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Metastatic Squamous Cell Carcinoma of an Unknown Primary Site With Cardiac Involvement: Case Report
SURGICAL ONCOLOGY AND RECONSTRUCTION
Metastatic Squamous Cell Carcinoma of an Unknown Primary Site With Cardiac Involvement: Case Report Reza Fouladi, DDS, MD,* Phillip Pirgousis, DMD, MD,y and Rui P. Fernandes, DMD, MDz Head and neck squamous cell carcinomas frequently metastasize to cervical lymph nodes. Distant metastasis by hematogenous dissemination pathways is less common. Cardiac involvement is a particularly rare occurrence. The first case of cardiac metastasis was reported in the early 18th century as a postmortem discovery. Since then, there have been sporadic reports of oropharyngeal cancer with cardiac metastasis. This report describes a case of metastatic squamous cell carcinoma of an unknown primary site involving the lungs, heart, and soft tissue of the bilateral paraspinal regions and lower extremity. Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:1998-2003, 2013
Head and neck squamous cell carcinomas frequently metastasize to the cervical lymph nodes. Distant metastasis by hematogenous dissemination pathways is less common. Cardiac involvement is a particularly rare occurrence.1 The first case of cardiac metastasis was reported in the early 18th century as a postmortem discovery. Since then, there have been sporadic reports of oropharyngeal cancer with cardiac metastasis. This report describes a case of metastatic squamous cell carcinoma of an unknown primary site involving the lungs, heart, and soft tissue of the bilateral paraspinal regions and lower extremity.
A 56-year-old woman presented to the emergency room at the University of Florida Shands Hospital for an evaluation of right neck swelling. The patient first noticed this swelling 1 month before her presentation, for which computed tomography of the neck was per-
formed at a different institution. The patient was evaluated by a surgeon in the community with needle aspiration of the right neck. She was subsequently scheduled by the treating surgeon for excision of the right neck mass. However, owing to financial limitations, she presented to the authors’ institution for definitive care. She also noticed a swelling on her right flank 1 week after the right neck swelling. Her social history was significant for a 30-pack-year smoking history and daily alcohol consumption for 30 years. She denied any medical conditions other than hypertension. She further denied any recent weight change, fever, chills, or night sweats. On clinical examination, a 6-cm firm mass of the right neck anterior to the Sternocleidomastoid muscle with tenderness to palpation was noted (Fig 1A, B). The rest of head and neck examination was unremarkable. A 6-cm firm mass of the right flank and a smaller mass on the left side also were noted. Flexible nasoendoscopy yielded unremarkable findings. The patient
Received from the Division of Oral and Maxillofacial Surgery,
Division of Oral and Maxillofacial Surgery, University of Florida, Col-
University of Florida, College of Medicine, Jacksonville, FL.
lege of Medicine, 653-1 W 8th Street, 2nd Floor LRC, Jacksonville, FL
Report of Case
*Chief Resident.
32209; e-mail: [email protected]
yAssistant Professor, Section of Head and Neck Oncology/
Published by Elsevier Inc on behalf of the American Association of Oral and
Reconstructive Surgery. zAssistant Professor and Director, Section of Head and Neck
Maxillofacial Surgeons
Oncology/Reconstructive Surgery.
