Ann Thorac Surg 2007;84:1735-1736. doi:10.1016/j.athoracsur.2007.06.009
© 2007 The Society of Thoracic Surgeons
Case Reports
Squamous Cell Carcinoma of the Pericardium Found During Coronary Bypass Surgery of Possible Cutaneous Origin
Alan P. Kypson, MDa,*,
Curtis A. Anderson, MDa,
Christopher M. Lochmuller, MDb,
Kenneth Dizon, DOa,
Evelio Rodriguez, MDa
a Division of Cardiothoracic Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina
b Department of Pathology, The Brody School of Medicine, East Carolina University, Greenville, North Carolina
Accepted for publication June 5, 2007.
* Address correspondence to Dr Kypson, Division of Cardiothoracic Surgery, The Brody School of Medicine, 600 Moye Blvd, LSB, Room 177, East Carolina University, Greenville, NC 27834 (Email: kypsona{at}ecu.edu).
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Abstract
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Metastatic neoplasms of the pericardium are more common than primary tumors. Isolated metastasis of cutaneous squamous cell carcinoma to the pericardium has not been described. We report a case of squamous cell carcinoma of the pericardium diagnosed after coronary bypass surgery without any primary tumor. The only significant history is the removal of multiple "skin cancers" in the past.
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Introduction
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Primary neoplasms of the pericardium are rare clinical entities that include mesotheliomas, lipomas, hemangiomas, and neurofibromas. More commonly, malignant neoplasms gain access to the pericardium secondarily through direct extension or lymphatic and hematogenous spread. The most common metastatic neoplasms of the pericardium are lung and breast carcinomas. No case of primary squamous cell carcinoma (SCC) of the pericardium has been described in the literature. If SCC of the pericardium is found, it is assumed to be metastatic and a search for a primary site is warranted. A case of pericardial SCC in a patient with a significant history of cutaneous basal cell carcinoma (BCC) and no other primary tumor is described.
A 73-year-old man presented with congestive heart failure and elevated cardiac enzymes. His work-up revealed significant three-vessel disease with an ejection fraction of 35%. Past medical history was significant for multiple "skin cancers" on his face, which were removed in the distant past. The only existent pathology report demonstrated BCC involving the left posterior ear extending into the postauricular region for which he underwent Mohs surgery approximately 6 years ago. He also had a remote history of tobacco use (50 pack years) and denies alcohol use. No obvious skin lesions were evident on physical examination.
At the time of coronary bypass surgery, enlarged lymph nodes were found along the left internal mammary chain. The pericardium was thickened, focally nodular, and fused with portions of the aorta and epicardial surface of the right ventricle. Adhesions were encountered within the pericardial space with minimal hemorrhagic effusion. Anterior pericardiectomy and off-pump coronary artery bypass grafting was performed.
Histologic examination of the nodular area within the pericardium revealed moderately differentiated SCC (Fig 1). Three chest wall lymph nodes revealed no evidence of disease. Head, chest, and abdominal computed tomography demonstrated no primary malignancy. He was discharged home on postoperative day 4 and is doing well.
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Fig 1. Representative hematoxylin and eosin section of squamous cell carcinoma (A) within pericardial tissue (x200).
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Comment
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Basal cell carcinoma is the most common cutaneous neoplasm, involving the head and neck region in approximately 85% of cases. Spread by local extension is the most common mechanism of metastasis; however, distant metastasis can occur rarely [1] through either lymphatic or hematogenous systems. To date, only one case report documenting metastatic BCC to multiple sites including the pericardium has been described [2]. Prognosis is poor with a survival time of 1 year after diagnosis [1].
Squamous cell carcinoma is the second most common skin cancer. Chronic overexposure to the sun is the primary cause of nearly all squamous cell carcinomas; however other causes include burns, scars, or long-standing sores. Therefore, most commonly, tumors appear on areas of the body that are chronically exposed to the sun, such as the head, neck, face, arms, and back. In addition, medical conditions that suppress the immune system for an extended period of time may encourage development of SCC. Whereas most of these tumors are localized, there is a small percentage that can metastasize and prove fatal [3].
Primary neoplasms of the pericardium are very rare entities. More commonly, secondary neoplasms that involve the pericardium by metastasis or direct invasion account for more than 95% of pericardial tumors. These include carcinoma of the lung, breast, esophagus, and lymphoma [4]. Typically, cutaneous malignancies do not metastasize to the pericardium. Whereas metastatic BCC and melanoma to the pericardium have been more frequently documented, metastatic cutaneous SCC is a particularly rare clinical occurrence with only two reports in the literature [3, 5]. Both patients died within 6 months. More commonly, metastatic SCC involving the pericardium originates from the lung and uterine cervix. Interestingly, our patient presented with a significant history of skin cancer with a confirmed diagnosis of BCC. Unfortunately, he did have two other lesions that were removed, but those pathology reports were no longer available. Presumably, with no other primary tumor identified, our patient had a cutaneous SCC of the head that metastasized to the pericardium. This would be the first documented case of cutaneous SCC with isolated metastasis to the pericardium diagnosed by biopsy at the time of cardiac surgery. More commonly, metastatic tumors have been diagnosed by analysis of pericardial effusion or at the time of necropsy. Nevertheless, when unexpected pericardial abnormalities are encountered, biopsy should be performed to rule out a malignant process.
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References
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- Conley J, Sachs ME, Romo T, Labay G, Gillooley J. Metastatic basal cell carcinoma of the head and neck Otolaryngol Head Neck Surg 1985;93:78-85.
- Degner RA, Kerley SW, McGregor DH, Dixon AY. Metastatic basal cell carcinoma: report of a case presenting with respiratory failure Am J Med Sci 1991;301:395-397.
- Boukhalil P, Debek A. Squamous-cell carcinoma with pericardial metastases N Engl J Med 2006;355:e24.
- Lam KY, Dickens P, Chan AC. Tumors of the heartA 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med 1993;117:1027-1031.
- Mohle J, Nickoloff BJ. Fatal cutaneous squamous cell carcinoma in a forty-three-year-old male J Dermatol Surg Oncol 1986;12:276-279.
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Abstract
Introduction
