- Email: [email protected]
Cardiac metastasis of head and neck squamous cell carcinoma
Int. J. Oral Maxillofac. Surg. 2012; 41: 1458–1462 http://dx.doi.org/10.1016/j.ijom.2012.07.017, available online at http://www.sciencedirect.com
Case Report Head and Neck Oncology
Cardiac metastasis of head and neck squamous cell carcinoma
S. Nagata, K. Ota, M. Nagata, M. Shinohara Department of Oral and Maxillofacial Surgery, Graduate School of Medical Sciences, Kumamoto University, Japan
S. Nagata, K. Ota, M. Nagata, M. Shinohara: Cardiac metastasis of head and neck squamous cell carcinoma. Int. J. Oral Maxillofac. Surg. 2012; 41: 1458–1462. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Two patients with cardiac metastasis from head and neck cancer are reported. Cardiac metastasis located in the left atrium was detected on a follow-up computed tomography (CT) scan 15 months after partial glossectomy for a tongue carcinoma in a 60-year-old man. The diagnosis was confirmed as cardiac metastasis of squamous cell carcinoma (SCC) by surgical excision of the cardiac lesion. The patient died 3 weeks after surgery. In a 69-year-old man with a partial maxillectomy for primary soft palate cancer, a follow-up CT scan 5 months after surgery revealed a mass in the right atrium and ventricle, and multiple lung metastases. He died of heart failure 3 weeks after the diagnosis of cardiac metastasis. Information on these cases should add to knowledge about rarely encountered cardiac metastasis.
Cardiac metastasis of head and neck squamous cell carcinoma (SCC) is rare in the literature. Patients are rarely diagnosed while still alive, and such cases are generally diagnosed at autopsy, because they often present no clinical symptoms.1 The authors report two cases of cardiac metastasis from head and neck cancer. One case was detected as a solitary metastasis; the other was diagnosed as part of widespread metastases in its terminal stage. Case 1
A 59-year-old male visited the authors’ department in January 2004 complaining of a right lingual mass and oral pain. The mass extended to the midline of the tongue, and its size was 45 mm 30 mm. The histological diagnosis of the biopsy specimen was well differentiated SCC. Computed tomography (CT), positron 0901-5027/01201458 + 05 $36.00/0
emission tomography (PET), and magnetic resonance imaging (MRI) detected lymph node metastasis to the right superior deep cervical node, and he was staged as having carcinoma of the tongue T2N1M0 (Stage III). He had no history of smoking or alcohol drinking. His electrocardiogram was within the normal range at the time. The patient was treated concurrently with induction chemotherapy with S-1 (120 mg/day for 14 days) and external beam radiotherapy for a total dose of 30 Gy. Subsequently, he underwent a partial glossectomy and right radical neck dissection, and received a reconstructed rectus abdominis musculocutaneous flap in March 2004. After discharge, he received adjuvant chemotherapy (UFT 600 mg/day) for 2 months. No evidence of local recurrence had been noted on routine follow-up examinations.
Accepted for publication 26 July 2012 Available online 24 August 2012
In June 2005, the patient developed a marked fever and had elevated C-reactive protein in the blood after he underwent the repair of an abdominal incisional hernia. A chest CT scan and echocardiogram showed a mass reaching from the left atrium to the left pulmonary vein, and pericardial effusion. The left lower pulmonary vein was occluded by the mass (Fig. 1a and b). The cytology results of the pericardial fluid were positive for malignancy (Fig. 1c). In diagnostic imaging examinations, he did not have any other metastasis or another primary tumour. He had not shown any other clinical symptoms. The patient underwent surgery by a cardiovascular surgeon to remove the tumour in order to delay the growth of the mass up to the mitral valve (Fig. 2a and b), but he died of heart failure 3 weeks after surgery. That tumour was considered
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Cardiac metastasis of head and neck squamous cell carcinoma
1459
Fig. 1. Cardiac metastasis detected by imaging studies. (a) CT and (b) echocardiogram images of case 1, 4 months after primary surgery, showing a left atrial mass (arrows). (c) Photomicrograph of the cytology gleaned from the cardiac effusion. LA, left atrium; LV, left ventricle; RA, right atrium; and RV, right ventricle.
to be cardiac metastasis of oral cancer, as the pathological diagnosis of the tumour was SCC (Fig. 3a and b). Case 2
A 69-year-old male visited the authors’ department in January 2010 with the chief complaint of a left palatal mass. The ulcerative tumour reached from the soft palate to the hard palate, and was 30 mm 32 mm in size. It did not invade the nasal cavity or the maxillary sinus. The histological diagnosis of the biopsy specimen was well-differentiated SCC. The patient had a past history of smoking. CT, PET, and MRI detected lymph node metastasis to the right superior deep cervical nodes. No evidence of distant metastasis was noted in any of these examinations. The disease stage of the soft palatal mucosa cancer was classified as T2N1M0 (Stage III). The patient underwent preoperative chemotherapy with S-1 (120 mg/day for 14 days) and radiotherapy at a dose of 40 Gy at the primary site and the cervical lesion. He was treated by surgery via a partial maxillectomy and radical neck dissection. After discharge, he received adjuvant chemotherapy (S-1 120 mg/day) for 2 months.
5 months after surgery, a follow-up CT study confirmed the presence of a 52 mm 30 mm mass in the right atrium and ventricle. It indicated that there was a large amount of pericardial effusion (Fig. 4a). His echocardiogram showed tumour progression around the coronary artery. The mass had reached the tricuspid valve and its mobility was depressed (Fig. 4b). His electrocardiogram showed a right bundle-branch block that was evident on admission, and a borderline Q wave not shown on admission (Fig. 4c). A cardiac MRI and PET-CT showed carcinomatous pericarditis and multiple lung metastases (Fig. 4d). The patient refused aggressive therapies, and died 3 weeks later. Discussion
The primary malignancies most commonly metastasizing to the heart are breast cancer, lung cancer, leukaemia, and melanoma.2–4 Distant metastasis of head and neck tumours is considered rare. The authors could find reports of only three other cases of cardiac metastases that were diagnosed before death in the literature (Table 1).5–7 Several studies reported finding cardiac metastases of head and neck tumours at autopsy. For example,
Gassman et al. reported that 2 (1.5%) of 126 patients with carcinoma of the tongue were found to have cardiac metastasis at autopsy, and Manojlovic8 reported that 9 (24%) of 38 tongue cancer patients had metastases to the heart noted at autopsy. Cardiac metastasis of carcinoma of the tongue is consistently reported with some frequency, although there is wide variability in the incidence of cardiac metastasis. These reports may indicate that cardiac metastasis occurs as a result of dissemination to many visceral organs. Tumours can spread to the heart through four alternative paths: by direct extension; through the bloodstream; through the lymphatic system; and by intracavitary diffusion through either the inferior vena cava or the pulmonary veins.9 In case 1, haematogenous metastasis through the bloodstream was most likely because the tumour was located in the left pulmonary vein and left atrium without lung lymph node metastasis or lung metastasis. On the other hand, cardiac metastasis was detected as part of widespread metastases, including to the mediastinal lymph nodes, in case 2. In addition, it was observed that the mass had invaded into the epicardium containing the coronary artery. These suggest that the cardiac metastasis occurred through the lymphatic system in case 2.
1460
Nagata et al.
Fig. 2. Macroscopic views and illustration of case 1 during cardiac surgery. (a) The presence of the protruding tumour in the left atrium. The left lower pulmonary vein (PV) was occluded by the tumour. (b) The pedunculated tumour was resected from the root of the mass.
Cardiac metastasis does not generally lead to clinical findings at an early stage. At more advanced stages, however, metastatic tumours in the heart gradually give rise to cardiac failure, conduction disturbances, valvular disease resembling mital stenosis, angina pain or Strokes–Adams syndrome.10 All of the reported cases in Table 1 showed some changes in their electrocardiograms. The
present patients showed no clinical cardiogenic signs, but the electrocardiogram of case 2 showed a right bundlebranch block that was shown on admission, and a borderline Q wave that was not. This may suggest the presence of right coronary artery occlusion, although the signs and symptoms of cardiac metastasis are non-specific. Improved accuracy and earlier diagnosis can be
achieved by combining PET and CT to detect metastasis to the heart.3 Generally, patients with distant metastases are considered to be inoperable, and only palliative treatments, such as chemotherapy or irradiation of the tumour, are indicated.3 All cases in Table 1 received only palliative treatment or terminal care. The present case 1 patient underwent palliative surgery to delay the growth
Fig. 3. Microphotograph of the primary tumour and the cardiac metastasis. (a) A biopsy specimen of the primary tumour in the tongue was diagnosed as well-differentiated SCC. (b) The isolated tissue from the left atrial mass was diagnosed as cardiac metastasis of SCC. The histopathological images of the protruding tumour in the left atrium were similar to those of the primary carcinoma of the tongue.