http://dx.doi.org/10.1016/j.joms.2013.04.025
0278-2391/13/00427-8$36.00/0
Address correspondence and reprint requests to Dr Pirgousis: Section of Head and Neck Oncology/Reconstructive Surgery,
1998
1999
FOULADI, PIRGOUSIS, AND FERNANDES
FIGURE 1. A 6-cm right neck mass in the A, anterior and B, lateral views. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
FIGURE 2. Coronal neck computed tomogram showing a large, centrally necrotic mass in the right infrahyoid neck with multiple hypermetabolic lymph nodes and a large necrotic right supraclavicular lymph node. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
was subsequently admitted to the oral and maxillofacial surgery service for further workup, where a neck computed tomogram displayed a large centrally necrotic mass in the right infrahyoid neck with additional enhancing, centrally necrotic, bilateral cervical and superior mediastinal adenopathy (Fig 2). Multiple subcentimeter pulmonary nodular densities also were evident. A chest computed tomogram was obtained to further characterize the lung metastases; it depicted an additional 3- 2.3-cm mass projecting in the region of the interventricular septum (Figs 3, 4). An electrocardiogram obtained on admission showed sinus rhythm. Fine-needle aspiration of the right neck and right paraspinal masses showed only acute inflammation consistent with an abscess. Because the clinical and radiographic findings were suspicious for a metastatic process, whole-body positron-emission computed tomography was performed. The results were consistent with diffuse metastatic disease, with multiple necrotic masses and lymph nodes mainly involving the cervical and supraclavicular regions and soft tissue
2000
METASTATIC SCC WITH CARDIAC INVOLVEMENT
FIGURE 3. Axial chest computed tomogram displaying an irregular 3-cm mass along the anterior interventricular septum, which is contiguous with the pericardium (arrow). Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
FIGURE 4. Coronal view of cardiac metastasis along interventricular septum (arrow). Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
2001
FOULADI, PIRGOUSIS, AND FERNANDES
FIGURE 5. Positron-emission computed tomogram confirming right lower extremity disease. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
deposits most prominent at the paraspinal regions and right lower extremity (Fig 5). Additional metastatic disease to the heart at the level of the cardiac apex was confirmed (Fig 6). Increased uptake within the left adrenal gland and focal increased uptake within the right retroperitoneum were noted. To confirm the diagnosis of metastatic disease, open node biopsy of the right neck was performed in the operating room with monitored anesthesia care. Pathology reported poorly differentiated squamous cell carcinoma (Figs 7, 8). No further investigative
FIGURE 6. Positron-emission computed tomogram depicting cervical and supraclavicular disease with a hypermetabolic lesion at the cardiac apex. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
studies were performed given the presence of multiple metastatic sites.
Discussion Metastatic disease with cardiac involvement is a rare finding at autopsy examination of an unselected group of patients. However, large studies looking at patients with disseminated cancer have shown approximately 15% intracardiac metastases.2 Interestingly, these metastases are asymptomatic in most cases.3 Cates et al4 reported that only 10% of patients with cardiac
2002
METASTATIC SCC WITH CARDIAC INVOLVEMENT
FIGURE 7. Low-power photomicrograph of open cervical lymph node biopsy confirming squamous cell carcinoma. H&E section, 100x magnification. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
metastasis had a new electrocardiographic finding suggestive of myocardial ischemia or injury. Tumors with a strong tendency for metastasis to the heart include malignant melanoma, leukemia, malignant germ cell tumors, and malignant thymoma.3 Although carcinoma of the lung and breast do not frequently metastasize to the heart, given the high incidence of these tumors, they are responsible for the largest number of cardiac metastases.3 The myocardium is most frequently affected by the metastatic process followed
by the pericardium and then the endocardium; the conducting system is significantly less frequently involved.5 Common metastatic sites of head and neck tumors include the lung, bone, liver, and mediastinum.6,7 Among head and neck cancers with cardiac metastasis, primary tumors of the tongue are most frequently involved.8 In the authors’ opinion, positron-emission computed tomography is a useful and sensitive tool to detect cardiac metastases, as supported by others.9
2003
FOULADI, PIRGOUSIS, AND FERNANDES
FIGURE 8. High-power photomicrograph of cervical lymph node containing metastatic squamous cell carcinoma deposit. H&E section, 400x magnification. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
References 1. Schwender FT, Wollner I, Kunju LP, et al: Squamous cell carcinoma of the buccal mucosa with metastases to the pericardial cavity, lung and thyroid. Oral Oncol 38:114, 2002 2. Burke A, Virmani R: Tumors metastatic to the heart and pericardium. in Rosai J (ed): Atlas of Tumor Pathology. Washington, DC: Armed Forces Institute of Pathology, 1996, p. 195–209 3. Alhakeem M, Arabi A, Arab L, et al: Unusual sites of metastatic involvement: Intracardiac metastasis from laryngeal carcinoma. Eur J Echocardiogr 9:323, 2008 4. Cates CU, Virmani R, Vaughn WK, et al: Electrocardiographic markers of cardiac metastasis. Am Heart J 112:1297, 1986
5. Ito T, Ishikawa N, Negishi T, et al: Cardiac metastasis of tongue cancer may cause sudden death. Auris Nasus Larynx 35:423, 2008 6. Merino OR, Lindberg RD, Fletcher GH: An analysis of distant metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer 40:145, 1977 7. Probert JC, Thompson RW, Bagshaw MA: Patterns of spread of distant metastases in head and neck cancer. Cancer 33:127, 1974 8. Deloach JF, Haynes JW: Secondary tumors of heart and pericardium: Review of the subject and report of one hundred thirtyseven cases. Arch Intern Med 91:224, 1953 9. Betka J: Distant metastases from lip and oral cavity cancer. ORL J Otorhinolaryngol Relat Spec 63:217, 2001
