Screening for second primary lung cancer after treatment of laryngeal cancer

Lung Cancer Surveillance for Patients With Head and Neck Cancer

Importance

Patients with head and neck squamous cell cancer (HNSCC) are at a greater risk of developing pulmonary metastases and/or second primary lung cancer. However, it remains uncertain whether lung screening in these patients, when the initial staging studies are negative, confers any survival benefit.

Objective

To evaluate long-term cancer survival outcomes in patients with HNSCC undergoing chest radiography vs low-dose computed tomography screening for pulmonary metastasis and/or second primary lung cancer.

Design, Setting, and Participants

This randomized parallel trial was conducted at a large academic hospital in Canada enrolling treatment-naive patients with de novo HNSCC from September 2015 to December 2022. Eligible patients did not meet the criteria for lung screening established by the US National Comprehensive Cancer Network guidelines. Participants were randomized to chest radiography or low-dose computed tomography screening groups. Data were analyzed from March to August 2024.

Intervention or Exposure

Comparison of chest radiography vs low-dose computed tomography screening methods.

Main Outcomes and Measures

Primary outcomes were the lung cancer detection rate measured by comparing the sensitivity and specificity of low-dose computed tomography with chest radiography. Secondary outcomes were overall survival and disease-free survival.

Results

A total of 137 patients (mean [SD] age, 65.1 [14.1] years; 34 [24.8%] females and 103 [75.2%] males) were included and randomized, 68 (49.6%) to chest radiography and 69 (50.4%) to low-dose computed tomography. Nine of 137 patients (6.5%) developed a second primary lung cancer (6 patients) or lung metastases (3 patients). There were no clinically meaningful differences in survival outcomes between the 2 groups (hazard ratio, 1.2; 95% CI, 0.4-3.9). Chest radiography exhibited a relatively low sensitivity of 66.7% but a specificity of 100%. Low-dose computed tomography demonstrated both high sensitivity (100%) and specificity (100%), for an overall accuracy of 100%.

Conclusions and Relevance

The findings of this randomized parallel trial indicate that low-dose computed tomography exhibits statistically significant superior sensitivity compared with chest radiography for diagnosing lung metastases and second primary lung cancer. However, there were no important differences in survival rates. These results hold practical significance, offering valuable insights to clinicians who are guiding decisions regarding lung screening protocols.

Trial Registration

ISRCTN10954990.

Should fluorodeoxyglucose positron emission tomography/computed tomography be the first-line imaging investigation for restaging the laryngeal carcinoma patients?

Posttreatment detection of residual/recurrence disease in the head and neck cancers is not an easy task. Treatment induces changes create difficulties in diagnosis on conventional imaging (computed tomography [CT], magnetic resonance imaging) as well as macroscopic inspection (direct laryngoscopy). Hence, we evaluate the diagnostic performance of contract-enhanced F-18 fluorodeoxyglucose positron emission tomography (FDG PET)/CT in restaging of laryngeal carcinoma Postchemotherapy-surgery and/or radiation therapy. We retrospectively analyzed patients of carcinoma larynx (n = 100) who has completed treatment and were referred for FDG PET/CT. Two reviewers performed image analysis to determine recurrence at primary site and/lymph nodes and distant metastases. Receiver operating characteristic (ROC) was used to determine the maximum standardized uptake value (SUV_max) cut off for disease detection. Histopathological examination and clinical or imaging follow-up were taken as gold standard for recurrence. One hundred laryngeal carcinoma patients with mean age of 57.2 years (range of 40–76) were included in the present study. Among the 100 patients, 96 were male and remaining 4 were female. The average interval between completion of treatment and FDG PET/CT scan was 8.5 months (minimum 6 months). Of the 100 patients, FDG PET/CT detected FDG avid lesions in 66 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of FDG PET/CT for residual/recurrence disease detection was 90.3%, 73.7%, 84.8%, 82.3%, and 84.0%, respectively (P < 0.05). In addition, in 10 patients, metachronous primaries were detected (lung-4, thyroid-2, tongue, colon, esophagus, and lymphoma-one each). On ROC curve analysis, SUVmax >6.1 had sensitivity and specificity of 80.6% and 94.7% respectively for detection of recurrent/metastatic disease. FDG PET/CT demonstrates high diagnostic accuracy for detection of residual/recurrent disease in treated laryngeal cancer patients and our findings suggest that this imaging modality should be the first-line diagnostic investigation in this cohort of patients.