Cardiac metastasis of head and neck squamous cell carcinoma
1461
Fig. 4. The results of imaging studies and the electrocardiogram of case 2, 5 months after primary surgery. (a) CT and (b) echocardiogram images showing the presence of a mass in the right atrium and ventricle. (c) The electrocardiogram showed a right bundle-branch block and borderline Q wave. (d) PET-CT showed multiple lung metastases. Table 1. Reported cases of cardiac metastasis from head and neck cancer (present cases included).
Patient
Study
Year of publication
Primary site
Location of metastasis
1
Werbel et al.5
1985
Tongue
Percardium right atrium
2
Rivkin et al.6 Schwender et al.7
1999
Tongue
Right ventricle
2002
Buccal mucosa
Percardial
4
Present case 1
2012
Tongue
5
Present case 2
2012
Soft palatal mucosa
Pericardium left lower pulmonary vein Pericardium right atrium and ventricle, Lung
3
Electrocardiogram findings
Treatment against cardiac metastasis
Cardiac murmur, Chest pain Chest pain, Oedema Malaise, Respiratory distress Fever up
ST resolution
RT, OP
Dead
7 weeks after surgery
ST elevation, Af, Q-wave Af
CT
Dead
None
Dead
Several months N/A
Normal
OP
Dead
None
Borderline Q wave
None
Dead
Symptoms
Prognosis
Follow-up periods
4 weeks after surgery for cardiac metastasis 3 weeks
Af, atrial fibrillation; RT, radiotherapy; N/A, not available.
of the mass up to the mitral valve. It is unclear whether the resection of the cardiac mass resulted in an improved prognosis. The accumulation of reports about cardiac metastases of head and neck SCC may help to elucidate the best therapy for these patients.
Funding
Ethical Approval
None.
Not required.
Competing Interests
Acknowledgement. The authors are most grateful to Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University.
None declared.
1462
Nagata et al.
References 1. Maeda M, Goto T, Harigai M, Itoh T, Moriki T, Miyashita T. Myocardial metastasis from squamous cell carcinoma of the esophagus. Gen Thorac Cardiovasc Surg 2009;57: 440–5. 2. Duband S, Paysant F, Scolan V, Forest F, Peoc’h M. Sudden death due to myocardial metastasis of lingual squamous cell carcinoma. Cardiovasc Pathol 2011;20:242–3. 3. Zemann W, Feichtinger M, Kowatsch E, Schanbacher M, Karcher H. Cardiac metastasis after squamous cell carcinoma of the oral cavity: case report. Br J Oral Maxillofac Surg 2007;45:425–6. 4. Hans S, Chauvet D, Sadoughi B, Brasnu DF. Cardiac metastasis after squamous cell car-
cinoma of the base of tongue. Am J Otolaryngol 2009;30:206–8. 5. Werbel GB, Skom JH, Mehlman D, Michaelis LL. Metastatic squamous cell carcinoma to the heart. Unusual cause of angina decubitus and cardiac murmur. Chest 1985;88: 468–9. 6. Rivkin A, Meara JG, Li KK, Potter C, Wenokur R. Squamous cell metastasis from the tongue to the myocardium presenting as pericardial effusion. Otolaryngol Head Neck Surg 1999;120:593–5. 7. Schwender FT, Wollner I, Kunju LP, Nakhleh RE, Chan KM. Squamous cell carcinoma of the buccal mucosa with metastases to the pericardial cavity, lung and thyroid. Oral Oncol 2002;38:114–6.
8. Manojlovic S. Metastatic carcinomas involving the heart. Review of postmortem examination. Zentralbl Allg Pathol 1990;136: 657–61. 9. Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol 2007;60:27–34. 10. Gassman HS, Meadows Jr R, Baker LA. Metastatic tumors of the heart. Am J Med 1955;19:357–65.
