malignant metastatic involvements of oral tissues have been infrequently reported only in 1% of all oral malignancies.[14 ] breast , lung , kidney , thyroid , and prostate are the most common primary sites . furthermore , metastasis to soft tissues is less common compared with the osseous structures , and metastasis to gingiva is very rare and usually occurs as gingival hyperplastic or reactive lesions with clinical appearance of pyogenic granuloma or epulis.[79 ] a case of metastatic signet ring cell adenocarcinoma of the esophagus in a 60-year - old patient is reported here in which the patient had no complaint related to the primary site and presented as multiple localized gingival growths .
a 60-year - old male patient came to opd of karnavati school of dentistry , uvarsad , gandhinagar , gujarat , with the chief complaint of mobile teeth in lower right back teeth region since 1 year and he noticed swelling of gums in right side upper and lower back teeth region since 1 month with occasional bleeding tendency .
he had history of exfoliation of 11 , 18 , and 26 before 45 years .
intraoral examination revealed exophytic sessile growth of gingiva of 33 cm in size in right mandibular posterior region , which was extending from right mandibular first molar to third molar and extending into lower vestibular mucosa .
on palpation , growth was firm , non - tender , with 47 and 48 grade iii mobile . bleeding on probing was also present .
we found another exophytic growth of 23 cm in size with pedunculated base in maxillary right posterior region extending from distal of 15 to distal of 16 [ figure 1 ] .
lesions in ( a ) maxilla and ( b ) mandible orthopantomograhic examination showed mild - to - moderate bone loss in all the teeth except 27 , 36 , 41 , 47 , and 48 , which showed severe bone loss with root resorption and 11 , 18 and 26 teeth were missing [ figure 2 ] .
( a ) pre - treatment and ( b ) post - treatment opg showing moderate - to - severe interdental bone loss we made diagnosis of generalized periodontitis with pyogenic granuloma in right maxillary and mandibular posterior region with differential diagnosis of other reactive lesions like fibrous epulis , giant cell lesion , and neoplastic lesion involving gingiva .
excisional biopsy of the lesion was carried out along with the removal of teeth 47 , 48 [ figure 3 ] .
specimen was sent for histopathologic examination , which showed features of signet ring cell adenocarcinoma [ figure 4 ] .
the possibility of metastatic lesion was considered because it is extremely rare for a signet ring cell adenocarcinoma to develop in gingiva as the primary site .
immunohistochemistry was performed to know more about tumor cells , which was positive for ema ( epithelial membrane antigen ) , ck7 ( cytokeratin ) , and ck15 markers [ figure 5 ] and negative for ck20 , ttf-1 ( thyroid transcription factor ) , and psa ( prostate specific antigen ) markers  suggestive of the gi tract as the possible primary site .
the patient did not have any complaints related to any other region of the body like difficulty in swallowing or hematemesis .
( a ) maxillary and ( b ) mandibular specimen of excisional biopsies with extracted teeth histopathologic features of metastatic signet ring cell adenocarcinoma [ h and e stain in ( a ) 10 and ( b ) 40 ] immunohistochemistry stains positive for ( a ) ck7 , ( b ) ck15 , and ema , 10 and 20 respectively the patient was referred to gujarat cancer research institute , ahmedabad , for further examination .
barium swallow was performed , which showed 8 cm long defect in lower one - third of the esophagus .
computed tomography ( ct ) scan of thorax was performed , which showed malignant lesion involving lower esophagus , gastro - esophageal junction , and fundus of the stomach [ figure 6 ] . a biopsy from esophagus
ct scans of other regions were taken to rule out metastasis but did not show any such involvement .
the patient was advised for surgical treatment and chemotherapy but patient refused to take any treatment and he expired within 5 months of the final diagnosis .
ct scan of thorax showing lesion involving the lower one - third of esophagus and gastro - esophageal junction as esophageal signet ring cell adenocarcinoma had not been recognized at the time of diagnosis of oral lesion .
the oral lesion was identified as a metastatic signet ring cell adenocarcinoma with lower third of esophagus identified as the primary site .
primary signet ring cell adenocarcinomas are mainly associated with the gastrointestinal tract , breast , or lung and have a more aggressive behavior .
it is unlikely that it will be surpassed by adenocarcinoma in number in the near future .
the highest reported increase in esophageal adenocarcinoma has been reported in usa at 10% per annum . among the asian countries , china and singapore
esophageal adenocarcinoma is the 15 most common cancer in developed country and the 4 in the developing world .
esophageal adenocarcinoma tends to grow locally , invading surrounding tissues , which may lead to death .
most common invasion of esophageal adenocarcinoma is into tracheo - esophageal fistula / broncho - esophageal fistula .
mediastinum and lung are secondarily involved ; lymphatic , liver , and spinal cord can be involved , rarely involving supraclavicular organs .
gastric signet ring adenocarcinomas have a lower rate ( 8% ) of lymph node metastasis than the non - signet ring cell type .
cases of gingival metastasis are usually found in the later stages of tumor growth and are most often associated with metastatic deposits in other organs . therefore it has a poor prognosis , leading to death of the patient within a few weeks or months . in this case ,
patient died within 5 months of diagnosis of metastatic signet ring cell adenocarcinoma . despite this , an early diagnosis is must for successful treatment and prevention of other complications like tissue destruction and pain .
like in the present case , clinically early gingival metastatic lesions may imitate benign reactive lesions such as pyogenic granuloma , giant cell granuloma , or peripheral ossifying fibroma
batson proposed valveless vertebral venous plexus as the mechanism for bypassing filtration through the lungs in an attempt to explain the metastasis to the oral region from a primary tumor of the lower part of the body , particularly in the absence of lung metastasis .
once circulating malignant cells reach the oral region , they can be trapped by the rich capillary network of the chronically inflamed attached gingiva .
the criteria for diagnosis of a metastatic neoplasm are : ( 1 ) primary lesion must be histologically verified , ( 2 ) histologically , the metastatic lesion must be the same subtypes as the primary lesion , ( 3 ) the possibility of direct extension from a primary lesion must be excluded . in the present case ,
gingival lesion was diagnosed before detection of the primary lesion ( esophagus ) . according to bhasker , approximately 33% of oral secondary tumors are an initial indication of the existence of a primary tumor .
histopathologically , gingival and esophageal lesions were same in terms of subtypes and morphology of tumor cells , so our final diagnosis was consistent with the above - mentioned criteria .
the treatment modalities are limited to conservative and palliative therapies intended to improve the quality of life of these patients , and include local resection , radiotherapy , or chemotherapy .
most of patients die within the first year of diagnosis with a survival rate at 4 years of 10% cases .
in the patients with the history of malignant tumors or with a rapidly growing oral soft tissue mass , possibility of the metastatic tumor should be considered in differential diagnosis .
detailed and careful oral examination is must to determine if there are any metastatic lesions that could manifest in the oral cavity , with or without swelling , pain , and looseness of the teeth .
 localized gingival enlargement is often associated with systemic medications , abscess formation , trauma , or reactive lesions . 
 very few reports are available reporting enlargement of gingiva due to metastasis of adenocarcinoma of the esophagus . a case of localized gingival growth affecting right maxillary and mandibular gingiva 
 was reported in a 60-year - old male patient in which excisional biopsy of the lesion was done . 
 histopathological examination showed metastatic signet ring cell adenocarcinoma , which on further examination showed lower one - third of esophagus as the primary site of metastasis . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION