Surgical treatment of lung metastases of head and neck tumors

Lymphadenectomy during pulmonary metastasectomy: Impact on survival and recurrence

Background and Objectives: Lymphadenectomy during pulmonary metastasectomy (PM) is widely carried out. We assessed the potential benefit on patient survival and tumor recurrence of this practice.

Methods: One hundred eighty‐one patients undergoing a first PM were studied. Eighty‐six patients (47.5%) underwent lymphadenectomy (L+ group) whereas 95 (52.5%) did not undergo nodal harvesting (L−group). Main outcomes were overall survival (OS) and disease‐free survival (DFS). Median follow‐up was 25 months (interquartile range [IQR], 13‐49).

Results: At follow‐up 84 patients (46.4%) died, whereas 97 (53.6%) were still alive with recurrence in 78 patients (43%). There was no difference in 5‐year survival (L+ 30.0% vs L− 43.2%; P = .87) or in the 5‐year cumulative incidence of recurrence (L + 63.2% vs L−80%; P = .07) between the two groups. Multivariable analysis indicated that disease‐free interval (DFI) less than 29 months (P < .001) and lung comorbidities (P = .003) were significant predictors of death. Metastases from non‐small–cell lung cancer increased the risk of lung comorbidities by a factor of 19.8, whereas the risk of DFI less than 29 months was increased nearly 11‐fold. Competing risk regression identified multiple metastases (P = .004), head/neck primary tumor (P = .009), and age less than 67 years (P = .024) as independent risk factors for recurrence.

Conclusion: Associated lymphadenectomy showed not to give any additional advantage in terms of survival and recurrence after PM.

Pulmonary metastasectomy: a multivariate analysis of 440 patients undergoing complete resection

Surgical resection is currently a standard approach for isolated lung metastases from different primary tumours. The aim of the present analysis is to evaluate the outcome of patients submitted to complete resection of pulmonary metastases and to determine prognostic factors for long-term survival. A group of 440 consecutive patients previously diagnosed with primary malignant solid tumours and submitted to complete surgical resection of lung nodules with suspected or diagnosed metastatic lesion were retrospectively reviewed. The average follow-up time was 43.2 months (range: 0-192) and the 60-month O.S. was 43.7%. Univariate analysis: patients with adenocarcinoma presented the highest 5-year survival rates (53.4%, P = 0.0001); DFI >36 months (P < 0.0001), number of nodules on CT scan (P = 0.0052), number of malignant nodules resected (P = 0.0252) and the size of the largest resected nodule (P < 0.0001) were also significant. Multivariate analysis: number of malignant nodules resected (P = 0.01), size of the largest nodule resected (P = 0.001), DFI >36 months (P < 0.001) and histology of the primary tumour (P = 0.017) had significant impact on survival. The benefit of such an aggressive surgical approach is only limited to selected subgroups of patients. The decision to consider a patient for resection of metastastic disease should include factors beyond the feasibility of complete removal.

Factors determining the survival of nasopharyngeal carcinoma with lung metastasis alone: does combined modality treatment benefit?

Background

Nasopharyngeal carcinoma (NPC) with lung metastasis alone has been reported as a relatively favorable prognostic group, and combined modality treatment might be indicated for selected cases. However, the prognostic factors determining survival of this group and the indication of combined therapy have not been thoroughly studied.

Methods

We retrospectively reviewed 246 patients of NPC with lung metastasis(es) alone presented at diagnosis or as the first failure after primary treatment from 1993 to 2008 in an academic tertiary hospital. Univariate and multivariate survival analyses of post-metastasis survival (PMS) and overall survival (OS) were carried out to determine the prognostic factors.

Results

The 3-year, 5-year, and 10-year of PMS and OS for the whole cohort were 34.3%, 17.0%, 8.6% and 67.8%, 45.4%, 18.5%, respectively. The median PMS (45.6 months vs. 23.7 months) and OS (73.7 months vs. 46.2 months) of patients treated with combined therapy was significantly longer than that of those treated with chemotherapy alone (P < 0.001). Age, disease-free interval (DFI) and treatment modality were evaluated as independent prognostic factors of OS, while only age and treatment modality retain their independent significance in PMS analysis. In stratified survival analysis, compared to chemotherapy alone, combined therapy could benefit the patients with DFI > 1 year, but not those with DFI ≤ 1 year.

