Oral and maxillofacial pain as the first sign of metastasis of an occult primary tumour: A fifteen-year retrospective study

Figure 4 A patient with metastatic adenocarcinoma of the jaw of primary liver cancer. A: Intraoral image before tooth extraction showed swelling of the gingival surrounding the wisdom tooth (arrow); B: Panorama radiograph before tooth extraction showed periodontal bone loss around the involved tooth (arrow); C: At a two-month follow-up visit, the extraction wound did not heal completely; D: Four months after tooth extraction, oblique sagittal cone beam computed tomography (CT) showed lesion (arrow) turned bulky with a permeative margin. The wall of the inferior alveolar nerve was invisible; E: Immunohistochemistry for the expression of CK8/18 revealed uniform positivity in the cytoplasm of tumour cells (Magnification: 100 ×); F: Immunohistochemistry for the expression of Ki-67 revealed scattered positivity in more than 65% of the tumour cells (Magnification: 100 ×); G: Positron emission tomography-CT scans showed asymptomatic hepatocellular carcinoma as the primary site and multiple metastases mainly involving the right mandible, spine, and bilateral pelvic bone (arrows).