|Ahead of print publication
Cutaneous and cardiac metastases in carcinoma of anterior tongue
Saroj Kumar Das Majumdar1, Tapan Kumar Sahoo2, Dillip Kumar Parida1
1 Department of Radiotherapy, All India Institute of Medical Sciences, Bhubaneswar, India
2 Department of Radiotherapy, HCG Panda Cancer Hospital, Cuttack, Odisha, India
Tapan Kumar Sahoo,
Department of Radiotherapy, HCG Panda Cancer Hospital, Cuttack, Odisha
Source of Support: None, Conflict of Interest: None
Distant metastases in squamous cell carcinoma of the head and neck are uncommon, and the incidence rises with neck node metastasis. The lung, liver, and bones are the common possible sites for distant metastasis. Cutaneous and cardiac metastases are extremely rare situations with aggressive behaviors and present in the late course of the disease. Here, we report a case of anterior tongue cancer with cutaneous, bone, cardiac, lung, and soft tissue of right suprascapular area metastases after a gap of 2 years of follow-up of completion of treatment with radical surgery and adjuvant concurrent chemoradiation therapy. The present case developed such type of aggressive distant metastases without any locoregional recurrence and died within 6 months of diagnosis of distant metastases.
Keywords: Cardiac, cutaneous, metastasis, tongue
| > Introduction|| |
Head and neck cancer (HNC) is one of the common cancers in the eastern zone of India, with the rising incidence due to poor socioeconomic status, increased use of tobacco, and smoking habits. Majority of the head and neck squamous cell carcinomas (HNSCC) spread by locoregional metastases. The incidence of distant metastasis in HNSCC is lower in comparison to other malignancies, with a poor prognosis., Different multimodality treatments improve locoregional control nowadays, but survival is not improved due to distant metastasis.
Tongue represents 35% of the oral cavity squamous cell carcinoma (SCC) with high lymphatic spread. Nonlymphatic-distant spread occurs in approximately 10% of cases. Lung followed by bone and liver are the common possible sites of distant metastases.,, Cardiac and skin metastases are extremely rare in HNSCC, and mechanism for metastases is doubtful. We report a case of SCC of the anterior tongue with extensive distant metastases including cutaneous and cardiac metastases.
| > Case Report|| |
A 38-year-old male patient with a history of ulceroproliferative growth over the left lateral border of tongue diagnosed as SCC of the tongue with clinical stage CT3N0M0. Wide local excision with hemimandibulectomy and modified neck node dissection were performed and pathological staging showed PT3N0MX with the margin positive. The patient received adjuvant concurrent chemoradiation therapy under proper dose schedule. After 26 months of follow-up, the patient developed an ulceroproliferative growth over the right posterior parietal scalp. Physical examination showed no lesion in the oral cavity [Figure 1]a and an ulceroproliferative growth measuring approximately 3 cm × 3 cm over the right posterior parietal scalp [Figure 1]b. No neck nodes were palpable clinically. Biopsy from the scalp growth showed features of metastatic SCC. Electrocardiography (ECG) showed T-wave inversion in the lead III and avf [Figure 2]a and [Figure 2]b. positron emission tomography-computed tomography (PET-CT) scan revealed a hypermetabolic mass measuring 2.5 cm × 2.5 cm over the right parietal scalp, retrotracheal and subcarinal lymphadenopathy, a hypermetabolic soft tissue mass lesion at the right suprascapular area, multiple lung metastases, skeletal metastasis over multiple ribs, fifth lumbar spine and left ileum, and two metabolically hyperactive lesions over the left ventricle of heart (suggestive of cardiac metastasis) [Figure 3]a and [Figure 3]b. The patient received palliative chemotherapy with nimotuzumab and nanopaclitaxel on weekly basis and bone-stabilizing agent zoledronic acid 4 mg on 3-weekly basis along with pain management and tolerating well. As there was no new development of cardiac symptoms during the treatment course, the follow-up ECG was not done. The patient died from aggressive disease during 6 months of diagnosis of the distant metastasis.
|Figure 1: (a) Postoperative and postradiotherapy status of oral cavity, (b) cutaneous lesion at right parietal scalp area|
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|Figure 2: Electrocardiography showing T-wave inversion in lead III (a) and lead avf (b)|
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|Figure 3: Positron emission tomography-computed tomography scan showing (a) cutaneous lesion at right scalp area, soft tissue lesion at right shoulder area, lung, bone, and cardiac metastases and (b) lung and cardiac metastases|
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| > Discussion|| |
Hypopharynx (60%) is the most common primary site for distant metastasis among HNSCC, followed by base of tongue (53%) and anterior tongue (50%). It usually occurs within 2 years of the initial diagnosis. Location of primary tumor, histopathology grade, initial T and N stage, advanced neck node particularly with jugular vein invasion, extensive soft tissue diseases, preoperative neck disease, extracapsular spread, lymphovascular invasion, and ≥3 positive lymph nodes and regional control are the clinicopathological risk factors.
