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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 617-619

Cardiac metastasis from squamous cell carcinoma of the buccal mucosa: A case report and review of the literature


1 Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal, India
2 Department of Nuclear Medicine, Tata Medical Center, Kolkata, West Bengal, India

Date of Submission03-Mar-2020
Date of Decision23-Mar-2020
Date of Acceptance26-Mar-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Joydeep Ghosh
Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_62_20

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How to cite this article:
Ghosh J, Das J, Ganguly S, Biswas B, Dabkara D. Cardiac metastasis from squamous cell carcinoma of the buccal mucosa: A case report and review of the literature. Cancer Res Stat Treat 2020;3:617-9

How to cite this URL:
Ghosh J, Das J, Ganguly S, Biswas B, Dabkara D. Cardiac metastasis from squamous cell carcinoma of the buccal mucosa: A case report and review of the literature. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 26];3:617-9. Available from: https://www.crstonline.com/text.asp?2020/3/3/617/295525



In the Indian subcontinent, cancers of the oral cavity are very common. The incidence rate is 1 in 143 for both mouth and tongue cancers.[1] Most of our patients have locally advanced disease. The most common sites of recurrence are the local site, neck nodes, lungs, distant nodes, and bones. Metastasis to the myocardium is very uncommon from squamous cell carcinoma of the oral cavity and poses a diagnostic dilemma.

A 41-year old male, with no comorbidities, with a history of tobacco usage, presented with an ulceroproliferative growth over the left buccal mucosa, with left level 1b node palpable. He got operated with a wide local excision with neck dissection and received adjuvant concurrent chemoradiotherapy (60 Gy in 30 fractions at 200 cGy per fraction, with cisplatin weekly 30 mg/m2 for 7 weeks) till September 2019. He was then on routine follow. In November 2019, he presented with neck pain and swelling. Clinical examination revealed suspicious nodes. Fine-needle aspiration cytology confirmed a recurrence. Restaging positron emission tomography-computed tomography (PET-CT) showed locoregional disease in the nodes and a suspicious intracardiac metastasis. Since he was platinum refractory disease, immunotherapy was offered, but he was not willing for the same. Hence, he was offered single-agent methotrexate as an alternative at an outside center. After 3 months, a PET-CT was repeated at our center and showed evidence of progressive disease. There was metabolic as well as morphological progression in the locoregional disease as compared to the previous PET-CT scan. The focal intramyocardial radiotracer activity showed progression in metabolic activity in the present scan [Figure 1].
Figure 1: Positron emission tomography-computed tomography scan of a case of carcinoma buccal mucosa before (a-d) and after (e-h) chemotherapy. Buccal mucosal lesion (black single arrow) showed increase in size. Submental lymph node (black double arrow) showed increase in size and metabolic activity. Intramyocardial mass lesion (white single arrow) in the lateral wall of the right ventricle corresponded to a nodular mass in the computed tomography image and showed increase in size and metabolic activity

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There was no evidence of any arrhythmia. Echocardiography confirmed the mass. Since the mass was located in the outer aspect of the pericardium, he had a very high risk of fatal arrhythmia. Hence, after taking the cardiologist's opinion, biopsy for histopathology was avoided. The patient was offered single-agent weekly paclitaxel, but he opted for best supportive care. He is presently on morphine and other supportive medications for pain control. The timeline of events in the case is summarized in [Table 1].
Table 1: Important timelines

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Intracardiac metastasis from head-and-neck cancer is a very rare phenomenon. Autopsy studies have shown incidence rates ranging from 2.3% to 18.3%.[2] In one report, an elderly woman presented with features of acute myocardial ischemia. She had a large pericardial mass, likely to be metastasis from the oral primary.[3] In one report, a young male had a recurrence in the lungs as well as the pericardium. He did not respond to systemic therapy and died within 2 months of diagnosis of metastasis.[4] Another patient also presented with cardiac decompensation.[5] One patient had a cardiac arrest and could not be revived. Autopsy study done later showed the presence of cardiac metastasis.[6] Another report from Japan was that of a middle-aged woman who died of a cardiac metastasis 7 months post curative treatment.[7] Cardiac metastasis was the only site of distant recurrence in one patient, who presented with features of cardiac decompensation.[8] Intraventricular thrombus and pulmonary embolism were the complications found in one patient who had multiple recurrences.[9] Summarizing from the above evidence, it is clear that most of the patients presented with cardiac symptoms. Few were clinically silent. Almost all of them had very dismal outcomes, and the cause of death was mostly due to cardiac decompensation and arrhythmia. The possibility of cardiac metastasis should be kept in mind as a possibility for such a radiological picture. Cardiac magnetic resonance imaging (MRI) may be done for further characterizing the lesions. MRI appearances are variable and generally nonspecific for the site of origin, with the exception of melanoma which causes characteristic high T1 signal masses due to T1 shortening effects of melanin. Lesions with a hemorrhagic component may also have some areas of high T1 signal secondary to blood breakdown products.[10] Most of the cases mentioned above either had an endocardial component from which biopsy was feasible, or were histopathologically confirmed at autopsy, which remains the gold standard.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Asthana S, Patil RS, Labani S. Tobacco-related cancers in India: A review of incidence reported from population-based cancer registries. Indian J Med Paediatr Oncol 2016;37:152-7.  Back to cited text no. 1
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2.
Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol 2007;60:27-34.  Back to cited text no. 2
    
3.
Pattni N, Rennie A, Hall T, Norman A. Cardiac metastasis of oral squamous cell carcinoma. BMJ Case Rep. 2015;2015:bcr2015211275.   Back to cited text no. 3
    
4.
Tandon V, Kethireddy N, Balakumaran K, Kim AS. Metastatic squamous cell carcinoma to the heart: an unusual cause of ST elevation-a case report. Eur Heart J Case Rep 2019;3:ytz029.   Back to cited text no. 4
    
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Patel H, Francke M, Stahura H, El-Hajjar M, Schulman-Marcus J. Solitary cardiac metastasis from primary oral squamous cell carcinoma presenting as ST-elevation MI. BMJ Case Rep 2018;2018:bcr2018224732.   Back to cited text no. 5
    
6.
Kim HJ, Jeon SH, Seo JS. Death due to cardiac metastasis after treatment of oral squamous cell carcinoma: An autopsy case. Korean J Legal Med 2012;36:115-8.  Back to cited text no. 6
    
7.
Fujio H, Otsuki N, Horichi Y, Yanagisawa S, Nishio M, Teshima M, et al. Cardiac metastasis in a living patient with oral cancer. Auris Nasus Larynx 2019;46:902-6.  Back to cited text no. 7
    
8.
Martell K, Simpson R, Skarsgard D. Solitary myocardial metastasis from locoregionally controlled squamous cell carcinoma of the oral cavity. Cureus 2016;8:e650.  Back to cited text no. 8
    
9.
Malekzadeh S, Platon A, Poletti PA. Cardiac metastasis of tongue squamous cell carcinoma complicated by pulmonary embolism: A case report. Medicine (Baltimore) 2017;96:e7462.  Back to cited text no. 9
    
10.
Hoey ET, Shahid M, Ganeshan A, Baijal S, Simpson H, Watkin RW. MRI assessment of cardiac tumours: Part 2, spectrum of appearances of histologically malignant lesions and tumour mimics. Quant Imaging Med Surg 2014;4:489-97.  Back to cited text no. 10
    


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