Lung cancer after head and neck cancer: role of chest radiography

Is long-term screening for lung cancer justified in patients with head and neck carcinoma?

OBJECTIVE

Patients with head and neck squamous cell carcinoma (HNSCC) have a higher risk of second lung neoplasms than the general population. The aim of the present study is to evaluate the long-term incidence of second lung malignancies after the diagnosis of a HNSCC and to consider the convenience of the screening for lung cancer in these patients.

MATERIAL AND METHODS

We conducted a retrospective study performed on 4954 patients with an index tumor located in the oral cavity, oropharynx, hypopharynx, or larynx during the period 1985-2017.

RESULTS

During the follow-up period 469 patients (9.5%) presented a second pulmonary neoplasm. The incidence of second lung neoplasm was 1.26% per year and remained practically constant throughout the 25-year follow-up period analyzed. According to the results of a multivariate study, male patients, aged between 50 and 80 years, with a history of tobacco use, and with tumors located in the oropharynx or the supraglottis were those with the highest risk of second lung neoplasms.

CONCLUSION

Patients with a HNSCC index tumor have a high risk of second neoplasms located in the lung. In order to achieve an early diagnosis of these second neoplasms, it would be advisable to establish screening protocols based on the use of low-dose lung CT, which should be maintained indefinitely during the follow-up period.

To CT or not to CT: Questioning the Cost-Effectiveness of CT Thorax in Head and Neck Cancers

Computed tomography (CT) scan has been an integral part of the diagnostic workup for patients with head and neck squamous cell carcinoma. Our study was designed to find out the incidence of distant metastasis and second primary tumor and to correlate the cost-effectiveness of CT thorax in detecting the same. This study was conducted among 326 cancer patients who visited our center with curative intent in the year 2021, with lesions in various head and neck subsites. Data were collected based on their pathological TNM staging and the presence of distant metastasis as evident on their CT thorax imaging with various variables related to the disease. Incremental cost-effectiveness ratio (ICER) was calculated for detecting a single metastatic deposit and second primary tumor in terms of Indian currency and was correlated to each subsite and stage of disease at presentation. Out of these 326 patients, 281 patients were included in our study after considering the inclusion criteria, and among these 281 patients, 235 of them underwent CT thorax for metastatic workup. No patient was found to have a second primary. Metastases were found in 12 patients. The site of primary lesion and clinical tumor (cT) staging were found to be significantly influencing the incidence of metastasis on CT thorax. ICER was least for larynx, pharynx, and paranasal sinuses and was highest for oral cavity primaries and early-stage disease. As per our observations and results of ICER, CT thorax is indeed a valuable modality but should be used judiciously when it comes to initial diagnostic workup.

Survival Outcomes of Complete Pulmonary Metastasectomy for Head and Neck Squamous Cell Carcinomas

Purpose

Metastatic head and neck squamous cell carcinoma (HNSCC) is relatively poor; however, depending on the selected cases, pulmonary metastasectomy can be a practical therapeutic option. This study aimed to identify the outcomes of complete metastasectomy based on each primary site and to investigate unfavorable prognostic factors.

Patients and Methods

We used the database from the Metastatic Lung Tumour Study Group of Japan. Between November 1980 and April 2017, 231 patients were deemed eligible. According to anatomy and the current epidemiology of HNSCC, the patients were divided into three groups: nasopharynx, oropharynx, and salivary gland (n = 40, Group 1), oral cavity, tongue, and paranasal sinuses (n = 69, Group 2), and larynx and hypopharynx (n = 122, Group 3).

Results

The 5-year overall survival after complete pulmonary metastasectomy was 58.5%, 25.0%, and 46.9% in G1, 2, and 3, respectively (p < 0.01). Multivariate analyses revealed unfavourable prognostic factors to be G2, and pathological maximum diameter was >20 mm. Therefore, on dividing group 1 and 3 with or without diameter, the 5-year overall survival was significantly worse in HNSCC with a diameter >20 mm (n = 74) than that in the remnant (n = 88; 61.9% vs 35.5%; p < 0.01).

Conclusion

According to the multi-institutional Japanese data, pulmonary metastasectomy from HNSCC indicates a potential survival benefit. Oral cavity, tongue, and paranasal sinuses cancer, and tumour size (>20 mm) were poor prognostic factors for pulmonary metastasectomy from head and neck cancer.

