The mandibular condyle as uncommon metastatic site of neuroendocrine carcinoma: Case report and review of literature

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Pleasecitethisarticleinpressas:VairaLA,etal.Themandibularcondyleasuncommonmetastaticsiteofneuroendocrinecarcinoma: Casereportandreviewofliterature.JOralMaxillofacSurgMedPathol(2017),http://dx.doi.org/10.1016/j.ajoms.2017.01.006

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JournalofOralandMaxillofacialSurgery,Medicine,andPathologyxxx(2017)xxx–xxx

ContentslistsavailableatScienceDirect

Journal

of

Oral

and

Maxillofacial

Surgery,

Medicine,

and

Pathology

jou rn a l h om ep ag e :w w w . e l s e v i e r . c o m / l o c a t e / j o m s m p

Case

report

The

mandibular

condyle

as

uncommon

metastatic

site

of

neuroendocrine

carcinoma:

Case

report

and

review

of

literature

Luigi

Angelo

Vaira

c,a,∗

_,

_Olindo

_Massarelli

a

_,

_Angelo

_Deiana

b

_,

_Gabriele

_Vacca

a

_,

Giovanni

Dell’aversana

Orabona

c

_,

_Pasquale

_Piombino

d

_,

_Giacomo

_De

_Riu

a

a_University_Hospital_of_Sassari,_{Maxillofacial}_Surgery_Unit,_Viale_San_Pietro_43B,₀₇₁₀₀_Sassari,_Italy b_University_Hospital_of_Sassari,_Human_Pathology_Unit,_Via_Matteotti_58,₀₇₁₀₀_Sassari,_Italy c_University_Hospital_of_Naples_“Federico_II”,_{Maxillofacial}_Unit,_Via_Pansini_5,₈₀₁₃₁_Naples,_Italy d_Second_University_of_Naples_Hospital,_ENT_Unit,_Via_Pansini_5,₈₀₁₃₁_Naples,_Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received4November2016

Receivedinrevisedform19January2017 Accepted28January2017 Availableonlinexxx Keywords: Temporo-mandibularjoint Temporo-mandibularmetastasis Condylarmetastasis

Temporo-mandibularjointdisorders Neuroendocrinecarcinoma

a

b

s

t

r

a

c

t

Temporo-mandibularjoint(TMJ)metastasesareaveryrareeventandonly73casesarereportedin literature.Inabout40%ofcasescondylarmetastasesrepresentthefirstclinicalmanifestationofatumor ofelsewhereandmaythenallowanearlydiagnosis.However,theidentificationofthistumoralprocess canbedifficultasinover50%ofthecasesithasanuancedclinicalpresentationthatisverysimilarto temporo-mandibulardisorders.

Theﬁrstcaseofmetastaticneuroendocrinecarcinoma(NEC)ofthetemporo-mandibularjoint(TMJ) mimickingatemporo-mandibularjointdisorderispresentedinthisreport.Furthermore,anextensive reviewoftheliteraturehasbeenperformedinordertoestablishacorrectdiagnostic–therapeuticprotocol fortheseoncologicpatients.

1. Introduction

Primary neoplasmof the mandible are more common than metastaticdisease,whichrepresentsonly1%ofsuchtumors[1]. Metastases are more commonly seen in the hematopoietically activemarrowoftheskeletalbones.Thecancellousboneatthese levelsisindeedrichwithsinusoidalvascularspacesthatpermit tumorcellspenetration.Themandibleisnotasiteofactivemarrow inhumans,particularlyinolderindividuals.Whencancellous mar-rowispresent,itisusuallyintheposterioraspectofthemandible

[2].

Ifmetastatictumorsofthemandiblearerare,involvementof themandibularcondylesbysuchgrowthsisevenrarerand,since theﬁrstdescriptionbyDeCholnokyin1941[3],only73casesare reportedininternationalliterature.

Anunusualcaseofmetastaticneuroendocrinecarcinoma(NEC) ofthetemporo-mandibularjoint(TMJ)isdescribedinthisreport.

夽 AsianAOMS:AsianAssociationofOralandMaxillofacialSurgeons;ASOMP:Asian SocietyofOralandMaxillofacialPathology;JSOP:JapaneseSocietyofOral Pathol-ogy;JSOMS:JapaneseSocietyofOralandMaxillofacialSurgeons;JSOM:Japanese SocietyofOralMedicine;JAMI:JapaneseAcademyofMaxillofacialImplants.

