Yonago Acta medica 2008;51:49–54

A 6-Year Controlled Gastric Adenocarcinoma
Metastasized to the Lung, Cervical Spine and Mandible
in a Japanese Male: A Patient Report
Takayuki Tamura, Isamu Kodani, Kazunori Kidani, Kazuko Takubo, Miyuki Oki,Hiroatsu Sakai, Shigeki Amekawa, Rieko Doi, Kazuhiko Tanio and Kazuo Ryoke
Division of Oral and Maxillofacial Biopathological Surgery, Department of Medicine of Sensory
and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504
JapanGastric adenocarcinoma metastasized to the lung, cervical vertebrae and mandible 6years after gastrectomy in a 70-year-old man. When the man visited our clinic, he complained of pain in the left mandible with paralysis in the left lower lip and diffuse swelling with a fluctuation inside the left ramus of the mandible. Medium contrast computed
tomography (CT) presented bone loss that looked like a wormhole at the left angle ofthe mandible. Magnetic resonance imaging (MRI) revealed abscess or osteomyelitis atthe site. He showed no response despite treatment with antibiotics, and we suspected aneoplastic lesion. With a mandibular ramus specimen obtained by biopsy and examinedhistopathologically, adenocarcinoma of the salivary gland was strongly suspected. MRI
presented a neoplastic lesion in his cervical vertebrae, and by biopsy he was diagnosed
with adenocarcinoma. Thereafter, chest CT presented multiple pulmonary metastases. Considering the patient’s history of gastrectomy due to gastric adenocarcinoma, thestomach, cervical vertebrae or mandible were examined pathologically and immunohistochemically by biopsy: all specimens showed a moderately differentiated type of tubular
adenocarcinoma, and the results for cytokeratin-related tumor markers were the same.
We finally diagnosed him as having metastases from gastric adenocarcinoma to the lung,cervical vertebrae and mandible. Because the metastases had spread to multiple organs,the mandibular lesion was not treated, and terminal care in another facility was unavoidably selected. In making a differential diagnosis of multiple metastases, pathologicaland immunohistochemical examinations of metastatic lesions by biopsy were very usefulbased on the diagnostic imagings by CT and MRI.
Key words: controlled gastric adenocarcinoma; cytokeratin; mandible; metastatic tumor
Metastatic tumors in the oral region account for lungs and on his cervical vertebrae and mandible.
about 1% of all oral carcinomas. The incidence is
Here we report a brief summary of the case.
low, and many patients contract metastatic tumors
with no former management of primary sites. We
encountered a patient with gastric adenocarcinoma
Patient Reporttreated by 75% gastrectomy 6 years previously
wherein the primary site had long been kept under
A 70-year-old man noticed a pain in the left
control. We found cancerous metastases in his
mandible with paralysis in the left lower lip, andAbbreviations: CT, computed tomography; MRI, magnetic resonance imaging
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visited a nearby dental clinic in December 2004,
where his lower left 1st molar was extracted.
However, the symptoms did not improve andswelling of the buccal region appeared with anincreasing frequency. He visited our clinic atTottori University Hospital in January 2005. The
patient had gastric adenocarcinoma resected 6years previously. By intraoral examination, weobserved discharge of pus from the extraction
wound of the lower left 1st molar, and diffuse
swelling with fluctuations inside the left ramusof the mandible. Viscous fluid was obtained bypuncturing the swelling. A medium contrast
computed tomography (CT) scan revealed boneloss resembling a wormhole at the left angle ofthe mandible (Fig. 1). Magnetic resonance imaging (MRI) showed a high signal with T2 emphasis at the left angle of the mandible, where theinternal cortex was partially destroyed. During
examination, a T2 high signal appeared multilocularly between the destroyed cortex andinside of the masseter muscle. The signal fromthe left masseter muscle to the periphery of thelateral pterygoid muscle suggested the spread ofinflammation. So, we suspected osteomyelitis
or abscess (Fig. 2). Laboratory studies showednormal values except for the amylase level (161abFig. 1. Bone loss looking like a wormhole is visible atthe left angle of the mandible (arrow) by computed tomography with contrast medium. a: Transaxial view. b:
Lateral view.

IU/L). We histopathologically examined a biopsy
specimen of the mandibular ramus and suspectedadenocarcinoma originating from the salivary
gland (Fig. 3). At that time, the patient noticed asharp pain in the cervix, and was referred to theOrthopedic Surgery Clinic of our hospital. There,
he underwent MRI, which revealed a neoplastic
lesion of the cervical vertebrae (Fig. 4). Throughbiopsy carried out under CT guidance, we madethe diagnosis of adenocarcinoma. Consequently,
he was subjected to a complete medical workup:a CT scan showed multiple tubercles and cystic
lesions in both pulmonary fields by which wemade the diagnosis of lung metastases. Consider-Fig. 2. Magnetic resonance imaging shows partial lossof the cortical bone of the left ramus of the mandible,
which shows a high signal destroyed by T2 emphasis.
The high T2 signal is multilocularly seen between thedestroyed cortex and inside of the left masseter muscle(arrowFig. 3. Glandular atypical epithelium is found in several
places with inflammation on the biopsy specimen of themandibular ramus (hematoxylin and eosin stain). Bar=100 μm.

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