Cardiac metastasis of tongue carcinoma

LV

AoLATumorFig. 2. A cardiac echogram with its schema showing a tumor mass in the left ventricle. LV, left ventricle; LA,left atrium; Ao, aorta.

Since February 1998, however, anorexia
and constipation appeared. Because the symptoms did not improve, he was admitted again inMarch 1998. On admission, there was no sign ofrecurrence in the tongue, mesopharynx, hypopharynx, esophagus or neck. His blood pressure was 103/60 mmHg, and his pulse rate was78 beats/min. Laboratory findings revealed hyperleucocytosis, hyponatremia, hypercalcemia

and a high value of C-reacting protein (Table1). ECGs showed elevations of ST waves inleads I, aVL, V5 and V6, and a depression inlead aVF (Fig. 1). Cardiac echography revealed a tumor mass in the lower portion of the lateral wall of the left ventricle (Fig. 2). Sudden
and serious arrhythmias were provoked on 12March 1998, and he died on 22 March of cardiac insufficiency by arrhythmia. The post-Fig. 3. The heart at autopsy. The metastatic tumor mainly exists in the anterior andlateral wall of the left ventricle, reaching to the septum.

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Fig. 4. Tumor cells composed of squamous cell carcinoma. Hematoxylin eosin stain, × 200.

mortem examination showed the heart was 550
g in weight and involved in the tumor. The cardiac tumor metastasized mainly into the anterior and lateral wall of the left ventricle, andreached the septum (Fig. 3). Microscopically, a
low or moderately differentiated type of squamous cell carcinoma invaded the myocardium(Fig. 4). Other distant metastases were foundat autopsy in the right lung, bilateral adrenalglands, renal chorion, bilateral kidneys andright upper extremity.

Discussion
Concerning the incidence of cardiac metastases
from malignant tumors, Abraham et al. (1990)
reported 11.8% and Nakayama et al. (1966),
9.7%. However, reported incidences have varied according to the type of institutions, because
cardiac metastases are generally found at autopsy, and clinically evident cardiac metastases areuncommon (Abraham et al., 1990). Malignant
tumors of the head and neck with cardiac metastases are particularly rare. Among tumors of

the head and neck, primary malignant tumors of
the tongue are frequent (DeLoach and Haynes,1953; Nakayama et al., 1966). Nakayama et al.
(1966) reported that cardiac metastases werefound at autopsy in 6 of 12 patients with tongue
carcinomas. Myocardial or pericardial involvement was observed at autopsy in 1 of 9 patientswith tongue carcinomas (DeLoach and Haynes,1953), and in 2 of 126 patients with primary
tongue carcinoma (Gasman et al., 1955). To thebest of our knowledge, antemortem diagnosis
was reported only in 3 cases, including the present one, of squamous cell carcinoma of thetongue with metastasis to the heart (Werbel etal., 1985; Rivkin et al., 1999). Concerning thedistribution of metastases within the heart,
Abraham et al. (1990) carried out postmortem
examinations for 3314 cases over a 14-year period, and reported that the myocardium was themost common site (53.9%), followed by thepericardium (28.4%), epicardium (13.7%) andendocardium (3.9%). Most reported cases ofcardiac metastases have been involved in theright atrium or ventricle, and metastases in theleft ventricle have been quite uncommon. The134

Cardiac metastasis of tongue carcinoma

present case suffered from a metastatic tumor in
the left ventricle, presumably spread by the hematogenous route.
Cardiac metastases have no characteristic
symptoms nor peculiar ECG findings. Differentiation of cardiac metastases from ischemic
heart disease or endocarditis is difficult. Bisel
et al. (1953) reported a retrospective survey on
ECG findings in 59 patients with cardiac metastasis: ECGs showed normal findings in 42%
and abnormal findings in 58%. Of the abnormal
findings, T-wave abnormalities were the mostcommon (14 cases), followed by low-voltage
QRS complexes (7 cases), ST-segment deviations (5 cases), Q-wave abnormalities (2 cases)
and prolonged A-V conduction (1 case). But
these abnormal findings occur also in other diseases such as ischemic heart disease and endocarditis. In our case, follow-up was carried out
through periodical ambulatory examination, in
which the oral cavity, chest and abdomen were
carefully checked by CT. Examination of theheart was not done because there were no suspected symptoms of cardiac metastasis. But withthe uncommon ECG and cardiac-echographic
findings, we could clinically have made anantemortem diagnosis in retrospect. Because
echogram-guided biopsy was not carried out, definite diagnosis depended on postmortem examinations.
Cardiac metastases are highly likely to provoke conduction disorder of the heart, myocardial ischemia and cardiac tamponade. In
preventing sudden death, it is important to makea correct diagnosis. However, even if cardiac
metastasis is diagnosed, applying curative therapy is difficult because most cardiac metastasesare spread by a systematic route, causing a relatively critical status in general. Werbel et al.
(1985), Moser et al. (1991) and Murase et al.
(1992) reported on resection of cardiac metastasis, but surgery in each case was unsuccessful. Shelburne and Aronson (1940) reported ona conservative treatment for cardiac metastasis,
which was irradiation for a case of pericardialeffusion. Rivkin et al. (1999) reported treatment by chemotherapy for palliation. In a caseof squamous cell carcinoma in the uterine cer-vix reported by Batchelor et al. (1997), chemotherapeutic treatment applied for 1 year successfully produced no recurrence. For the present patient, application of curative or palliative
therapy such as radiation and chemotherapy
was not possible because he had already been ina critical status. Almost all patients are considered fatal when they are diagnosed with cardiac metastasis. But, if cardiac metastases ofmalignant tumors are found early by ECG or
cardiac echogram, chemotherapy or radiation
therapy could bring apothanasia to patients.
The paucity of antemortem diagnosis of cardiac
metastasis emphasizes the importance and significance of this.

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Received May 7, 2001; accepted June 11, 2001
Corresponding author: Dr. Katsuyuki Kawamoto