Korean Society of Thyroid-Head and Neck Surgery Guideline Task Force, Joo YH, Cho JK, Koo BS, Kwon M, Kwon SK, Kwon SY, Kim MS, Kim JK, Kim H, Nam I, Roh JL, Park YM, Park IS, Park JJ, Shin SC, Ahn SH, Won S, Ryu CH, Yoon TM, Lee G, Lee DY, Lee MC, Lee JK, Lee JC, Lim JY, Chang JW, Jang JY, Chung MK, Jung YS, Cho JG, Choi YS, Choi JS, Lee GH, Chung PS. Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to "surgical management of oral cancer" published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient's treatment goals.

Immunohistochemical pattern analysis of squamous cell carcinoma: Lung primary and metastatic tumors of head and neck

OBJECTIVES

This study aimed to develop an immunohistochemical (IHC) diagnostic algorithm for primary lung squamous cell carcinoma (LSCC) and pulmonary metastasis of head and neck SCC (HNSCC).

MATERIALS AND METHODS

We selected three antibodies (CK19, MMP3, and PI3) from a web-based gene expression database and an IHC analysis available online. We developed an IHC diagnostic algorithm using tissue microarrays from 39 LSCCs and 48 HNSCCs as the training set. It was validated using whole tumor sections of 32 LSCCs and 23 HNSCCs. The algorithm was applied to 28 cases with a history of HNSCC and who underwent resection of pulmonary squamous cell tumors.

RESULTS

The sensitivity, specificity, and accuracy of the algorithm were 90%, 62%, and 77%, respectively, in the training set and 96%, 44%, and 65%, respectively, in the validation set. Twenty-three of 28 SCCs were diagnosed as metastasis of HNSCC; the remaining five tumors were diagnosed as LSCC. Among the patients in the HNSCC group, 18 developed postoperative recurrence and 11 died of the disease, whereas only one patient in the LSCC group had recurrence. Compared with the LSCC group, the HNSCC group had poorer prognosis (P=0.07). IHC diagnosis coincided with the retrospective diagnosis in 22 (79%) of the 28 patients (sensitivity, 95%; specificity, 44%).

CONCLUSION

The IHC diagnostic algorithm may be clinically useful for distinguishing between LSCC and pulmonary metastasis of HNSCC.

Differential diagnosis between primary lung squamous cell carcinoma and pulmonary metastasis of head and neck squamous cell carcinoma

Differentiation between lung squamous cell carcinoma and pulmonary metastasis of head and neck squamous cell carcinoma is clinically important because the prognoses and therapeutic options are considerably different. However, the clinical, pathological, and immunohistochemical diagnostic methods have not yet been fully established. Although various molecular methods have been developed, they have not yet been practically applied. A combined approach involving molecular and immunohistochemical analysis, such as one that uses antibodies selected on the basis of comprehensive genetic analysis results, may be effective. We suggest a new diagnostic criteria using the clinical characteristics and the result of immunohistochemical analysis. However, there are two underlying problems in the development of new diagnostic methods: tumor heterogeneity and determination of the diagnostic accuracy.

Follow-Up in Head and Neck Cancer: A Management Dilemma

Follow-up program in squamous cell carcinoma of head and neck district is crucial to detect locoregional recurrence and second primary tumors and to manage treatment toxicities. The choice of the appropriate frequency of visits and imaging modality can be troublesome. Details of timing surveillance and type of diagnostic procedure are still not well defined. This review highlights the problem from a clinician’s point of view.