∗ Correspondingauthorat:ViaPietroCanalis12,07100Sassari,Italy. E-mailaddress:luigi.vaira@gmail.com(L.A.Vaira).

Thecaecumwasthesiteofarisingoftheprimarytumor.Thisisthe ﬁrstreportofmetastaticTMJinvolvementofaNEC.

2. Casereport

A 66-year-old Caucasian man presented withan episode of acuteintestinalobstruction.Hismedicalhistoryincludedchronic ischemicheartdisease,hypercholesterolemiaandhypertension.He wasthereforehospitalizedattheDepartmentofSurgery.

AtotalbodyCTscanwasthenexecutedshowinga9cm cae-calmasswithinfiltrationofthelastilealloopandtheappendix. Aregionallymphonodalinvolvementandthepresenceofasingle livermetastasiswererevealed.Thepatientunderwentimmediate rightcolectomywithcontemporaryresectionofthehepatic metas-tasis.Histologicalexaminationrevealed aLarge CellNECof the largebowel.Theintestinalmucosawasinfiltratedbya prolifer-ationoftumorcellfaintlyarrangedinaorganoidgrowthpattern. Thetumorwascomposedoflargecellslayerswithscantcytoplasm andenlarged,pleomorphicnuclei.Numerousapoptoticbodiesand mitoticfigureswereobserved.High powermagnification ofthe tumorshowedglandulardifferentiationandprominent intracyto-plasmicmucinvacuoles,yieldinga“signetringcell”appearance. Tumorcellsshowedimmunoreactivityforchromograninand Ki-67;labelingindexwas95%(Fig.1).

http://dx.doi.org/10.1016/j.ajoms.2017.01.006

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2 L.A.Vairaetal./JournalofOralandMaxillofacialSurgery,Medicine,andPathologyxxx(2017)xxx–xxx

Fig.1. HistologicfeaturesofcaecumNEC.A(H&E,20×):Theintestinalmucosaisinfiltratedbyaproliferationoftumorcellfaintlyarrangedinaorganoidpattern.B(H&E, 40×):Thetumoriscomposedofsheetsoflargecellswithscantcytoplasmandenlarged,pleomorphicnuclei.Numerousapoptoticbodiesandmitoticfiguresareobserved.C (H&E,100×):High-powermagnificationofthetumorshowingglandulardifferentiationandprominentintracytoplasmicmucinvacuolesoftumorscells,yieldinga“signet ringcell”appearance.D(Peroxidasestain,40×):Thetumorcellsshowimmunoreactivityforchromogranin.Ki-67labelingindexwas95%.

During the post-operative period the patient complained ingravescentright TMJ pain and wasreferred toMaxillo-Facial SurgeryDepartmentforevaluation.

Hereportedthat,actually,rightTMJpainandlimitationofjaw movementsstartedabout8monthsbefore.Forthatproblemhe alreadyturnedtohisdentistthat,inthesuspicionofaTMJ disor-der,prescribedNSAIDsandmyorelaxanttherapy.Twoweeksafter, duetothesymptomspersistence,thepatientperformed radiologi-calexams.OrthopantomographanddynamicTMJradiographswere totallynegative.TMJmagneticresonance,ofwhichthepatienthad noimages,referredanteriordisplacementoftherightdisk,without reduction,intra-articulareffusionandmorphologicalalterationsof thecondylecompatiblewitharthriticdegeneration.Clinical and radiologicaldiagnosisofnotreducibleTMJdiskanterior displace-mentwasthenmadeandthepatientbeginsaconservativetherapy withocclusalbitethatwascontinued,withoutanybeneﬁt,for5 monthsuntiltheadmissionattheDepartmentofSurgery.

Clinical examination of thepatient didnot show masses or swellingoftherightTMJ,masticatorymusclesappearedcontracted andpainful.Thepatientcomplainedpainbothatrest(VAS5)and duringmandibularmovement(VAS9).Maximummouthopening was15mmwithrightdeviation;leftlateralexcursionwas2mm whereasthere wasnorestrictionof therightlateralexcursion. Parotidglandssecretionwasclearandthepatientdidnotshow cervicallymphadenopathy.Theoralcavityinspectionwasnormal. Therewasdeepbite,ClassIIocclusionwithcompletemolar eden-tulism.