Conclusions

Age ≤ 45 years, DFI > 1 year, and the combined therapy were good prognostic factors for NPC patients with lung metastasis(es) alone. The combination of local therapy and the basic chemotherapy should be considered for these patients with DFI > 1 year.

Risk subset of the survival for nasopharyngeal carcinoma patients with bone metastases: who will benefit from combined treatment?

Bone metastasis from nasopharyngeal carcinoma (NPC) is the most frequent type of distant metastasis (DM). The purpose of this study was to elucidate survival, prognostic factors, and significant of treatment in NPC patients with bone metastasis. A total of 221 patients who developed single type of DM from NPC at the first failure after primary treatment were retrospectively recruited from January 1998 to October 2000. The correlation between disease-free interval (DFI) and clinicopathologic features was assessed by the Chi-square test. Univariate and multivariate analyses of clinicopathologic variables were performed using Cox proportional hazards regression models. Actuarial survival rates were plotted against time using the Kaplan-Meier method, and log-rank testing was used to compare the differences between the curves. The median overall survival (OS) of the whole cohort and bone metastatic NPC patients were 38.5 and 33.3months, respectively. After univariate and multivariate analyses of clinicopathologic variables, age, local recurrence, subsequent metastasis, DFI and treatment modality were independently significant prognostic factors. The outcomes of bone metastatic NPC patients in low- and high-risk subset were significantly different (49.5 vs. 19.4months, P<0.001). In stratified survival analysis, compared to chemotherapy alone, chemoradiotherapy (CRT) could benefit the patients in low-risk subset (P<0.001), but not those in high-risk subset (P=0.135). Our findings indicated that clinicopathologic variables could provide easily available prognostic factors for survival in NPC patients with bone metastasis. A subset of bone metastatic NPC patients would benefit from aggressive combined treatment and receive a long-term survival.

ErbB receptors and fatty acid synthase expression in aggressive head and neck squamous cell carcinomas

SUMMARY

Overexpression of ErbB receptors is frequent in head and neck squamous cell carcinomas (HNSCC) and seems to be correlated with tumor progression and metastasis. Fatty acid synthase (FASN), the key lipogenic enzyme responsible for the endogenous synthesis of fatty acids, is regulated by ErbB2 and overexpressed in several human malignancies.

METHODS

This study was performed to examine the immunohistochemical expression patterns of ErbB1, ErbB2, ErbB3, ErbB4, and FASN in a tissue microarray, containing 33 representative areas from aggressive primary HNSCC (whose patients had distant metastasis), and 21 matched lung metastasis.

RESULTS

Strong correlation among the expression of ErbB family receptors was found (ErbB1-ErbB2 P = 0.008, ErbB1-ErbB4 P = 0.018, EbB2-ErbB3 P = 0.001, ErbB2-ErbB4 P = 0.006, ErbB3-ErbB4 P=0.012) in the HNSCC. FASN expression was significantly associated with ErbB2 (P = 0.024). Lymphatic permeation was correlated with ErbB3 (P = 0.033) and histological grade with ErbB4 staining (P = 0.050). ErbB1 and ErbB2 were found mainly in patients with smoking habit (P = 0.011 and P = 0.027), and ErbB2 was associated with alcohol consumption and clinical stage (P = 0.014 and P = 0.031). Finally, FASN was overexpressed in lung metastasis, in comparison with matched HNSCC samples (P = 0.006).

CONCLUSIONS

  The results showed that high FASN immunohistochemical expression is a feature of HNSCC lung metastasis, and ErbB1-ErbB2, ErbB1-ErbB4, ErbB2-ErbB3, ErbB2-ErbB4, and ErbB3-ErbB4 expression levels are correlated in the respective primary tumors, being ErbB2 the preferred coexpression partner of all the other ErbB receptors.

Indications and approach to surgical resection of lung metastases

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

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.