Pulmonary Screening Practices of Otolaryngology-Head and Neck Surgeons Across Saudi Arabia in the Posttreatment Surveillance of Squamous Cell Carcinoma: Cross-sectional Survey Study

Background

With respect to patients with head and neck squamous cell carcinoma (HNSCC), posttreatment surveillance for distant disease has mostly focused on the lungs, as HNSCC distant metastasis occurs in this organ in 90% of HNSCC cases. Additionally, the incidence rate of primary tumors in the lungs is high due to the field cancerization of the entire upper aerodigestive tract.

Objective

Our cross-sectional survey study aims to evaluate the current beliefs and pulmonary screening practices of otolaryngology–head and neck surgeons across Saudi Arabia with respect to the posttreatment surveillance of HNSCC.

Methods

This nationwide cross-sectional survey was conducted among head and neck surgeon members of the Saudi Society of Otolaryngology from June 1 to June 30, 2020. A predesigned questionnaire was used for data collection, and a descriptive analysis was carried out.

Results

This study included 22 participants and had a 78% (22/28) response rate. This study found that the majority of participants (9/22, 41%) used lung radiography for routine lung screening during posttreatment follow-ups, whereas 32% (7/22) used low-dose computed tomography (CT; 7/22, 32%). With regard to the number of years for which participants perform lung screening during follow-ups, the majority of participants (17/22, 77%) reported 5 years, and only 9% (2/22) have performed lifelong lung screening. With regard to the frequency of lung screening, 77% (17/22) of participants conduct screening annually, 18% (4/22) conduct screening half-yearly, and 5% (1/22) conduct screening biennially. With regard to beliefs about the effectiveness of screening procedures in reducing lung cancer mortality rates during follow-ups, 36% (8/22) of participants believed them to be very effective or somewhat effective, 18% (4/22) did not know, and only 9% (2/22) believed that they were not effective.

Conclusions

The participants mainly used lung radiography (9/22, 41%), low-dose CT (7/22, 32%), or positron emission tomography/CT (6/22, 27%) as a routine lung screening method during the posttreatment follow-up of patients with head and neck cancer for 5 years (17/22, 77%) or 10 years (3/22, 14%), and only a small percentage of participants have performed lifelong lung screening (2/22, 9%). Lung screening was mostly conducted annually or half-yearly. Such screening was believed to be very effective or somewhat effective.

Second primary lung cancer following laryngeal cancer: retrospective study of incidence and multivariate analysis of risk factors in 209 patients

OBJECTIVE

To analyse the incidence of second primary lung cancer following treatment for laryngeal cancer and to identify risk factors for its development.

METHOD

Retrospective case series.

RESULTS

The five-year actuarial incidence of second primary lung cancer was 8 per cent (1.6 per cent per year). This was associated with a very poor median survival of seven months following diagnosis. Supraglottic tumours were associated with an increased risk of second primary lung cancer compared to glottic tumours in both univariate (hazard ratio = 4.32, p = 0.005) and multivariate analyses (hazard ratio = 4.14, p = 0.03).

CONCLUSION

Second primary lung cancer occurs at a rate of 1.6 per cent per year following a diagnosis of laryngeal cancer, and this is associated in a statistically significant manner with supraglottic primary tumour. The recent National Lung Cancer Screening Trial suggests a survival advantage of 20 per cent at five years with annual screening using low-dose computed tomography scanning of the chest in a comparable cohort to ours. These findings have the potential to inform post-treatment surveillance protocols in the future.

Clinical parameters predicting development of pulmonary malignancies in patients treated for head and neck squamous cell carcinoma

BACKGROUND

As the locoregional control rates in head and neck squamous cell carcinoma (HNSCC) have increased, these patients may suffer distant metastasis in a higher proportion of cases. Clinicopathological characteristics allowing prediction of high-risk profile would allow adapting posttreatment surveillance to individual risk.

METHODS

A retrospective review of all patients with HNSCC treated at the Jewish General Hospital, McGill University, Montreal, Quebec, Canada, between 1999 and 2008 was conducted for this study.

RESULTS

The study included 428 patients with a mean follow-up of 65 months (±SEM 1.7). Eighty patients (18.6%) developed pulmonary malignancy during follow-up. In multivariate Cox-regression analysis, locoregional failure and current smoking were associated with higher risk of pulmonary malignancy (p < .001 and p = .008, respectively).

