Surgical reconstruction after resection of cardiac metastasis from oropharyngeal carcinoma: a case report

概要

MEDICAL IMAGE AT A GLANCE
Nagoya J. Med. Sci. 85. 875–879, 2023
doi:10.18999/nagjms.85.4.875

Surgical reconstruction after resection of cardiac metastasis
from oropharyngeal carcinoma: a case report
Toshihiko Nishi1, Kazuro L. Fujimoto1, Mariko Hiramatsu2, Tohru Okada3,
Yuka Suzuki4, Yoshie Shimoyama4, Sachie Terazawa1, Yoshiyuki Tokuda1,
Masato Mutsuga1 and Akihiko Usui1
1
Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
3
Department of Radiology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
4
Department of Pathology and Clinical Laboratories, Nagoya University Graduate School of Medicine,
Nagoya, Japan
2

Keywords: cardiac metastatic carcinoma, oropharyngeal carcinoma, reconstruction
Abbreviation:
RAA: right atrial appendage
This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Cardiac metastasis in patients with head and neck cancer is rare.1-3 Considering the cases
reported from 1985 to 2020, oral cancer was the most common head and neck cancers leading
to cardiac metastasis, accounting for 62% of all cases. Conversely, only 12% of oropharyngeal
carcinoma cases resulted in metastatic cardiac tumors.3 Oropharyngeal carcinoma has a low
incidence of distant metastases, with the lungs and liver being the most common sites and
cardiac metastases being rare.4,5 A 72-year-old woman was diagnosed with left oropharyngeal
carcinoma at the age of 67 years. Subsequently, the patient underwent tumor resection along
with left cervical lymph node dissection. The oncological diagnosis was highly differentiated,
p16 negative, pT2N2bM0, and stage IVa squamous carcinoma. Four years later, local recurrence
was noted, with poorly differentiated carcinoma. The patient underwent another tumor resection,
right neck lymph node dissection, and tongue reconstruction using a rectus flap. After six months,
follow-up contrast-enhanced computed tomography revealed a mass in the right atrial appendage
(RAA) extending into the right ventricle (Fig. 1A). Transthoracic echocardiography revealed a
mobile mass between the right atrium and right ventricle (Fig. 1B). Magnetic resonance imaging
revealed a connection between the tumor in the RAA and the mobile mass (Fig. 1C). Whole-body
positron emission tomography-computed tomography revealed high tumor accumulation in the
RAA (Fig. 1D). Since the obtained images did not reveal any other tumors, distant metastasis
from the oropharyngeal carcinoma was suspected. The mass was large and mobile enough to
Received: September 2, 2021; accepted: December 15, 2022
Corresponding Author: Kazuro L. Fujimoto, MD, PhD
Department of Cardio-vascular Surgery, Tosei General Hospital, 160 Nishi-oiwake-cho, Seto 489-8642, Japan
TEL: +81-561-82-5101, Fax: +81-561-82-9139, E-mail: fujimotokl@tosei.or.jp
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Toshihiko Nishi et al

