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Cardiac metastasis of squamous cell carcinoma of the buccal mucosa
G Model JOMSMP-286; No. of Pages 4
ARTICLE IN PRESS Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Case Report
Cardiac metastasis of squamous cell carcinoma of the buccal mucosa Takaaki Kamatani a,∗ , Kenji Mishima b , Seiji Kondo a , Yasuto Yoshihama a , Yohko Kohno b , Tatsuo Shirota a a
Department of Oral and Maxillofacial Surgery, School of Dentistry, Showa University, Kitasenzoku 2-1-1, Ota City, Tokyo 145-8515, Japan Division of Pathology, Department of Oral Diagnostic Sciences, School of Dentistry, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo 142-8555, Japan b
a r t i c l e
i n f o
Article history: Received 26 November 2013 Received in revised form 8 March 2014 Accepted 7 April 2014 Available online xxx
a b s t r a c t We reported an extremely rare case of cardiac metastasis of squamous cell carcinoma of the buccal mucosa. There were no abnormalities in the electrocardiogram and no prior symptoms. We performed an autopsy and confirmed metastatic lesions in the heart, lung, and liver that originated from the buccal mucosa carcinoma. This case should add to knowledge about rarely encountered cardiac metastasis. © 2014 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
Keywords: Cardiac metastasis Squamous cell carcinoma Buccal carcinoma
1. Introduction Metastasis of head and neck squamous cell carcinoma (SCC) to the heart is unusual [1–3]. In patients with cancer, cardiac metastasis is usually difficult to diagnose unless they cause symptoms [3]. Only few cases with distant metastasis of SCC of the buccal mucosa have been reported in the English language literature [1,4,5]. To the best of our knowledge, this is a rare case of SCC of the buccal mucosa with multiple distant metastases to the heart, lung, and liver diagnosed by post-mortem examination.
whole body detected the large buccal tumor with a maximum standardized uptake value of 15.0 and one enlarged neck lymph node (Fig. 2B). A biopsy specimen showed poorly differentiated SCC (Fig. 3). We diagnosed a T4aN1M0 SCC of the buccal mucosa. The patient was treated with CyberKnife. The dose for the tumor ranged from 30.6 Gy (42.85% of dose) to 71.4 Gy (100% of dose), delivered five separate times as fractionated stereotactic radiation. No side effects were noted, except for slight stomatitis. His disease was stabilized by CyberKnife. In March 2013, he presented with
2. Case report A 90-year-old Japanese male presented with a chief complaint of progressive right buccal tumor (Fig. 1) in January 2013. A computed tomography (CT) scan of the head and the neck showed the large buccal tumor and metastatic neck lymph node (Fig. 2A). The 18 F-fluorodeoxyglucose positron emission tomography of the
夽 Asian AOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants. ∗ Corresponding author. Tel.: +81 3 3787 1151; fax: +81 3 5498 1543. E-mail addresses: [email protected], [email protected], [email protected] (T. Kamatani).
Fig. 1. Facial findings of the right side of the buccal tumor at first visit.
http://dx.doi.org/10.1016/j.ajoms.2014.04.001 2212-5558/© 2014 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001
G Model JOMSMP-286; No. of Pages 4 2
ARTICLE IN PRESS T. Kamatani et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
Fig. 2. (A) Computed tomography scan of the face and the neck showed the large buccal tumor and metastatic neck lymph node. (B) The 18 F-fluorodeoxyglucose positron emission tomography detected the large buccal tumor and one enlarged neck lymph node.
Fig. 3. Histological finding of biopsy specimen shows poorly differentiated squamous cell carcinoma.
weakness and shortness of breath. A CT scan of the chest and the abdomen showed pneumonia, multiple lung metastases (Fig. 4A), and liver metastasis (Fig. 4B). He ultimately developed respiratory failure and considering the advanced state of his metastatic cancer, life support was discontinued 2 months after the first visit to our hospital. Post-mortem examination revealed metastatic tumor nodules in the right ventricle (Fig. 5A), lung (Fig. 5B), and liver (Fig. 5C). Microscopic examination revealed metastatic poorly differentiated SCC cells in the right ventricle (Fig. 6A), lung (Fig. 6B), liver (Fig. 6C), heart, thoracic diaphragm, and pleura. Multiple nests of SCC cells within neck lymph nodes were also noted. After conducting a retrospective survey of electrocardiographic findings with cardiac
Fig. 4. (A) Chest computed tomography scan of the lung shows pneumonia and multiple metastases. (B) Abdominal computed tomography scan of the liver shows metastatic tumor.