CONCLUSION

Locoregional failure and smoking persistence are predictors of pulmonary malignancy in patients with HNSCC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1277-E1280, 2016.

A survey on pulmonary screening practices among otolaryngology-head & neck surgeons across Canada in the post treatment surveillance of head and neck squamous cell carcinoma

Background

Post treatment lung screening for head and neck cancer patients primarily focuses on the distant metastasis and a high rate of second primary can also be expected. The best screening tool and timing for this purpose is controversial. We sought out to assess the current practice and beliefs among Canadian Head and Neck Surgeons.

Methods

After Ethical Board approval, a nationwide survey was conducted through the Canadian Society of Otolaryngology (CSO) among head and neck surgeons regarding their practices for pulmonary screening in HNSCC patients.

Results

Our CSO survey among Otolaryngology-head and neck surgeons showed that 26 out of 32 respondents perform routine lung screen, out of which 23 (88%) feel that chest radiography should be preferred. The majority of respondents felt that lung screening could impact beneficially on mortality. For symptomatic patients, low-dose spiral CT was the preferred modality (48%), followed by PET/CT scan (14%) and sputum cytology (14%). In high-risk asymptomatic patients (current smoker, radiation exposure, family history and advanced HNSCC), 31% of respondents performed a CXR. The same percentage performed a low dose CT, while 19% relied on PET scan. A further 19% of respondents did not perform any screening in high-risk patients. Most respondents (77%) had more than 10 years practice since graduation from medical school and came from the provinces of Quebec, Ontario and Alberta.

Conclusion

Chest radiography remains the preferred modality for lung screening and was believed to be impacting beneficially on lung mortality. The recent literature does not seem to be in agreement with those beliefs. Further studies to establish which modality is best and concurrent nation-wide education are warranted.

Searching for metachronous tumours in patients with head and neck cancer: the ideal protocol!

PURPOSE OF REVIEW

As treatment changes in the management of head and neck cancer, patients are reportedly living longer; therefore, their death may be due to comorbidity, metastatic disease or the development of a metachronous second primary tumour (MSPT). This review describes recent developments in the identification of MSPTs of head and neck cancer, oesophagus and lung, and suggests/recommends an 'ideal surveillance protocol'.

RECENT FINDINGS

The rate of MSPT development ranges between 6 and 9% annually for life. Improved accuracy in the detection of mucosal asymptomatic premalignant and early cancer has been enhanced by incorporating fluorescence spectroscopy in addition to modern flexible endoscopic techniques in the outpatient setting. Newer imaging has replaced old techniques (chest radiograph, barium swallow, etc.) by using radiotracer PET-computed tomography to detect local tumour activity. Further advances are anticipated in optical diagnostics and the incorporation of radiopharmaceuticals with labelled antibodies to enhance PET imaging, thus making tumour identification more accurate. Genetic classification of head and neck cancer has already identified high-risk patient groups, thereby allowing expensive tumour screening techniques to be used selectively and specifically. Patients who continue to smoke and abuse alcohol must be helped and encouraged to quit.

SUMMARY

It is now possible to review traditional follow-up policy for treated head and neck cancer patients, to encourage the implementation of an evidence-based surveillance protocol, to identify only patients who are at high-risk of developing a MSPT, to incorporate modern targeted expensive tumour screening and to allow treatment of early cancer and effective treatment, thereby improving patients' quality of life and increasing survival.

Surgical resection for oral tongue cancer pulmonary metastases

The aim of this study was to evaluate the efficacy of surgical resection of oral tongue cancer (OTC) pulmonary metastases. Between 1977 and 2003, 23 OTC patients who developed 1-3 pulmonary metastases underwent metastasectomy. There were 14 men and nine women with a median age at the time of first metastasectomy of 56 years. All patients had advanced squamous cell OTC with synchronous or metachronous regional lymph node metastases. The median tumor-free interval after the last OTC treatment was 12 months. Five patients underwent pneumonectomy, three bilobectomy, 13 lobectomy, and two wedge resection. Two patients underwent a second pulmonary metastasectomy. One patient continues to survive, without recurrence 19 years after metastasectomy. Another patient was alive with disease at 24 months after metastasectomy but was lost to follow-up. Twenty-two out of 23 patients developed systemic metastases. The median interval to systemic recurrence after lung resection was 4.1 months, and 21 out of 23 patients died of OTC (median, 9.5 months) after metastasectomy. Most patients who underwent pulmonary metastasectomy died of the disease within two years of metastasectomy. Even for patients with a solitary metastasis, surgical metastasectomy is not a recommended treatment option.