Address: Kazutoshi Ota 1-1-1 Honjo Kumamoto 860-8556 Japan Tel: +81 96 373 5288; Fax: +81 96 373 5286 E-mail: [email protected]
Case Report Head and Neck Oncology
Cardiac metastasis of head and neck squamous cell carcinoma
S. Nagata, K. Ota, M. Nagata, M. Shinohara Department of Oral and Maxillofacial Surgery, Graduate School of Medical Sciences, Kumamoto University, Japan
S. Nagata, K. Ota, M. Nagata, M. Shinohara: Cardiac metastasis of head and neck squamous cell carcinoma. Int. J. Oral Maxillofac. Surg. 2012; 41: 1458–1462. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Two patients with cardiac metastasis from head and neck cancer are reported. Cardiac metastasis located in the left atrium was detected on a follow-up computed tomography (CT) scan 15 months after partial glossectomy for a tongue carcinoma in a 60-year-old man. The diagnosis was confirmed as cardiac metastasis of squamous cell carcinoma (SCC) by surgical excision of the cardiac lesion. The patient died 3 weeks after surgery. In a 69-year-old man with a partial maxillectomy for primary soft palate cancer, a follow-up CT scan 5 months after surgery revealed a mass in the right atrium and ventricle, and multiple lung metastases. He died of heart failure 3 weeks after the diagnosis of cardiac metastasis. Information on these cases should add to knowledge about rarely encountered cardiac metastasis.
Cardiac metastasis of head and neck squamous cell carcinoma (SCC) is rare in the literature. Patients are rarely diagnosed while still alive, and such cases are generally diagnosed at autopsy, because they often present no clinical symptoms.1 The authors report two cases of cardiac metastasis from head and neck cancer. One case was detected as a solitary metastasis; the other was diagnosed as part of widespread metastases in its terminal stage. Case 1
A 59-year-old male visited the authors’ department in January 2004 complaining of a right lingual mass and oral pain. The mass extended to the midline of the tongue, and its size was 45 mm 30 mm. The histological diagnosis of the biopsy specimen was well differentiated SCC. Computed tomography (CT), positron 0901-5027/01201458 + 05 $36.00/0
emission tomography (PET), and magnetic resonance imaging (MRI) detected lymph node metastasis to the right superior deep cervical node, and he was staged as having carcinoma of the tongue T2N1M0 (Stage III). He had no history of smoking or alcohol drinking. His electrocardiogram was within the normal range at the time. The patient was treated concurrently with induction chemotherapy with S-1 (120 mg/day for 14 days) and external beam radiotherapy for a total dose of 30 Gy. Subsequently, he underwent a partial glossectomy and right radical neck dissection, and received a reconstructed rectus abdominis musculocutaneous flap in March 2004. After discharge, he received adjuvant chemotherapy (UFT 600 mg/day) for 2 months. No evidence of local recurrence had been noted on routine follow-up examinations.
Accepted for publication 26 July 2012 Available online 24 August 2012
In June 2005, the patient developed a marked fever and had elevated C-reactive protein in the blood after he underwent the repair of an abdominal incisional hernia. A chest CT scan and echocardiogram showed a mass reaching from the left atrium to the left pulmonary vein, and pericardial effusion. The left lower pulmonary vein was occluded by the mass (Fig. 1a and b). The cytology results of the pericardial fluid were positive for malignancy (Fig. 1c). In diagnostic imaging examinations, he did not have any other metastasis or another primary tumour. He had not shown any other clinical symptoms. The patient underwent surgery by a cardiovascular surgeon to remove the tumour in order to delay the growth of the mass up to the mitral valve (Fig. 2a and b), but he died of heart failure 3 weeks after surgery. That tumour was considered
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Cardiac metastasis of head and neck squamous cell carcinoma
1459
Fig. 1. Cardiac metastasis detected by imaging studies. (a) CT and (b) echocardiogram images of case 1, 4 months after primary surgery, showing a left atrial mass (arrows). (c) Photomicrograph of the cytology gleaned from the cardiac effusion. LA, left atrium; LV, left ventricle; RA, right atrium; and RV, right ventricle.