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001
G Model JOMSMP-286; No. of Pages 4
ARTICLE IN PRESS T. Kamatani et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
3
Fig. 5. Autopsy findings demonstrating myocardial metastases in the right ventricle (A), bilateral lung (B), and liver (C).
metastasis, there were no characteristic features among the electrocardiograms showing abnormalities.
3. Discussion Cardiac involvement by metastatic malignancy is very rare in pathological practice, essentially associated with lung and breast cancers, melanoma, and leukemia [6]. Cardiac metastasis of head and neck tumors were considered to be rare. Common metastatic sites of head and neck SCC include lung, bone, liver, and mediastinum [1]. In a review of several autopsy cases with various malignancies, cardiac involvement was found in 2–31% of cases [7]. Cardiac metastasis does not generally lead to clinical findings at an early stage [8]. At more advanced stages, however, metastatic tumors in the heart gradually give rise to cardiac failure, conduction disturbances, valvular disease resembling mitral stenosis, angina pain or Strokes–Adams syndrome [9]. The electrocardiogram is rarely diagnostic [10], but changes including tachycardia, arrhythmias, conduction defects, and low voltage in patients with a known primary tumor, may be suggestive of cardiac involvement [7,11]. We would therefore like to emphasize that one should consider the possibility of cardiac metastasis, even if the patient has shown no abnormal cardiac signs.
Fig. 6. Histological finding of autopsy specimen shows poorly differentiated squamous cell carcinoma in the right ventricle (A), lung (B), and liver (C).
Conflict of interest None.
Funding None.
Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001
G Model JOMSMP-286; No. of Pages 4
ARTICLE IN PRESS T. Kamatani et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
4
References [1] 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. [2] Zemann W, Feichtinger M, Kowatsch E, Schanbacher M, Kärcher H. Cardiac metastasis after squamous cell carcinoma of the oral cavity: case report. Br J Oral Maxillofac Surg 2007;45:425–6. [3] Ito T, Ishikawa N, Negishi T, Ohno K. Cardiac metastasis of tongue cancer may cause sudden death. Auris Nasus Larynx 2008;35:423–5. [4] Mathew BS, Jayasree K, Madhavan J, Nair MK, Rajan B. Skeletal metastases and bone marrow infiltration from squamous cell carcinoma of the buccal mucosa. Oral Oncol 1997;33:454–5. [5] Pichi B, Marchesi P, Manciocco V, Ruscito P, Pellini R, Cristalli G, et al. Carcinoma of the buccal mucosa metastasizing to the talus. J Craniofac Surg 2009;20:1142–5.
[6] Duband S, Paysant F, Scolan V, Forest F, Péoc’h M. Sudden death due to myocardial metastasis of lingual squamous cell carcinoma. Cardiovasc Pathol 2011;20:242–3. [7] Wilkes JD, Fidias P, Vaickus L, Perez RP. Malignancy-related pericardial effusion, 127 cases from the Roswell Park Cancer Institute. Cancer 1995;76: 1377–87. [8] Nagata S, Ota K, Nagata M, Shinohara M. Cardiac metastasis of head and neck squamous cell carcinoma. Int J Oral Maxillofac Surg 2012;41: 1458–62. [9] Gassman HS, Meadows Jr R, Baker LA. Metastatic tumors of the heart. Am J Med 1955;19:357–65. [10] Hans S, Chauvet D, Sadoughi B, Brasnu DF. Cardiac metastasis after squamous cell carcinoma of the base of tongue. Am J Otolaryngol 2009;30:206–8. [11] Fiocco M, Krasna MJ. The management of malignant pleural and pericardial effusions. Hematol Oncol Clin North Am 1997;11:253–65.