ToinvestigatethepresenceofaTMJmetastaticlesion, maxillo-facialcontrastedCTscanwasthenperformedshowingstructural subversion of therightcondyle withosteosclerotic areas alter-nateto3–5mmindiameterosteolyticlesions.Theperiosteumand

Fig.2. RightTMJCT-scanshowingosteoscleroticareasalternateto3–5mmin diam-eterosteolyticlesions.

thelateralpterygoid musclepresented increasedthickness and oedemawithoutotherssigniﬁcantalterations(Fig.2).

The patient was submitted to open biopsy, frozen sections confirmedthemalignancysuspicion.Condylectomywithhealthy marginswasthenperformedinthesamesurgery(Fig.3).Definitive histologicexaminationconfirmedthediagnosisofmetastaticlesion showingepithelialscatteredsignet-ringcellscontaining intracyto-plasmicmucinaandpoorlyformedglandularlumenarrangedin

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L.A.Vairaetal./JournalofOralandMaxillofacialSurgery,Medicine,andPathologyxxx(2017)xxx–xxx 3

Fig.3.Intraoperativeviewshowingtherighttemporo-mandibularjoint.

clustersandislandgrowingwithinthebone.Tumoralcellswere immunoreactiveforchromograninAandKi-67,labelingindexwas 80%(Fig.4).

Aftersurgery,thepatientwassubjectedtoregional radiother-apyassociatedwithchemotherapy(streptozotocinincombination with5-ﬂuorouracil).Threemonthsaftersurgeryanewtotalbody CTscanhasbeenexecutedshowingtheappearanceofpulmonary and hepaticmetastases. Therapiddeterioration inthepatient’s conditionledtohisdeathsixmonthsafterdiagnosis.

3. Discussion

NECofthecolonandrectumarequiterare,representing approx-imately 0.3–0.1%of all colorectal carcinomas [4,5]. The growth patterns and cytological features are typicalof neuroendocrine tumors.Thepresenceofneurosecretorygranulesinthecytoplasm oftumorcellsdetectedbyelectronmicroscopyischaracteristic. Furthermore,neuroendocrine carcinomas typically stainfor the immunohistochemicalmarkerssynaptophysin,chromogranin,or neuron-speciﬁcenolase.Comparedwithcolo-rectal adenocarcino-mas,NEChaveasigniﬁcantlypoorerprognosisandmostpatients (around70%)hadmetastaticdiseaseatthetimeofdiagnosis.The metastaticpattern is relativelyconsistentandincludes regional lymphatics andlymphnodes,otherthantheliverand thelungs

[6].Bonemetastasesarelesscommon,althoughtheirfrequency isincreasingduetoimprovementsinsurgicalandmedical man-agementofthesepatients.

BonemetastasesmechanismofNECshowedthespreadof neo-plasticcellsfromtheprimarytumorinvadingbloodvesselsand spreadingasembolitodistantregions,suchasthebone. Malig-nanttumorcellsadheretobloodvesseltoenterthebonematrix throughextravasations,weretheythenproliferate.NEC’scells pro-ducedifferentchemokines,thusbothosteoblasticandosteolytic metastasescanbeobserved[7].

Fig.4. HistologicfeaturesofcondylarNECmetastasis.A(H&E,4×):Epithelialtumorcellsarrangedinclustersandislandsaregrowingwithinthebone.B(H&E,40×):Clustersof carcinomacellsshowscatteredsignet-ringcellscontainingintracytoplasmicmucinaandpoorlyformedglandularlumen.C(H&E,100×):Smallclusterofepithelialcarcinoma cellsshowasignet-ringappearancewithcellcontainingintracytoplasmicmucina.D(Peroxidasestain,40×):ThetumorcellsareimmunoreactiveforchromograninAand Ki-67.Thelabelingindexis80%.

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Please cite this article in press as: Vaira LA, et al. The mandibular condyle as uncommon metastatic site of neuroendocrine carcinoma: Case report and review of literature. J Oral Maxillofac Surg Med Pathol (2017), http://dx.doi.org/10.1016/j.ajoms.2017.01.006

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JOMSMP-600; No. of Pages 7 4 L.A. Vaira et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2017) xxx–xxx Table1

Reportofcondylarmetastasisininternationalliterature(1941–2016)[Abbreviations:NR:notreported;w:week;m:month;y:year].