Incidence of second primary malignancies in patients with treated head and neck cancer: a comprehensive review of literature

BACKGROUND

Increased incidence of a second primary aero-digestive malignancy after an index head and neck cancer (HNC) is well-documented. Furthermore, a clear set of surveillance strategies for second primary aero-digestive cancers in these patients exists.

METHODS

The goal of this article is to review the published literature on risk of second primary malignancies (SPMs) (including aero-digestive malignancies) after a treated index HNC as well as its associated predictors, prognosis and surveillance. Most relevant publications were identified through searching the PubMed database for articles published up to July 2012; epidemiologic evidence was synthesized and thoroughly analyzed.

FINDINGS

Data from randomized controlled trials, meta-analyses, population-based and cohort group studies, prior reviews, and case reports indicate an increased incidence of various SPMs after occurrence of a HNC. These cancers are not limited to upper aero-digestive sites. Common risk factors including environmental, genetic and immune factors may explain the increased incidence of second cancers in this patient population. In addition, site of the index HNC may predict the site of a future SPM.

CONCLUSIONS

As a general rule, oral cavity and oropharyngeal squamous cell cancers are associated more with head and neck region SPM, while laryngeal and hypopharyngeal cancers - with that of the lung. As these cancers confer dismal prognosis and shorter survival in patients with HNCs, several literature sources recommend close surveillance for and an aggressive therapy of SPM. Notwithstanding, their optimal management and follow-up schedule remains to be established.

Second primary lung cancer after head and neck squamous cell cancer: population-based study of risk factors

BACKGROUND

Patients with head and neck squamous cell cancer (HNSCC) are at risk of developing second primary lung cancer (SPLC).

METHODS

Among 61,883 patients with HNSCC from the Surveillance, Epidemiology and End Results (SEER) database, 4522 developed SPLC (any histology) ≥2 months after HNSCC. We correlated risk with demographic and tumor-related parameters.

RESULTS

The risk of SPLC after HNSCC was 5.8%, 11.4%, and 16.4% at 5, 10, and 15 years, respectively. From Cox regression, significantly adverse (p < .0001) risk factors for SPLC included: regional versus localized HNSCC stage (hazard ratio [HR] = 1.16), hypopharyngeal or supraglottic laryngeal site (HR = 1.57), increased age (HR = 1.26/decade), black race (HR = 1.27), and male sex (HR = 1.26). Glottic (HR = 0.75) and tonsillar or oral cavity sites (HR = 0.80) were associated with significantly (p < .0001) lower risks of SPLC.

CONCLUSION

From population-based actuarial analyses, HNSCCs with more aggressive clinicopathologic features were more apt to develop SPLC, suggestive of similar environmental and/or host factors for these cancers.

Resection of secondary pulmonary malignancies in head and neck cancer patients

BACKGROUND

This study aimed to evaluate a single institute's experience with resection of metachronous pulmonary malignancy in patients treated for squamous cell carcinoma of the head and neck.

METHODS

Sixty-three consecutive patients treated curatively for head and neck squamous cell carcinoma underwent surgical resection of malignant lung lesions. Survival was estimated and potential prognostic factors investigated.

RESULTS

The median overall survival for the total group was 22.2 months. Fifty-one patients (81 per cent) had one lung lesion, while the remainder had multiple lesions (range, two to seven). In the 63 patients, 35 lobectomies, 4 pneumonectomies and 24 wedge resections were performed. For patients with pulmonary squamous cell carcinoma (n = 52), the three-year survival rate was 35 per cent (95 per cent confidence interval, 22-48); for patients with resected adenocarcinoma (n = 10), it was 50 per cent (95 per cent confidence interval, 18-75). The overall five-year survival rate was 30 per cent (95 per cent confidence interval, 19-42).

CONCLUSION

In patients treated curatively for head and neck squamous cell carcinoma, resection of secondary pulmonary cancer is associated with favourable long term overall survival, especially for patients with adenocarcinoma lesions.