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001
ARTICLE IN PRESS Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Case Report
Cardiac metastasis of squamous cell carcinoma of the buccal mucosa Takaaki Kamatani a,∗ , Kenji Mishima b , Seiji Kondo a , Yasuto Yoshihama a , Yohko Kohno b , Tatsuo Shirota a a
Department of Oral and Maxillofacial Surgery, School of Dentistry, Showa University, Kitasenzoku 2-1-1, Ota City, Tokyo 145-8515, Japan Division of Pathology, Department of Oral Diagnostic Sciences, School of Dentistry, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo 142-8555, Japan b
a r t i c l e
i n f o
Article history: Received 26 November 2013 Received in revised form 8 March 2014 Accepted 7 April 2014 Available online xxx
a b s t r a c t We reported an extremely rare case of cardiac metastasis of squamous cell carcinoma of the buccal mucosa. There were no abnormalities in the electrocardiogram and no prior symptoms. We performed an autopsy and confirmed metastatic lesions in the heart, lung, and liver that originated from the buccal mucosa carcinoma. This case should add to knowledge about rarely encountered cardiac metastasis. © 2014 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
Keywords: Cardiac metastasis Squamous cell carcinoma Buccal carcinoma
1. Introduction Metastasis of head and neck squamous cell carcinoma (SCC) to the heart is unusual [1–3]. In patients with cancer, cardiac metastasis is usually difficult to diagnose unless they cause symptoms [3]. Only few cases with distant metastasis of SCC of the buccal mucosa have been reported in the English language literature [1,4,5]. To the best of our knowledge, this is a rare case of SCC of the buccal mucosa with multiple distant metastases to the heart, lung, and liver diagnosed by post-mortem examination.
whole body detected the large buccal tumor with a maximum standardized uptake value of 15.0 and one enlarged neck lymph node (Fig. 2B). A biopsy specimen showed poorly differentiated SCC (Fig. 3). We diagnosed a T4aN1M0 SCC of the buccal mucosa. The patient was treated with CyberKnife. The dose for the tumor ranged from 30.6 Gy (42.85% of dose) to 71.4 Gy (100% of dose), delivered five separate times as fractionated stereotactic radiation. No side effects were noted, except for slight stomatitis. His disease was stabilized by CyberKnife. In March 2013, he presented with
2. Case report A 90-year-old Japanese male presented with a chief complaint of progressive right buccal tumor (Fig. 1) in January 2013. A computed tomography (CT) scan of the head and the neck showed the large buccal tumor and metastatic neck lymph node (Fig. 2A). The 18 F-fluorodeoxyglucose positron emission tomography of the
夽 Asian AOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants. ∗ Corresponding author. Tel.: +81 3 3787 1151; fax: +81 3 5498 1543. E-mail addresses: [email protected], [email protected], [email protected] (T. Kamatani).
Fig. 1. Facial findings of the right side of the buccal tumor at first visit.
http://dx.doi.org/10.1016/j.ajoms.2014.04.001 2212-5558/© 2014 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001
G Model JOMSMP-286; No. of Pages 4 2
ARTICLE IN PRESS T. Kamatani et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
Fig. 2. (A) Computed tomography scan of the face and the neck showed the large buccal tumor and metastatic neck lymph node. (B) The 18 F-fluorodeoxyglucose positron emission tomography detected the large buccal tumor and one enlarged neck lymph node.
Fig. 3. Histological finding of biopsy specimen shows poorly differentiated squamous cell carcinoma.
weakness and shortness of breath. A CT scan of the chest and the abdomen showed pneumonia, multiple lung metastases (Fig. 4A), and liver metastasis (Fig. 4B). He ultimately developed respiratory failure and considering the advanced state of his metastatic cancer, life support was discontinued 2 months after the first visit to our hospital. Post-mortem examination revealed metastatic tumor nodules in the right ventricle (Fig. 5A), lung (Fig. 5B), and liver (Fig. 5C). Microscopic examination revealed metastatic poorly differentiated SCC cells in the right ventricle (Fig. 6A), lung (Fig. 6B), liver (Fig. 6C), heart, thoracic diaphragm, and pleura. Multiple nests of SCC cells within neck lymph nodes were also noted. After conducting a retrospective survey of electrocardiographic findings with cardiac
Fig. 4. (A) Chest computed tomography scan of the lung shows pneumonia and multiple metastases. (B) Abdominal computed tomography scan of the liver shows metastatic tumor.