Authors Previousmalignancy Presentingsymptoms Primarysite Tumortype Treatment Prognosis

DeCholnoky,1941[3] Yes Notreported Toe Melanoma NR NR

Thoma,1947[11] No TMJdysfunction Unknown Adenocarcinoma NR NR

Thoma,1947[11] No TMJdysfunction Unknown Transitionalcellcarcinoma NR NR

Salman,1954[12] 1mbefore Hardmass Uterus Squamouscellcarcinoma None Died3mlater

Blackwood,1956[13] 3mbefore Swellingandtrismus Breast Adenocarcinoma None Died4mlater

Ameli,1965[14] No Notreported Lung Bronchogeniccarcinoma NR NR

Worth,1966[15] No TMJdysfunction Rectum Adenocarcinoma NR NR

Epker,1969[16] 5ybefore Pathologicfracture Breast Adenocarcinoma RT Died1mlater

Hartman,1973[17] 5mbefore TMJdysfunction Breast Adenocarcinoma NR NR

Agerberg,1974[18] 2ybefore TMJdysfunction Breast Adenocarcinoma RT/CT Died5mlater

Butler,1975[19] 2ybefore TMJdysfunction Breast Melanoma NR NR

Mace,1978[20] 3ybefore Swelling,trismusandmentalparesthesia Breast Adenocarcinoma Tumorresection Died6mlater

Wolujewicz,1980[21] No Swelling Prostate Adenocarcinoma RT Diedshortlyafter

Mizukawa,1980[22] 3ybefore TMJdysfunction Breast Adenocarcinoma NR NR

Compère,1981[23] No Swellingandtrismus Lung Bronchogeniccarcinoma NR NR

Compère,1981[23] No Swellingandtrismus Pancreas NR NR NR

Compère,1981[23] 6mbefore TMJdysfunction Breast Adenocarcinoma NR NR

Donazzan,1981[24] 21ybefore TMJdysfunction Lung Bronchogeniccarcinoma NR NR

Gerlach,1982[25] NR Swellingandpain Lung Bronchogeniccarcinoma RT Died8mlater

Giles,1982[26] 6ybefore TMJdysfunction Rectum Adenocarcinoma NR NR

Peacock,1982[27] No TMJdysfunction Lung Bronchogeniccarcinoma RT Died3mlater

DeBoom,1985[28] No Pathologicfracture Prostate Adenocarcinoma NR NR

Owen,1985[29] No TMJdysfunction Lung Adenocarcinoma NR NR

Hecker,1985[30] No TMJdysfunction Unknown Adenocarcinoma NR NR

Tatcher,1986[31] NR Swelling Prostate Adenocarcinoma NR NR

Sokolov,1986[32] 12ybefore TMJdysfunction Breast Adenocarcinoma NR NR

Sokolov,1986[32] 6ybefore TMJdysfunction Breast Adenocarcinoma NR NR

Lowicke,1987[33] Yes Notreported Kidney NR NR NR

Gormann,1987[34] No TMJdysfunction Prostate Adenocarcinoma NR NR

Webster,1988[35] 2ybefore Notreported Lung Bronchogeniccarcinoma NR NR

Webster,1988[35] Yes TMJdysfunction Breast Adenocarcinoma NR NR

Cuttino,1988[36] 2ybefore TMJdysfunction Breast Adenocarcinoma NR NR

Rubin,1989[37] No TMJdysfunction Unknown Adenocarcinoma NR NR

Catrambone,1990[38] Yes Swelling Prostate Adenocarcinoma NR NR

Karr,1991[39] 21mbefore TMJdysfunction Leftfoot Synovialsarcoma NR NR

Lalaikos,1992[40] Yes Swelling Liver Hepatocellularcarcinoma NR NR

VanRensburg,1992[41] 2ybefore TMJdysfunction Unknown Adenocarcinoma NR NR

MacAfee,1993[42] NR Swelling,paresthesiaofthelip Colon Adenocarcinoma NR NR

Stavropoulos,1993[43] 7ybefore TMJdysfunction Breast Adenocarcinoma NR NR

Johal,1994[9] No TMJdysfunction Kidney Clearcellcarcinoma CT Died18mlater

Nortjé,1996[44] 2ybefore TMJdysfunction Nose Melanoma CT Died6mlater

Porter[45] Yes Swellingandpain Testicle Teratoma RT Died5mlater

Beck-Managetta,1997[46] 1ybefore Swelling Lung Adenocarcinoma RT Aliveafter18m

Cohen,1998[47] No TMJdysfunction Unknown Squamouscellcarcinoma NR NR

Kolk,2003[48] Yes TMJdysfunction Stomach Adenocarcinoma Tumorresection+RT/CT NR

Deeming,2003[49] 3ybefore TMJdysfunction Breast CystosarcomaPhyllodes RT Died6mlater