Second Primary Lung Cancer with Glottic Laryngeal Cancer as Index Tumor - A Case Report

Patients with laryngeal cancer have a high risk of developing lung cancer in the future. A patient presented with a complaint of left-sided chest pain for the last 3 months. Chest X-ray posterior-anterior view showed a homogeneous opacity in the left upper lung field with elevation of the diaphragm on the left side. CECT thorax revealed a heterogeneously enhancing soft tissue density mass lesion in the superior segment of the lingular lobe. On histopathological examination of the mass lesion, it was diagnosed as adenocarcinoma of the lung. About 10 months previously, the patient was treated for a laryngeal squamous cell carcinoma. Patients with laryngeal cancer should be routinely screened during follow-up with chest X-ray or CT scan for the early detection of lung cancer.

Clinical factors related to suspected second primary lung cancer development in patients with head and neck cancer

PURPOSE

The rate of second primary lung cancer development for patients with head and neck cancer (HNC) has been noted. The aim of our study was to evaluate the incidence and clinical features of suspected second primary lung cancer that developed in patients with primary HNC.

MATERIALS AND METHODS

We conducted a retrospective study of 469 patients who were newly diagnosed with HNC at the Korea University Medical Center between January 2000 and December 2006.

RESULTS

A total of 469 patients were included (389 men and 80 women). Eighteen patients (3.8%) had suspected second primary lung cancers. Statistically significant clinical variables for lung cancer development included the origin site for the primary HNC (oro-hypopharynx and larynx) (p=0.048), abnormal chest x-ray findings (p=0.027) and the histological HNC type (squamous cell carcinoma) (p=0.032). When the second primary lung cancers were combined with HNCs, the adjusted overall survival of patients with a second primary lung cancer was 16 months (p<0.001).

CONCLUSIONS

Considering the relative risk factors for a second primary lung cancer developing in patients with HNC, advanced diagnostic tools, such as chest CT or PET CT scan, should be applied for the early detection of a second primary lung cancer.

Primary lung cancer after treatment of head and neck cancer without lymph node metastasis: is there a role for autofluorescence bronchoscopy?

BACKGROUND

Head and neck cancer (HNC) is the 5th most common cancer worldwide. As good locoregional tumor control can be achieved with current treatment strategies, patients who develop second primary tumors from field cancerization have poorer prognosis.

OBJECTIVES

To determine if autofluorescence bronchoscopy (AF) played a role in the detection of second primary lung cancer (SPLC), and impact of SPLC on survival of patients with HNC and no cervical lymph node metastasis (N0).

METHODS

Patients with HNC(N0) referred for symptoms and/or radiology suspicious for lung cancer were assessed with AF. Data on patient demographics, smoking, cancer characteristics, and outcome were prospectively collected.

RESULTS

Fifty-one patients (44 males) with curatively treated HNC(N0) were evaluated. Median age was 70 years, all were current or former smokers of 35 pack years, and 25 had chronic obstructive lung disease. Over a median follow up of 60 months, 8 patients were diagnosed with synchronous and 26 with metachronous SPLC. Forty-two SPLC were found; 12 (29%) affected the tracheobronchial tree and 30 (71%) involved the lung parenchyma. Median time to metachronous SPLC was 22 months. Most of SPLC were surgically resectable. Five radiographically occult lung cancers detected by AF were successfully treated with endobronchial therapy. Lung cancer mortality was 24%. HNC patients who developed synchronous and metachronous SPLCs had significantly shorter survival (51 and 144 months) compared to those without (240 months) (p=0.0005).

CONCLUSION

SPLC impacted negatively on the survival of patients with HNC. Close surveillance with AF and CT for SPLC combined with aggressive treatment of early stage lung cancer might be a strategy to improve outcome.

The psychological impact of annual chest X-ray follow-up in head and neck cancer

CONCLUSION

Annual post-treatment screening of head and neck squamous cell carcinoma (HNSCC) patients for second primary lung cancer and metastatic recurrence appeared to form no major burden for head and neck cancer patients. A majority of patients regard the annual chest X-ray as a reassurance. Given these results a more intensive screening program seems psychologically justifiable for this group.