to be cardiac metastasis of oral cancer, as the pathological diagnosis of the tumour was SCC (Fig. 3a and b). Case 2
A 69-year-old male visited the authors’ department in January 2010 with the chief complaint of a left palatal mass. The ulcerative tumour reached from the soft palate to the hard palate, and was 30 mm 32 mm in size. It did not invade the nasal cavity or the maxillary sinus. The histological diagnosis of the biopsy specimen was well-differentiated SCC. The patient had a past history of smoking. CT, PET, and MRI detected lymph node metastasis to the right superior deep cervical nodes. No evidence of distant metastasis was noted in any of these examinations. The disease stage of the soft palatal mucosa cancer was classified as T2N1M0 (Stage III). The patient underwent preoperative chemotherapy with S-1 (120 mg/day for 14 days) and radiotherapy at a dose of 40 Gy at the primary site and the cervical lesion. He was treated by surgery via a partial maxillectomy and radical neck dissection. After discharge, he received adjuvant chemotherapy (S-1 120 mg/day) for 2 months.
5 months after surgery, a follow-up CT study confirmed the presence of a 52 mm 30 mm mass in the right atrium and ventricle. It indicated that there was a large amount of pericardial effusion (Fig. 4a). His echocardiogram showed tumour progression around the coronary artery. The mass had reached the tricuspid valve and its mobility was depressed (Fig. 4b). His electrocardiogram showed a right bundle-branch block that was evident on admission, and a borderline Q wave not shown on admission (Fig. 4c). A cardiac MRI and PET-CT showed carcinomatous pericarditis and multiple lung metastases (Fig. 4d). The patient refused aggressive therapies, and died 3 weeks later. Discussion
The primary malignancies most commonly metastasizing to the heart are breast cancer, lung cancer, leukaemia, and melanoma.2–4 Distant metastasis of head and neck tumours is considered rare. The authors could find reports of only three other cases of cardiac metastases that were diagnosed before death in the literature (Table 1).5–7 Several studies reported finding cardiac metastases of head and neck tumours at autopsy. For example,
Gassman et al. reported that 2 (1.5%) of 126 patients with carcinoma of the tongue were found to have cardiac metastasis at autopsy, and Manojlovic8 reported that 9 (24%) of 38 tongue cancer patients had metastases to the heart noted at autopsy. Cardiac metastasis of carcinoma of the tongue is consistently reported with some frequency, although there is wide variability in the incidence of cardiac metastasis. These reports may indicate that cardiac metastasis occurs as a result of dissemination to many visceral organs. Tumours can spread to the heart through four alternative paths: by direct extension; through the bloodstream; through the lymphatic system; and by intracavitary diffusion through either the inferior vena cava or the pulmonary veins.9 In case 1, haematogenous metastasis through the bloodstream was most likely because the tumour was located in the left pulmonary vein and left atrium without lung lymph node metastasis or lung metastasis. On the other hand, cardiac metastasis was detected as part of widespread metastases, including to the mediastinal lymph nodes, in case 2. In addition, it was observed that the mass had invaded into the epicardium containing the coronary artery. These suggest that the cardiac metastasis occurred through the lymphatic system in case 2.
1460
Nagata et al.
Fig. 2. Macroscopic views and illustration of case 1 during cardiac surgery. (a) The presence of the protruding tumour in the left atrium. The left lower pulmonary vein (PV) was occluded by the tumour. (b) The pedunculated tumour was resected from the root of the mass.
Cardiac metastasis does not generally lead to clinical findings at an early stage. At more advanced stages, however, metastatic tumours in the heart gradually give rise to cardiac failure, conduction disturbances, valvular disease resembling mital stenosis, angina pain or Strokes–Adams syndrome.10 All of the reported cases in Table 1 showed some changes in their electrocardiograms. The
present patients showed no clinical cardiogenic signs, but the electrocardiogram of case 2 showed a right bundlebranch block that was shown on admission, and a borderline Q wave that was not. This may suggest the presence of right coronary artery occlusion, although the signs and symptoms of cardiac metastasis are non-specific. Improved accuracy and earlier diagnosis can be
achieved by combining PET and CT to detect metastasis to the heart.3 Generally, patients with distant metastases are considered to be inoperable, and only palliative treatments, such as chemotherapy or irradiation of the tumour, are indicated.3 All cases in Table 1 received only palliative treatment or terminal care. The present case 1 patient underwent palliative surgery to delay the growth
Fig. 3. Microphotograph of the primary tumour and the cardiac metastasis. (a) A biopsy specimen of the primary tumour in the tongue was diagnosed as well-differentiated SCC. (b) The isolated tissue from the left atrial mass was diagnosed as cardiac metastasis of SCC. The histopathological images of the protruding tumour in the left atrium were similar to those of the primary carcinoma of the tongue.
