Mandibular metastasis of adenocarcinoma from prostate cancer: case report\naccording to epidemiology and current therapeutical trends of the advanced prostate\ncancer
Male patient, white, 54 years old, was admitted in the Oral and Maxillofacial Trauma and\nSurgery Team at Hospital de Base de Bauru (Bauru Base Hospital), in March 2009. The\npatient's main complaint was pain in the left mandibular region above the median line\nand paresthesia of the anatomical areas sensitized by the Left Alveolar Inferior Nerve,\nbranch of the Mandibular Nerve and Trigeminal Nerve. The first signal related by the\npatient was a pathology originated from a root treatment about one year before, which\ndeveloped a mandibular abscess clinically treated. Once healed from this abscess,\nchronic pain persisted in half mandible associated with localized paresthesia. Because\nof the posterior absence of dental symptoms even as mandibular pain and face\nparesthesia, the clinical dentist referred the patient to the one who suggested the\ndiagnosis of Trigeminal Neuralgia, establishing treatment with Carbamazepin 200 mg and\nGabapentin 300 mg, both once a day, that lasted about 1 year or more.\nThe patient's medical history revealed pharmacologically controlled diabetes and\nprostate acinar adenocarcinoma Gleason score 7 (3+4), with initial PSA score on 4.78.\nThis latter treated in 2005 by means of radical prostatectomy performed in January 2006\n(pT3N0M0), having follow-up procedures with urology, but in a random and intermittent\nmanner, a history not explored or valued by neurology.\nPhysical examination revealed left mandibular bulging in the buccolingual aspect and\ntooth mobility involving bulging region extending to the opposite canine tooth\nassociated with a slight gums erythema, but without symptoms compatible with periodontal\ndisease. In addition, we observed the absence of pathognomonic signs and symptoms of\nclassic Trigeminal Neuralgia, showing no intermittent pain, neither specific localized\npain spots (trigger-points). Based on this clinical symptomatology, we established a\nhypothesis of diagnosis as osteomyelitis and/or cancer, not yet discarding the\npossibility of Atypical Neuralgia of the Trigeminal Nerve ().\nThrough a radiography exam, it was possible to define a mild, diffuse radiolucency in\nthe left mandibular body. The Computed Tomography Scan showed an anatomical structure\nalteration with osteolysis areas in the premolars, molars and in the left region of the\nchin ( and ).\nBecause of that, we carried out an incisional biopsy and culture/antibiogram of\nsensitivity of the affected area. The results showed adenocarcinoma (clear cell type)\nwith necrosis areas and infiltrating bone and soft tissue. The isolated microorganism\nwas Staphylococcus aureus. These findings suggest a metastatic tumor\ninfected by via hematogenous route. The tumor had no communication between the internal\nand external environment, without skin or mucosa fistula, confirmed by whole-body bone\nscintigraphy with special interest in the mandibular region, where increased uptake of\nthe radiocontrast agent was observed, as well as in many areas, such as the right\nclavicle and scapula, humerus, ribs, spine, sternum, hip bone and femur (right/left)\n().\nAfter confirming a definitive diagnosis, the patient was taken to the Oncology Clinic,\nwhere in May 2009 was admitted to the Clinical Oncology Department with a metastatic\nbone disease diagnosis (prostate acinar adenocarcinoma) confirmed by three different\nmethods: bone scintigraphy, incisional biopsy and immunohistochemical analysis of\nmandibular lesions. The treatment consisted of the use of goserelin acetate (3.6\nmg/month) and bisphosphonate (clodronate, 4 ampoules/month). The patient was evaluated\nas having good disease control and good tolerance to treatment for some months, when\ndisseminated neoplasm and pulmonary involvement led to a lethal outcome, with the\npatient's death in less than a year.