OBJECTIVE

To assess the psychological impact of annual post-treatment screening for second primary lung cancer and metastases in HNSCC patients.

PATIENTS AND METHODS

In a cohort of 106 patients, 68 men and 38 women, with a mean age of 56, the impact of the yearly chest radiograph was evaluated by means of a nine-item questionnaire.

RESULTS

In all, 90% of the patients were in favor of annual post-treatment screening, 2% would not like to receive this screening, and 8% had no preference. A majority (98%) considered the screening as an extra medical check and 76% felt reassured. Although 21% of the patients were very nervous about the outcome of the screening, only 3% wanted to avoid the yearly chest X-ray for this reason.

Cancer recurrence after total laryngectomy: treatment options, survival, and complications

BACKGROUND

A follow-up schedule to detect asymptomatic cancer recurrence is offered to all patients with laryngeal cancer. In this study, the therapeutic options, prognosis, and morbidity of patients with total laryngectomy, who were found to have cancer recurrence during this follow-up schedule were determined.

METHODS

Patients who had undergone a total laryngectomy between January 1, 1990, and January 1, 2000, and had cancer recurrence were included. Data from this group were analyzed retrospectively.

RESULTS

The prognosis was poor after the development of cancer recurrence. Curative therapy could only be offered to 27.5% of these patients. Only 5% of the patients were disease free at the end of the study period. Many patients with cancer recurrence needed interventions. A large proportion of them had complications.

CONCLUSIONS

The follow-up schedule offered to patients after total laryngectomy should put greater emphasis on care than on early detection of cancer recurrence.

Effectiveness of routine follow-up of patients treated for T1-2N0 oral squamous cell carcinomas of the floor of mouth and tongue

BACKGROUND

The duration of follow-up after treatment for head and neck cancer, the depth of the routine visits, and the diagnostic tools used are determined on the basis of common acceptance rather than evidence-based practice. Patients with early-stage tumors are more likely to benefit from follow-up programs, because they have the best chance for a second curative treatment after recurrence. The purpose of this study was to determine the benefit of our 10-year follow-up program in patients with stage I and II squamous cell carcinoma (SCC) of the floor of mouth and tongue.

METHODS

In a longitudinal cohort study involving 102 patients who were treated with curative intent for a pT1-2N0M0 SCC of the floor of mouth and tongue from 1989-1998 with a minimum follow-up of 5 years, we evaluated the effect of routine follow-up.

RESULTS

During the follow-up (mean, 61 months; SD, 4 months), 10 patients had a recurrence, and 20 patients had a second primary tumor. No regional lymph node recurrences in the neck were detected. Location, T classification of the primary tumor, choice of therapy, or measure of tumor-free margins in the resection did not significantly affect the occurrence of a secondary event (p >or= .1). The secondary event was discovered during a patient-initiated visit for complaints in 14 patients and was found during routine follow-up visits in 16 patients. Only seven second primary tumors were detected after 60 months, four on routine follow-up and three on a self-initiated visit. The mean disease-free survival time after treatment of the secondary event was 72 months (SD, 17 months) in the "own initiative" group and 65 months (SD, 13 months) in the routine follow-up group; this difference was not statistically significant (p=.3).

CONCLUSIONS

The effectiveness of a 10-year routine follow-up, even in patients with early-stage oral SCC, is very limited. These visits on routine basis can be stopped after 5 years.

Pulmonary squamous cell carcinoma following head and neck squamous cell carcinoma: metastasis or second primary?

PURPOSE

To distinguish a metastasis from a second primary tumor in patients with a history of head and neck squamous cell carcinoma and subsequent pulmonary squamous cell carcinoma.

EXPERIMENTAL DESIGN

For 44 patients with a primary squamous cell carcinoma of the head and neck followed by a squamous cell carcinoma of the lung, clinical data, histology, and analysis of loss of heterozygosity (LOH) were used to differentiate metastases from second primary tumors.