cause severe tricuspid stenosis or pulmonary embolism, increasing the likelihood of sudden death.
Treatment options included immediate surgical resection or implementation of palliative care.
Surgical resection could help prevent sudden death. Palliative care would help the patient avoid
physical exhaustion due to surgery and allow her to spend time at home. Therefore, the patient
preferred surgical resection to palliative care. Subsequently, the surgical procedure was performed
immediately. The main tumor occupied the RAA and slightly invaded the right ventricle (Fig.
2A). The mobile mass was saccular and connected to the tumor in the RAA (Fig. 2B). We
performed en bloc resection of the tumor. Furthermore, the right atrial wall defect was repaired
using a bovine pericardial patch (Fig. 2C). The tumor had invaded the right coronary artery.
Thus, tumor resection resulted in a 4 × 2 mm oval defect on the surface of the right coronary
artery. The injured area was repaired using an elliptical autologous pericardial patch. Complete
tumor resection would have required removal of a part of the right ventricle. Hence, complete
tumor resection was not performed to preserve cardiac function. The excision margin of the
tumor was likely positive. Therefore, recurrence might be unavoidable. Postoperative computed
tomography confirmed that almost all portions of the tumor had been resected. The repaired
right coronary artery was patent, with no stenosis or aneurysm (Fig. 2D). The postoperative
course was uneventful. Four weeks after surgery, the patient underwent radiation therapy and
was subsequently discharged home on postoperative day 39, with unchanged activities of daily
living. Pathological examination showed that both solid tumors (Fig. 2E) in the RAA and mobile
tumors were densely infiltrated by tumor cells containing distinct nucleoli and large atypical
nuclei. Both cardiac tumors resembled a previously recurrent oropharyngeal carcinoma (Fig. 2F)
and were found to be cardiac metastases of the carcinoma, with supporting evidence of positive
immunostaining for the epithelial markers: AE1/AE3, CAM5.2, and CK-MNF116. Histologically,
the surgical margins were positive. However, the patient was readmitted for recurrent carcinoma
of the right ventricular stump and metastasis to the pleura and retroperitoneum on postoperative
day 89. The patient eventually expired on postoperative day 98. Recently, it has been reported
that late gadolinium enhancement cardiovascular magnetic resonance could be used as a prognostic marker for cardiac metastases.6 Bussani et al reported that among 662 patients with
autopsy-evidenced cardiac metastases, lesions were present in the pericardium (69%), epicardium
(34%), myocardium (32%), and endocardium (5%).1 Pun et al also reported that the location
of cardiac metastasis varied. Moreover, 44% of cases with cardiac metastasis involved the right
ventricle, 19% involved the right atrium, 28% involved the left ventricle, 9% involved the left
atrium, and 25% involved the pericardium, while multi-chamber involvement was identified in
22% of cases.7 Intraoperative pathological examination may be used to determine the need for
complete resection.8 Cryocoagulation could also prevent local recurrence of cancer.8,9 Between
2017 and 2021, out of nine reported surgical cases of metastatic cardiac tumors, six had positive
resection margins, one had negative intraoperative findings, and two were unknown.8-11 Generally,
patients with distant metastases are considered inoperable and only palliative treatments, such as
chemotherapy or tumor irradiation, are indicated.12 In this case, cardiac surgery was performed
to avoid an acute cardiac event. However, the effect of palliative cardiac surgery on prognosis
remains unclear.

Nagoya J. Med. Sci. 85. 875–879, 2023

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Cardiac metastasis of OPSCCs

Fig. 1  Preoperative findings
Fig. 1A: Preoperative enhanced-CT.
Fig. 1B: Preoperative transthoracic echocardiography.
Fig. 1C: Preoperative magnetic resonance image.
Fig. 1D: Preoperative positron emission tomography-CT.
The arrowheads indicate the tumor in the RAA. The asterisks indicate a mobile mass. The arrow indicates the
stem between the two tumors.
CT: computed tomography
RAA: right atrial appendage
RA: right atrium
RV: right ventricle
LA: left atrium
LV: left ventricle
Ao: aorta
PA: pulmonary artery

Nagoya J. Med. Sci. 85. 875–879, 2023

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Toshihiko Nishi et al

Fig. 2  Intraoperative and postoperative findings and histopathological examination
Fig. 2A: Before tumor removal.
Fig. 2B: The mobile tumor.
Fig. 2C: Repaired right atrium.
Fig. 2D: Postoperative 3-dementional CT.
Fig. 2E: Tumor in the RAA (hematoxylin and eosin staining, ×200).
Fig. 2F: Local recurrence (hematoxylin and eosin staining, ×200).
CT: computed tomography
RAA: right atrial appendage

ACKNOWLEDGEMENTS
We thank the patient and her family for approving of the submission.
We would like to thank Editage (www.editage.com) for English language editing.

Nagoya J. Med. Sci. 85. 875–879, 2023

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Cardiac metastasis of OPSCCs

CONFLICTS OF INTEREST
Nothing to declare.

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