oral soft tissues, whereas the breast cancer is the most common for metastatic tumors to the jawbones. The mandible is the most common location for metastases, with the molar area being the most frequently involved site in the jaw bones [1-4]. These sites are considered vulnerable to the deposition of neoplastic cells because of the presence of hematopoietic bone marrow, branching of the local blood vessels and slowing of blood flow [4].

Metastatic tumors of the oral cavity do not exhibit a pathognomonic radiographic appearance; therefore, radiographic examination is rarely considered diagnostically important. The diagnosis of a metastatic lesion in the oral region is challenging. Although most patients are previously diagnosed with primary neoplasms and treated, in one-third of the metastases the oral region presents the first clinical sign of the malignancy [5].

Patients with metastatic jaw disease demonstrate various clinical signs and symptoms that include commonly pain, swelling, paresthesia of the lip, loose or extruded teeth, halitosis, gum irritation, trismus, regional lymphadenopathy, mandibular nerve involvement and numb-chin syndrome, cortical expansion of the jawbones, ulceration, and exophytic growth [1,2,4]. Numbness or paresthesia of the lower lip and chin is considered an important sign of metastatic disease [5].

The clinical presentation simulates common pathologic conditions such as toothache, osteomyelitis, inflammatory hyperplasia, temporomandibular joint pain, trigeminal neuralgia, periodontal conditions, pyogenic, or giant cell granuloma, and accordingly, it may be difficult to diagnose such cases.

In the initial stages of the disease, the lesion may not produce a radiographic appearance. In an analysis of 390 cases of metastatic tumors of the jaw, Hirshberg et al. found that 5.4% of them did not show any important radiographic change [5].

The clinical appearance and course of primary chronic osteomyelitis makes diagnosis more difficult compared with cases of acute and secondary chronic osteomyelitis. A predisposing event, such an oral surgical procedure or an infectious tooth is missing. Clear signs of infection, such as pus or fistula formation are lacking.

The purpose of this report is to describe late metastases of breast cancer mimicking primary chronic osteomyelitis and its differential diagnosis.

Case Presentation

An 80-year-old female with a history of breast cancer 16 years admitted to our ENT clinic with complaints of difficulty in feeding, fatigue and subtle pain in the area of right mandibular molar parts. She had numbness for 3 years and swelling for 1 year on the right side of the cheek. In the medical anamnesis, it was discovered that the patient was operated (modified radical mastectomy with axillary lymph node dissection) for breast carcinoma of the right breast 16 years ago. After operation the patient did not take radiotherapy and chemotherapy treatment. The patient did not take bisphosthatase treatment. She had visited her physician 5 years periodically for annual examination. The patient’s medical history included diabetes and hypertension, and there was no history of tobacco or alcohol use. Clinical examination was difficult because of severe trismus. An intra–oral examination diffuse swelling, hard in palpation was observed on the right half of the mandibula. Movement of the jaw was restructed. There was severe pain over the right half of the face and paresthesia of the lower lip and chin. Regional lymph nodes were not palpable.

Axial and serial cross-sectional 1 mm-thick Cone Beam Computed Tomography (CBCT) showed small radiolucent areas in close proximity to the third molar (Figure 1) that were not diagnostic of metastases.