Smolka,2004[50] 2ybefore Swelling,painandmalocclusion Stomach Adenocarcinoma Tumorresection+RT Aliveafter8m

Mason,2005[1] No Hardmass Rectosigmoidcolon Adenocarcinoma None Diedshortlyafter

Kaufmann,2005[51] Yes TMJdysfunction Lung Bronchogeniccarcinoma RT NR

Duker,2006[52] Yes TMJdysfunction Breast NR NR NR

Miles,2006[53] 19ybefore TMJdysfunction Breast Adenocarcinoma Tumorresection NR

Menezes,2008[54] No Swellingandpain Breast Adenocarcinoma NR NR

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Please cite this article in press as: Vaira LA, et al. The mandibular condyle as uncommon metastatic site of neuroendocrine carcinoma: Case report and review of literature. J Oral Maxillofac Surg Med Pathol (2017), http://dx.doi.org/10.1016/j.ajoms.2017.01.006

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JOMSMP-600; No. of Pages 7 L.A. Vaira et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2017) xxx–xxx 5 Table1(Continued)

Authors Previousmalignancy Presentingsymptoms Primarysite Tumortype Treatment Prognosis

Boniello,2008[56] No TMJdysfunction Lung Adenocarcinoma Tumorresection Died6mlater

Schulze,2008[57] No TMJdysfunction Lung Bronchogeniccarcinoma Biphosphonates NR

Gomes,2009[58] No Hardmass Unknown Adenocarcinoma NR Died4mlater

Kruse,2010[59] No Hardmassandpain Lung Bronchogeniccarcinoma CT Died4wlater

Kruse,2010[59] 9ybefore Pathologicfracture Tyroid NR NR NR

Kruse,2010[59] No Swelling,painandtrismus Lung Adenocarcinoma None Died2wlater

Katsnelson,2010[60] No Swelling,painandtrismus Lung Bronchogeniccarcinoma RT/CT NR

Cristofaro,2011[61] No Swellingandpain Prostate Adenocarcinoma Tumorresection+RT/CT Aliveafter2y

Cristofaro,2011[61] NR Swellingandtrismus Kidney Clearcellcarcinoma Tumorresection+CT Aliveafter8m

Patricia,2011[62] Yes TMJdysfunction Breast Adenocarcinoma RT Died6mlater

Kelles,2021[63] 3ybefore Swellingandtrisums Kidney Clearcellcarcinoma RT/CT NR

Scolozzi,2012[64] No TMJdysfunction Lung Largecellcarcinoma RT/Ct Died6mlater

Freudlsperger,2102[65] 5ybefore TMJdysfunction Prostate Adenocarcinoma RT/CT NR

Puranik,2013[10] Yes Asymptomatic Uterinecervix Squamouscellcarcinoma RT/CT NR

Qiu,2013[8] No Swelling Prostate Adenocarcinoma Tumorresection+CT Died1ylater

Qiu,2013[8] 6mbefore Swellingandnumbness Penis Squamouscellcarcinoma Chemotherapy Died3mlater

Qiu,2013[8] No Swellingandpain Bladder Adenocarcinoma Tumorresection+CT Died6mlater

Qiu,2013[8] 6ybefore Swellingandpain Colon Adenocarcinoma Chemotherapy Died3mlater

Qiu,2013[8] No TMJdysfunction Lung Bronchogeniccarcinoma Chemotherapy Died6mlater

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6 L.A.Vairaetal./JournalofOralandMaxillofacialSurgery,Medicine,andPathologyxxx(2017)xxx–xxx Besttoourknowledge,thisistheﬁrstreportofNECmetastatic

spread to TMJ. The frequency of metastatic spread of any malignancytothemandibularcondyleis lowforunknown rea-sons.Itmaypossiblyreﬂectthepoorlocalbloodsupply,thelackof hemopoieticmarrow,thepresenceofbonecortexthatlimitsthe spreadofsynovialmalignancyintothemarrowofthecondyleor thefactthathematogenousmetastasestosuchaminorjointusually representstheﬁnalstageofmalignantdisease,wheregeneralized metastasesalreadyshouldbeclinicallypresent[8–10].

Since1941only73casesofTMJmetastaseshavebeenreported.

