Metastatic breast cancer in the mandibular condyle mimicking temporomandibular joint (TMJ) disease
A 48-year-old woman was referred to our clinic for clarification of a preauricular swelling, headache and pain of the right TMJ.\nShe had a 12-year history of metastatic adenocarcinoma of the left breast. Mastectomy, axillar lymphadenectomy and primary chemotherapy of the left breast had been performed. Due to distant metastases right adnexectomy and radiotherapy of the left iliac bone were done.\nBecause of multiple bone metastases the patient had also received hormone and bisphosphonate therapy.\nSeveral months before referral the patient complained about symptoms in the right TMJ region and was then sent to an otorhinolaryngologist, who suspected a parotitis. The investigation with ultrasound showed a healthy parotid gland and an enlarged articular capsule. Aspiration cytology from the preauricular swelling was then performed. No malignant tumour cells were detected. After the aspiration she felt better and the swelling disappeared. The symptoms were interpreted as a degenerative arthritis.\nApproximately 4 months later symptoms returned. A computed tomography (CT) scan of the head was ordered by the oncologist. An osteolytic lesion and partial sclerosis of the right condylar head and neck were found, as well as effusion in the right TMJ (Fig. ). The signs were interpreted as arthritis of the TMJ.\nBecause of persistence of the swelling, massive preauricular and temporal pain and a slight impairment of mouth opening the patient was referred to us.\nClinically, a preauricular swelling on the right side which caused asymmetry was visible. The overlying skin was normal. Palpation was painful and consistence was fluctuant. No deviation was found at mouth opening. Mouth opening was 43 mm, but subjectively reduced. Occlusion was, despite the preauricular swelling, correct.\nAfter clinical examination an magnetic resonance imaging (MRI) scan was done. A large joint effusion in the right TMJ was found and interpreted as an arthritis (Fig. ).\nBecause of the history of breast cancer and the persistent pain and swelling, an arthrocentesis, lavage and application of 20 mg Kenacort into the right TMJ was performed. The histology showed synovial cells, hystiocytes, erythrocytes, but no malignant cells.\nOne week later there was no swelling visible and the patient was painless.\nA full-body skeletal scintigraphy was done, which did not show an obvious pathology in the right TMJ (Fig. ). Due to this, a SPECT/CT was performed for clarification. High uptake of nuclides was seen around the osteolysis of the right condyle (Fig. ). Sclerotic changes without increased uptake were noted in the left condyle (Fig. ).\nThe sclerosis of the left TMJ was suspected to be a non-active metastasis.\nIn summary, from the radiological findings bilateral TMJ metastases were diagnosed, which were, however, not confirmed histologically.\nBecause of persisting symptoms in the right TMJ, a palliative radiotherapy was done to the right condyle with a total dose of 40 Gy (16 fractions). After that the patient was free of pain.\nAt the last clinical follow-up (November 2013) the patient was free of complaints and no swelling was detectable.