Cardiac metastasis of head and neck squamous cell carcinoma
1461
Fig. 4. The results of imaging studies and the electrocardiogram of case 2, 5 months after primary surgery. (a) CT and (b) echocardiogram images showing the presence of a mass in the right atrium and ventricle. (c) The electrocardiogram showed a right bundle-branch block and borderline Q wave. (d) PET-CT showed multiple lung metastases. Table 1. Reported cases of cardiac metastasis from head and neck cancer (present cases included).
Patient
Study
Year of publication
Primary site
Location of metastasis
1
Werbel et al.5
1985
Tongue
Percardium right atrium
2
Rivkin et al.6 Schwender et al.7
1999
Tongue
Right ventricle
2002
Buccal mucosa
Percardial
4
Present case 1
2012
Tongue
5
Present case 2
2012
Soft palatal mucosa
Pericardium left lower pulmonary vein Pericardium right atrium and ventricle, Lung
3
Electrocardiogram findings
Treatment against cardiac metastasis
Cardiac murmur, Chest pain Chest pain, Oedema Malaise, Respiratory distress Fever up
ST resolution
RT, OP
Dead
7 weeks after surgery
ST elevation, Af, Q-wave Af
CT
Dead
None
Dead
Several months N/A
Normal
OP
Dead
None
Borderline Q wave
None
Dead
Symptoms
Prognosis
Follow-up periods
4 weeks after surgery for cardiac metastasis 3 weeks
Af, atrial fibrillation; RT, radiotherapy; N/A, not available.
of the mass up to the mitral valve. It is unclear whether the resection of the cardiac mass resulted in an improved prognosis. The accumulation of reports about cardiac metastases of head and neck SCC may help to elucidate the best therapy for these patients.
Funding
Ethical Approval
None.
Not required.
Competing Interests
Acknowledgement. The authors are most grateful to Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University.
None declared.
1462
Nagata et al.
References 1. Maeda M, Goto T, Harigai M, Itoh T, Moriki T, Miyashita T. Myocardial metastasis from squamous cell carcinoma of the esophagus. Gen Thorac Cardiovasc Surg 2009;57: 440–5. 2. Duband S, Paysant F, Scolan V, Forest F, Peoc’h M. Sudden death due to myocardial metastasis of lingual squamous cell carcinoma. Cardiovasc Pathol 2011;20:242–3. 3. Zemann W, Feichtinger M, Kowatsch E, Schanbacher M, Karcher H. Cardiac metastasis after squamous cell carcinoma of the oral cavity: case report. Br J Oral Maxillofac Surg 2007;45:425–6. 4. Hans S, Chauvet D, Sadoughi B, Brasnu DF. Cardiac metastasis after squamous cell car-
cinoma of the base of tongue. Am J Otolaryngol 2009;30:206–8. 5. Werbel GB, Skom JH, Mehlman D, Michaelis LL. Metastatic squamous cell carcinoma to the heart. Unusual cause of angina decubitus and cardiac murmur. Chest 1985;88: 468–9. 6. Rivkin A, Meara JG, Li KK, Potter C, Wenokur R. Squamous cell metastasis from the tongue to the myocardium presenting as pericardial effusion. Otolaryngol Head Neck Surg 1999;120:593–5. 7. Schwender FT, Wollner I, Kunju LP, Nakhleh RE, Chan KM. Squamous cell carcinoma of the buccal mucosa with metastases to the pericardial cavity, lung and thyroid. Oral Oncol 2002;38:114–6.
8. Manojlovic S. Metastatic carcinomas involving the heart. Review of postmortem examination. Zentralbl Allg Pathol 1990;136: 657–61. 9. Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol 2007;60:27–34. 10. Gassman HS, Meadows Jr R, Baker LA. Metastatic tumors of the heart. Am J Med 1955;19:357–65.
Address: Kazutoshi Ota 1-1-1 Honjo Kumamoto 860-8556 Japan Tel: +81 96 373 5288; Fax: +81 96 373 5286 E-mail: [email protected]