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001
G Model JOMSMP-286; No. of Pages 4
ARTICLE IN PRESS T. Kamatani et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
3
Fig. 5. Autopsy findings demonstrating myocardial metastases in the right ventricle (A), bilateral lung (B), and liver (C).
metastasis, there were no characteristic features among the electrocardiograms showing abnormalities.
3. Discussion Cardiac involvement by metastatic malignancy is very rare in pathological practice, essentially associated with lung and breast cancers, melanoma, and leukemia [6]. Cardiac metastasis of head and neck tumors were considered to be rare. Common metastatic sites of head and neck SCC include lung, bone, liver, and mediastinum [1]. In a review of several autopsy cases with various malignancies, cardiac involvement was found in 2–31% of cases [7]. Cardiac metastasis does not generally lead to clinical findings at an early stage [8]. At more advanced stages, however, metastatic tumors in the heart gradually give rise to cardiac failure, conduction disturbances, valvular disease resembling mitral stenosis, angina pain or Strokes–Adams syndrome [9]. The electrocardiogram is rarely diagnostic [10], but changes including tachycardia, arrhythmias, conduction defects, and low voltage in patients with a known primary tumor, may be suggestive of cardiac involvement [7,11]. We would therefore like to emphasize that one should consider the possibility of cardiac metastasis, even if the patient has shown no abnormal cardiac signs.
Fig. 6. Histological finding of autopsy specimen shows poorly differentiated squamous cell carcinoma in the right ventricle (A), lung (B), and liver (C).
Conflict of interest None.
Funding None.
Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001
G Model JOMSMP-286; No. of Pages 4
ARTICLE IN PRESS T. Kamatani et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx
4
References [1] 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. [2] Zemann W, Feichtinger M, Kowatsch E, Schanbacher M, Kärcher H. Cardiac metastasis after squamous cell carcinoma of the oral cavity: case report. Br J Oral Maxillofac Surg 2007;45:425–6. [3] Ito T, Ishikawa N, Negishi T, Ohno K. Cardiac metastasis of tongue cancer may cause sudden death. Auris Nasus Larynx 2008;35:423–5. [4] Mathew BS, Jayasree K, Madhavan J, Nair MK, Rajan B. Skeletal metastases and bone marrow infiltration from squamous cell carcinoma of the buccal mucosa. Oral Oncol 1997;33:454–5. [5] Pichi B, Marchesi P, Manciocco V, Ruscito P, Pellini R, Cristalli G, et al. Carcinoma of the buccal mucosa metastasizing to the talus. J Craniofac Surg 2009;20:1142–5.
[6] Duband S, Paysant F, Scolan V, Forest F, Péoc’h M. Sudden death due to myocardial metastasis of lingual squamous cell carcinoma. Cardiovasc Pathol 2011;20:242–3. [7] Wilkes JD, Fidias P, Vaickus L, Perez RP. Malignancy-related pericardial effusion, 127 cases from the Roswell Park Cancer Institute. Cancer 1995;76: 1377–87. [8] Nagata S, Ota K, Nagata M, Shinohara M. Cardiac metastasis of head and neck squamous cell carcinoma. Int J Oral Maxillofac Surg 2012;41: 1458–62. [9] Gassman HS, Meadows Jr R, Baker LA. Metastatic tumors of the heart. Am J Med 1955;19:357–65. [10] Hans S, Chauvet D, Sadoughi B, Brasnu DF. Cardiac metastasis after squamous cell carcinoma of the base of tongue. Am J Otolaryngol 2009;30:206–8. [11] Fiocco M, Krasna MJ. The management of malignant pleural and pericardial effusions. Hematol Oncol Clin North Am 1997;11:253–65.
Please cite this article in press as: Kamatani T, et al. Cardiac metastasis of squamous cell carcinoma of the buccal mucosa. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/10.1016/j.ajoms.2014.04.001