A 54-year-old man was referred to our department in May 2003 for odontalgia related to an erupted lower right third molar. On oral inspection, a swelling expanding the vestibulo-lingual cortices was observed in the region of the right mandibular third molar, decayed distally. The oral mucosa was intact, and no cervical adenomegaly was palpable. The patient reported the existence of hypoaesthesia in the distribution territory of the mentonian nerve, which had been present for fifteen days. The orthopantomography revealed the presence of a radiolucent image of poorly defined contours in the right mandibular body. Two days later, under local anaesthesia, the third molar was exodonticated and the underlying tissue was curettage-biopsied. During the operative procedure, heavy bleeding occurred, which could be contained with the use of Surgicel (Johnson & Johnson, New Brunswick, NJ) and by packing the alveolar bed with bone wax.

Postoperative haemogram and coagulation study showed no significant alterations. The histopathological diagnosis of the submitted material was: mandibular metastasis from well-differentiated hepatocarcinoma. The neoplastic cells did not stain with cytokeratins 19 and 20, nor with alpha-fetoprotein, but did show intense cytoplasmic granular staining with the hepatocyte N marker.

The patient's personal history included a history of type II diabetes for 8 years, controlled with oral hypoglycaemic agents. He was a drinker of 130 g. ethanol/day since the age of 30, and a smoker of 2 packs of cigarettes/day since the age of 20. One year before our assessment, the patient had been diagnosed with cirrhosis of the liver (Child Pugh stage A: 5/15) and multicentric hepatocarcinoma with involvement of segments II, III and IV, and underwent partial liver resection one month after diagnosis. He had previously undergone a complete study that included bone scintigraphy with technetium 99-MDP and computed tomography of the skull, lung, abdomen and pelvis, without finding the presence of metastases. Postoperative serum alpha-fetoprotein values were normal (3.6 ng/ml).
Fifteen days after surgery, there was a marked increase in alpha-fetoprotein levels (221 ng/ml), and bone scintigraphy and magnetic resonance imaging revealed the existence of multiple metastases affecting the left occipital, sternal body, pelvis and multiple vertebrae. The patient underwent palliative radiotherapy on the vertebral lesions (10 Gy at one week after Co 60) without improvement, and exited six months after our biopsy.