Table1showstheframeworksummaryoftheresultsofour

exten-sivereview.

Patient’s ages ranged from 15 to 85 (mean 57,7 years), 32 patients were male and 38 female, in 3 cases genre was not reported.Adenocarcinomaisthemostcommonhistotypefounded in TMJ metastases (56,1%), followed by squamous cellular car-cinoma (20,5%), melanoma (4,1%), clear cell carcinoma (4,1%), hepatocellularcarcinoma(2,7%),synovialcellsarcoma(1,3%),large cellcarcinoma(1,3%),transitionalcellcarcinoma(1,3%),teratoma (1,3%)andcystosarcomaphyllodes(1,3%).Regardingthe metas-tasesoriginsthemostcommonprimarytumorsiteswerebreast (27,6%),lung(21%),prostate(10,5%),largebowelandrectum(6,5%), kidney(5,2%),uterus(3,9%),liver(2,6%),foot(2,6%),bladder(1,3%), pancreas(1,3%),tyroid(1,3%),testicle(1,3%)andpenis(1,3%).In 9,2%ofthecasesprimarytumorremainedunknown.It’s impor-tanttoemphasizethatTMJmetastasis,signofadvancedmetastatic disease,wasthefirsttumoralmanifestationin28patients(36,8%). Thelack of anyother oncologicsign orsymptom madethe diagnosisvery difficult in these cases. When history of malig-nancywaspresent,TMJmetastasisappearedwithavariablelatency between1monthto21yearsafterthefirstcancerdiagnosis.Even clinicalpresentationishighlyvariableandoftennonspecific. Preau-ricolarswelling,masses orpathological fracturesarepresent in 42.4%ofthepatientsonly.In50,6%ofthecasesclinical presen-tationisnonspecificand, asinourcase, broadlycomparableto amandibulardysfunction:limitationoralterationofmandibular movements,pain,clicksandcrepitationswithoutanysignoftumor. Thisnuancedclinicalpresentationcantherebysignificantlydelay thecorrectdiagnosis.Thesymptomscanbemistakenascausedby mandibulardisorders,osteomyelitisordentalproblems.Thenon specificityoftheclinicalpresentationisreflectedinaradiological picturehighlyvariable:arerepresentedaggressiveTMJ destruc-tivemassesandlessdefinedosteolyticorosteoblasticalterations. Forthisreasonconventionalradiographsarenotparticularly sensi-tiveinidentifyingmetastaticlesions[45].Radioisotopicscannings (Scintigraphy,SPECT,PET/CT) can showan abnormal uptake of bone-seekingisotopesbeforethatalesioncanbeidentifiedonplain radiographs,butarenot specificandmaynotdetectmetastatic tumorswithminimalorabsentosteoblasticactivity.PET/CTdetects theabnormalglycometabolismof malignanttumorcells that is quitedifferentfromnormal cellsand benigntumorcells. How-everit hassomelimitationindistinguishinginflammationfrom malignancy[8].

Openbiopsyorﬁne-needlebiopsyarethereforenecessaryfor thecorrectdiagnosis.

Theprognosisofmandibularmetastasesisverypoor.Patient survivalrangedfrom2weeksto18months,withamediumlife expectancyofapproximately3months.Forpatientswith condy-larmetastases, thelowsurvival ratemaybeexplainedbecause thereareoftenmultipleconcurrentmetastasesinthelatestageof disease[8].Forpatientswithmultiplemetastases,themost com-montreatmentapproach was combinedpalliative radiotherapy andchemotherapy.

SurgicalTMJ metastaticresectionand adjuvant radiotherapy seemtobeindicatedonlywhenitisasolitarymetastasesandthe primarydiseaseiscontrolled[8,50,53,61].

4. Conclusions

InalltheTMJdiseases,primaryormetastaticcondylartumors shouldbeincludedinthedifferentialdiagnosis,especiallywhen thesymptomsdonotrespondtotreatmentandinpatientwithan historyofmalignancy.

Inthesecases,contrastedCTscanorMRIshouldbealwayspart ofthediagnosticprocedure.

However,theselesionsareoftenasignofadvancedneoplastic diseasewithverypoorprognosisleavingplaceforsurgeryonlyin afewselectedcases.

Ethicalapproval

ThisstudyisapprovedbyUniversityofSassariEthical commit-tee.

Conﬂictofinterest

Theauthorsdeclarethattheyhavenoconﬂictofinterest. Acknowledgment

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