RESULTS

Clinical evaluation suggested 38 patients with metastases and 6 with second primaries. We developed a novel interpretation strategy based on biological insight and on our observation that multiple LOH on different chromosome arms are not independent. LOH analysis indicated metastatic disease in 19 cases and second primary squamous cell carcinoma in 24 cases. In one case, LOH analysis was inconclusive. For 25 patients, LOH supported the clinical scoring, and in 18 cases, it did not. These 18 discordant cases were all considered to be second primary tumors by LOH analysis.

CONCLUSIONS

A considerable number of squamous cell lung lesions (50% in this study), clinically interpreted as metastases, are suggested to be second primaries by LOH analysis. For these patients, a surgical approach with curative intent may be justified.

Value of routine follow-up for patients cured of laryngeal carcinoma

BACKGROUND

Routine follow-up offered to patients with laryngeal carcinoma in The Netherlands consisted of 22 routine visits over a time period of 10 years after treatment. The primary aims of the follow-up were to detect cancer recurrence in asymptomatic patients and to achieve better survival outcome by reducing cancer-specific mortality rates.

METHODS

A longitudinal cohort study was performed to evaluate the effect of this follow-up schedule. Between January 1990 and January 1995, the authors studied all patients with primary laryngeal squamous cell carcinoma who were treated with intention to cure. For patients who developed cancer recurrence, all routine and extra visits were documented. Reported symptoms and physical evidence of tumor were mapped.

RESULTS

The patients complied with the follow-up protocol closely. In only 2% of all routine visits an asymptomatic cancer recurrence was found. There was no difference in survival and tumor mortality rates for patients with and without symptoms, despite the difference in whether the therapy applied had the intention to cure. It seemed that patients who developed tumor recurrence after therapy for laryngeal carcinoma received no benefit from screening for cancer recurrence detection. The lack of benefit for cancer detection screening among asymptomatic patients might be explained by unfavorable tumor biology parameters.

CONCLUSIONS

The routine follow-up program after treatment for laryngeal carcinoma did not lead to survival benefit for asymptomatic patients with tumor recurrence.

Evaluation of Local Recurrence and Second Malignancy in Patients with T1 and T2 Squamous Cell Carcinoma of the Larynx

PURPOSE

Evaluate outcome in patients with T1 and T2 laryngeal cancer treated with radiation therapy.

PATIENTS AND METHODS

Retrospective review of 190 patients with SCC of the larynx, stage T1(63%) orT2 (37%), treated with primary radiation therapy from 1/75 through 12/93. Median age was 61 years and median follow-up was 16.6 years. Median field size was 6.0 cm x 6.0 cm with a median fraction size of 2 Gy delivered in 33 daily fractions over 48 days. Energy used was 2 MV (19%), 4 MV (46%), 6 MV (26%), or other (9%). Univariate Cox proportional hazards regression analysis was performed using the following variables: gender, age, T stage, anterior commissure involvement, treatment energy, treatment interruption, alcohol use, smoking history, and tobacco use during treatment.

RESULTS

Overall actuarial 5-year survival was 76%, and 10-year survival was 56%. Actuarial local recurrence free survival (LRFS) at 5 years was 81%, and 10 years LRFS was 79%. Local relapse correlated with T stage (9% T1 versus 28% T2, P = 0.0009) and smoking history (14% for less than 100 pack-year versus 29% for greater than 100 pack-year, P = 0.02). Gender, age, anterior commissure involvement, treatment energy, treatment interruption, alcohol history, alcohol use during treatment, and tobacco use during treatment had no influence on outcomes. Actuarial second malignancies rate at 5 years was 18%.

CONCLUSION

Heavy tobacco use and T stage appears to correlate with an increase in local relapse rates. Gender, age, anteriorcommissure involvement, treatment energy, treatment interruption, and alcohol use did not significantly correlate with local relapse rates. The risk of second malignancies is comparable to that of local relapse.

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.