Cutaneous metastasis constitutes about 0.8%–1.3% in HNSCC and usually occurs at sites near to primary tumors such as scalp, neck, and chest wall. A study showed that the incidence of dermal metastases among HNSCC patients achieving locoregional control according to sites specific was hypopharynx and nasopharynx as 14% and 11%, respectively; oropharynx and supraglottis as 7% and 8%, respectively; and oral cavity and glottis less than 1%. Different morphological patterns of presentation for the cutaneous metastasis are infiltrating papules and/or nodules, alopecia neoplastica, zosteriform pattern, chest tumor, or lesions mimicking radiation dermatitis, and histopathology study is necessary to confirm metastasis. The survival is approximately 3 months after clinically evident skin metastases in HNSCC.
Cardiac metastasis is more common than the primary cardiac tumor. The incidence of cardiac metastasis varies from 2.3% to 18.3%. Lung, breast, esophagus, and kidney carcinomas, lymphoma, leukemia, sarcoma, and malignant melanoma are the common possible primary for cardiac metastasis. Hypopharynx and base of the tongue are the most common sites for cardiac metastasis among HNCs with 60% and 53% incidence, respectively. The incidence with tongue primary is variable (1.5%–50%), but the antemortem diagnosis is rare due to clinically silent nature., The present case is incidentally detected with cardiac metastasis during evaluation for cutaneous metastasis. Sites of cardiac metastasis in decreasing order of frequency are pericardium, myocardium, epicardium, endocardium, and intracavitary regions. The patient may present with hypotension, shortness of breath, congestive heart failure, arrhythmias due to tumor invasion of the septum, angina decubitus due to location of tumor, and pericardial effusion., Sudden death may occur in 3% cases due to invasion of myocardium, coronary flow interference, distortion of cardiac valves, intracardiac blood flow obstruction, rupture of myocardium, disturbance of rhythm, pericardial effusion-related tampanode, or large mass effect. CT, magnetic resonance imaging (MRI), transthoracic ECG, and PET-CT are the different techniques of cardiac imaging. ECG and MRI are the ideal tools for the diagnosis. In cardiac metastasis, there are no data to compare superiority of the PET-CT with other imaging techniques. However, ECG is relatively inexpensive, readily available, repeatable, and portable. Low-voltage QRS complex, prolonged ST = segment elevation without Q waves, nonspecific ST-T wave changes, and complete heart block above the bundle of His with a narrow QRS complex are the possible ECG findings. Cardiac imaging should be done to rule out cardiac metastasis for any ECG changes during follow-up of a primary malignant tumor. Although ECG did as a routine evaluation in our case with a known cutaneous metastasis, the finding of ECG changes and cardiac metastasis on PET-CT gives a clue to rule out cardiac metastasis with any ECG finding and cardiac imaging should be done.
Resection, radiotherapy, and chemotherapy may be used for palliation in the cardiac and cutaneous metastases, but the result is unsuccessful. Surgical excision may consider in isolated skin metastasis and may increase the survival time. Therefore, further imaging should be done carefully in skin metastasis to rule out association of other distant metastasis and further possibility of surgical resection for cutaneous metastasis to improve survival. Due to extensive metastasis to different sites, surgical resection for cutaneous lesion is not possible in the present case.
Axial skeleton is most commonly involved among skeletal metastases, with lumbar spine being the most common site as in the present case involving the fifth lumbar spine. Metastasis to gluteus muscle was detected in SCC of the larynx during follow-up.
The present case has cardiac metastasis along with extensive distant metastases to bone, lung, soft tissue, and skin in the absence of locoregional recurrence supporting the literature.
| > Conclusion|| |
Any cutaneous lesion in an existing primary malignancy should be biopsied to rule out the metastasis and decision of further treatment need complete evaluation. In any ECG changes during follow-up of the primary malignant tumor, cardiac metastases should be ruled out.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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