Second primary malignancies in squamous cell carcinomas of the tongue and larynx: an analysis of incidence, pattern, and outcome

BACKGROUND

Head and neck cancer patients have a higher risk of developing a second primary malignancy (SPM) than the general population. This study was conducted to identify the characteristics of SPM and its impact on survival in patients with squamous cell carcinoma of the tongue (TSCC) and larynx (LSCC).

METHODS

A retrospective study was conducted of 538 patients who were treated by surgery primarily for TSCC (n = 146) and LSCC (n = 392) from 1990 to 2000. The incidence, site, and overall survival of SPMs were evaluated.

RESULTS

Seventy-seven patients developed SPM during the follow-up period (median, 73 months), including 18 (12%) with TSCC and 59 (15%) with LSCC. Fifty-six percent of SPMs of the TSCC group appeared in the oral cavity. Among the SPMs of LSCC patients, 54% developed in the lung (31%) and larynx (24%). The 5-year overall survival after the diagnosis of SPM in the head and neck was 39%, compared to 29% for SPM in other areas (p = 0.010).

CONCLUSION

SPMs after treatment of TSCC and LSCC are similar in incidence but distinct in pattern. SPMs within the head and neck are associated with a better prognosis than those outside this area.

Coexistence of metastatic lung cancer and pulmonary tuberculosis diagnosed in the same cavity

A 79-year-old woman who had a past history of chronic renal failure 10 years earlier, tongue cancer (T2N2M0) 3 years earlier, and tuberculosis of the cervical lymph nodes 6 months earlier was suddenly admitted with the complaint of right chest pain on April 6, 2004. Right pneumothorax and mild pleural effusion were observed on a chest radiograph. There was no improvement in the patients collapsed lung despite the insertion of a chest drainage tube into the pleural cavity. Three thin-walled cavitary lesions were noted in the right lobe of segment 1 on computed tomography, and the cause of her pneumothorax was thought to be air leakage from the largest cavitary lesion adjacent to the visceral pleura. Partial resection of the right lung by video-assisted thoracoscopic surgery (VATS) was performed at the Department of Thoracic Surgery. Subsequently, it was determined that metastatic squamous cell carcinoma of the lung, corresponding to her tongue cancer, had invaded the visceral pleura adjacent to the largest cavitary lesion. Simultaneously, an epitheloid granuloma with caseating necrosis was observed adjacent to a partially thickened portion of this cavitary lesion. The epitheloid granuloma was found to be acid-fast bacilli-positive and a diagnosis of Mycobacterium tuberculosis pulmonary tuberculosis was made. We report a rare case of the coexistence of metastatic lung cancer originating from tongue cancer and active pulmonary tuberculosis diagnosed in the same large cavitary lesion.

Current concepts in the management of a second malignancy of the lung in patients with head and neck cancer

Simultaneous, synchronous, and metachronous presentation of lung malignancies when treating head and neck squamous cell cancers is one of the most difficult challenges in head and neck surgery. However, good (> 40%) 5-year survival can be obtained when proper screening techniques, patient selection, and therapy are combined. Because of the complexity of the head and neck resection and reconstruction and the multiple surgical and medical services used to diagnose and treat this clinical entity, a comprehensive review of the current literature is provided. The clinically pertinent meanings of simultaneous, synchronous, and metachronous second malignancy of the lung are presented. A review of the current literature is presented that divides second lung malignancy into two groups: second primary and metastasis. The incidence of a second lung malignancy is identified. The tools used in the screening of high-risk patients and the role of the new diagnostic studies such as positron emission tomography and positron emission tomography CT scans are reviewed. Finally, the current literature on patient selection and surgical therapy is used to put forth a clinical pathway followed at the authors' institution for the treatment of these patients.

Diagnostic assessment of laryngeal cancer

Laryngeal carcinoma must be diagnosed expeditiously to maximize curative efforts. Our approach combines useful aspects of the patient's presentation with application of appropriate diagnostic modalities. Newer methods of assessment and follow-up are being scientifically validated and will likely enhance the diagnostic efforts of the head and neck surgical oncologist.