Metastatic Squamous Cell Carcinoma of an Unknown Primary Site With Cardiac Involvement: Case Report Reza Fouladi, DDS, MD,* Phillip Pirgousis, DMD, MD,y and Rui P. Fernandes, DMD, MDz Head and neck squamous cell carcinomas frequently metastasize to cervical lymph nodes. Distant metastasis by hematogenous dissemination pathways is less common. Cardiac involvement is a particularly rare occurrence. The first case of cardiac metastasis was reported in the early 18th century as a postmortem discovery. Since then, there have been sporadic reports of oropharyngeal cancer with cardiac metastasis. This report describes a case of metastatic squamous cell carcinoma of an unknown primary site involving the lungs, heart, and soft tissue of the bilateral paraspinal regions and lower extremity. Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:1998-2003, 2013
Head and neck squamous cell carcinomas frequently metastasize to the cervical lymph nodes. Distant metastasis by hematogenous dissemination pathways is less common. Cardiac involvement is a particularly rare occurrence.1 The first case of cardiac metastasis was reported in the early 18th century as a postmortem discovery. Since then, there have been sporadic reports of oropharyngeal cancer with cardiac metastasis. This report describes a case of metastatic squamous cell carcinoma of an unknown primary site involving the lungs, heart, and soft tissue of the bilateral paraspinal regions and lower extremity.
A 56-year-old woman presented to the emergency room at the University of Florida Shands Hospital for an evaluation of right neck swelling. The patient first noticed this swelling 1 month before her presentation, for which computed tomography of the neck was per-
formed at a different institution. The patient was evaluated by a surgeon in the community with needle aspiration of the right neck. She was subsequently scheduled by the treating surgeon for excision of the right neck mass. However, owing to financial limitations, she presented to the authors’ institution for definitive care. She also noticed a swelling on her right flank 1 week after the right neck swelling. Her social history was significant for a 30-pack-year smoking history and daily alcohol consumption for 30 years. She denied any medical conditions other than hypertension. She further denied any recent weight change, fever, chills, or night sweats. On clinical examination, a 6-cm firm mass of the right neck anterior to the Sternocleidomastoid muscle with tenderness to palpation was noted (Fig 1A, B). The rest of head and neck examination was unremarkable. A 6-cm firm mass of the right flank and a smaller mass on the left side also were noted. Flexible nasoendoscopy yielded unremarkable findings. The patient
Received from the Division of Oral and Maxillofacial Surgery,
Division of Oral and Maxillofacial Surgery, University of Florida, Col-
University of Florida, College of Medicine, Jacksonville, FL.
lege of Medicine, 653-1 W 8th Street, 2nd Floor LRC, Jacksonville, FL
Report of Case
*Chief Resident.
32209; e-mail: [email protected]
yAssistant Professor, Section of Head and Neck Oncology/
Published by Elsevier Inc on behalf of the American Association of Oral and
Reconstructive Surgery. zAssistant Professor and Director, Section of Head and Neck
Maxillofacial Surgeons
Oncology/Reconstructive Surgery.
http://dx.doi.org/10.1016/j.joms.2013.04.025
0278-2391/13/00427-8$36.00/0
Address correspondence and reprint requests to Dr Pirgousis: Section of Head and Neck Oncology/Reconstructive Surgery,
1998
1999
FOULADI, PIRGOUSIS, AND FERNANDES
FIGURE 1. A 6-cm right neck mass in the A, anterior and B, lateral views. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
FIGURE 2. Coronal neck computed tomogram showing a large, centrally necrotic mass in the right infrahyoid neck with multiple hypermetabolic lymph nodes and a large necrotic right supraclavicular lymph node. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
was subsequently admitted to the oral and maxillofacial surgery service for further workup, where a neck computed tomogram displayed a large centrally necrotic mass in the right infrahyoid neck with additional enhancing, centrally necrotic, bilateral cervical and superior mediastinal adenopathy (Fig 2). Multiple subcentimeter pulmonary nodular densities also were evident. A chest computed tomogram was obtained to further characterize the lung metastases; it depicted an additional 3- 2.3-cm mass projecting in the region of the interventricular septum (Figs 3, 4). An electrocardiogram obtained on admission showed sinus rhythm. Fine-needle aspiration of the right neck and right paraspinal masses showed only acute inflammation consistent with an abscess. Because the clinical and radiographic findings were suspicious for a metastatic process, whole-body positron-emission computed tomography was performed. The results were consistent with diffuse metastatic disease, with multiple necrotic masses and lymph nodes mainly involving the cervical and supraclavicular regions and soft tissue
2000
METASTATIC SCC WITH CARDIAC INVOLVEMENT
FIGURE 3. Axial chest computed tomogram displaying an irregular 3-cm mass along the anterior interventricular septum, which is contiguous with the pericardium (arrow). Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
FIGURE 4. Coronal view of cardiac metastasis along interventricular septum (arrow). Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
2001
FOULADI, PIRGOUSIS, AND FERNANDES
FIGURE 5. Positron-emission computed tomogram confirming right lower extremity disease. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
deposits most prominent at the paraspinal regions and right lower extremity (Fig 5). Additional metastatic disease to the heart at the level of the cardiac apex was confirmed (Fig 6). Increased uptake within the left adrenal gland and focal increased uptake within the right retroperitoneum were noted. To confirm the diagnosis of metastatic disease, open node biopsy of the right neck was performed in the operating room with monitored anesthesia care. Pathology reported poorly differentiated squamous cell carcinoma (Figs 7, 8). No further investigative
FIGURE 6. Positron-emission computed tomogram depicting cervical and supraclavicular disease with a hypermetabolic lesion at the cardiac apex. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
studies were performed given the presence of multiple metastatic sites.
Discussion Metastatic disease with cardiac involvement is a rare finding at autopsy examination of an unselected group of patients. However, large studies looking at patients with disseminated cancer have shown approximately 15% intracardiac metastases.2 Interestingly, these metastases are asymptomatic in most cases.3 Cates et al4 reported that only 10% of patients with cardiac
2002
METASTATIC SCC WITH CARDIAC INVOLVEMENT
FIGURE 7. Low-power photomicrograph of open cervical lymph node biopsy confirming squamous cell carcinoma. H&E section, 100x magnification. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
metastasis had a new electrocardiographic finding suggestive of myocardial ischemia or injury. Tumors with a strong tendency for metastasis to the heart include malignant melanoma, leukemia, malignant germ cell tumors, and malignant thymoma.3 Although carcinoma of the lung and breast do not frequently metastasize to the heart, given the high incidence of these tumors, they are responsible for the largest number of cardiac metastases.3 The myocardium is most frequently affected by the metastatic process followed
by the pericardium and then the endocardium; the conducting system is significantly less frequently involved.5 Common metastatic sites of head and neck tumors include the lung, bone, liver, and mediastinum.6,7 Among head and neck cancers with cardiac metastasis, primary tumors of the tongue are most frequently involved.8 In the authors’ opinion, positron-emission computed tomography is a useful and sensitive tool to detect cardiac metastases, as supported by others.9
2003
FOULADI, PIRGOUSIS, AND FERNANDES
FIGURE 8. High-power photomicrograph of cervical lymph node containing metastatic squamous cell carcinoma deposit. H&E section, 400x magnification. Fouladi, Pirgousis, and Fernandes. Metastatic SCC With Cardiac Involvement. J Oral Maxillofac Surg 2013.
References 1. Schwender FT, Wollner I, Kunju LP, et al: Squamous cell carcinoma of the buccal mucosa with metastases to the pericardial cavity, lung and thyroid. Oral Oncol 38:114, 2002 2. Burke A, Virmani R: Tumors metastatic to the heart and pericardium. in Rosai J (ed): Atlas of Tumor Pathology. Washington, DC: Armed Forces Institute of Pathology, 1996, p. 195–209 3. Alhakeem M, Arabi A, Arab L, et al: Unusual sites of metastatic involvement: Intracardiac metastasis from laryngeal carcinoma. Eur J Echocardiogr 9:323, 2008 4. Cates CU, Virmani R, Vaughn WK, et al: Electrocardiographic markers of cardiac metastasis. Am Heart J 112:1297, 1986
5. Ito T, Ishikawa N, Negishi T, et al: Cardiac metastasis of tongue cancer may cause sudden death. Auris Nasus Larynx 35:423, 2008 6. Merino OR, Lindberg RD, Fletcher GH: An analysis of distant metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer 40:145, 1977 7. Probert JC, Thompson RW, Bagshaw MA: Patterns of spread of distant metastases in head and neck cancer. Cancer 33:127, 1974 8. Deloach JF, Haynes JW: Secondary tumors of heart and pericardium: Review of the subject and report of one hundred thirtyseven cases. Arch Intern Med 91:224, 1953 9. Betka J: Distant metastases from lip and oral cavity cancer. ORL J Otorhinolaryngol Relat Spec 63:217, 2001