Fatores de risco para metástases à distância no câncer de cabeça e pescoço

OBJETIVO: Identificar os fatores de risco para o desenvolvimento de metástase à distância (MD) entre pacientes com câncer de cabeça e pescoço cirurgicamente tratados. MÉTODOS: Realizou-se estudo retrospectivo de 253 pacientes entre janeiro de 1997 e dezembro de 2002. Deles, 10 desenvolveram MD durante o seguimento. Foram avaliados: gênero, idade, sítio primário, classificação TNM, nível de doença linfonodal e presença de invasão extracapsular macro ou microscópica. RESULTADOS: A média de sobrevida para pacientes com MD, a partir da finalização do tratamento oncológico, foi de 16 meses (com desvio-padrão de 2,256 meses). A presença de invasão extracapsular macro (risco relativo = 14,429) e microscópica (RR = 17,471) e os estadiamentos patológicos avançados cervical (RR = 4,409) e do tumor primário (RR = 2,929) apresentaram significado estatístico como fatores de risco para MD. CONCLUSÃO: Os fatores de risco para o surgimento de MD foram: invasão extracapsular macro e microscópica, presença de linfonodo positivo à avaliação histopatológica e tumor primário avançado.

Survival after surgical resection of pulmonary metastases and second primary squamous cell lung carcinomas in head and neck cancer

BACKGROUND

Patients with head and neck squamous cell carcinoma (HNSCC) are at risk for developing both pulmonary metastasis and second primary lung cancer (SPLC). The objective of this study was to determine survival characteristics of patients with pulmonary lesions after curative treatment for HNSCC.

METHODS

Lung resection or biopsy specimens of 36 patients, curatively treated for HNSCC between 1978 and 2002, were defined as second primary squamous cell lung cancer or metastasis by loss of heterozygosity (LOH analysis). Twenty-two of them underwent surgical resection. Survival characteristics were estimated using Kaplan-Meier analysis according to the LOH characterization.

RESULTS

The number of resected lung lesions ranged from 1 to 3. Median overall survival after lung surgery was 23.1 months for SPLC (n = 14) and 25.1 months for lung metastases (n = 8). Fourteen patients, SPLC (n = 6) and metastases (n = 8), did not undergo surgical resection, and their median overall survival was 3.7 and 4.4 months, respectively.

CONCLUSION

Survival after resection of metachronic lung lesions following curative treatment of HNSSC is similar for lesions characterized as second primary squamous cell lung cancer and those characterized as metastases.

Surgical resection of lung metastases: results from 529 patients

OBJECTIVE

The aim of this study is to determine clinical, pathological, and treatment-relevant variables associated with long-term (90-month) overall survival in patients with lung metastases undergoing pulmonary metastasectomy.

METHODS

A retrospective review was performed of patients who were admitted with lung metastases, and who underwent thoracotomy for resection, after treatment of a primary tumor. Data were collected regarding demographics, tumor features, treatment, and outcome.

RESULTS

Patients (n = 529) were submitted to a total of 776 thoracotomies. Median follow-up time across all patients was 21.6 months (range: 0-192 months). The postoperative complication rate was 9.3%, and the 30-day mortality rate was 0.2%. The ninety-month overall survival rate for all patients was 30.4%. Multivariate analysis identified the number of pulmonary nodules detected on preoperative CT-scan, the number of malignant nodules resected, and complete resection as the independent prognostic factors for overall survival.

CONCLUSION

These results confirm that lung metastasectomy is a safe and potentially curative procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after resection.

Oral cancer

Five percent of all tumors occur in the head and neck, and approximately half of those occur specifically in the oral cavity. Of the 615,000 new cases of head and neck [corrected] tumors reported worldwide in 2000, 300,000 were primary oral cavity squamous cell carcinomas. Recent data from the Surveillance, Epidemiology, and End Results Program suggest that 28,900 new cases of oral cancer will be identified and 7400 deaths attributed to oral cancer each year in the United States. The sixth leading cause of cancer-related mortality, oral cancer accounts for 1 death every hour in the United States. However, despite advances in screening tools, imaging technology, and access to primary care physicians, a considerable percentage of patients present with advanced-stage disease. Clinical signs and symptoms of head and neck tumors are often nonspecific and may be mistaken for other common ailments. Primary care physicians must be aware of the possibility of oral cancer, particularly the increasing incidence in young patients without traditional risk factors of alcohol and tobacco abuse. To improve survival, all patients should be routinely and vigilantly screened for oral mucosal lesions.

The role of thoracic computed tomography in staging newly-diagnosed oral squamous cell carcinoma

Patients who present with squamous cell carcinoma (SCC) in the head and neck have a serious risk of coincident thoracic malignancy. The aim of this study was to identify the incidence of thoracic malignancy in newly diagnosed, previously untreated, oral and oro-pharyngeal SCC, and to evaluate the role of thoracic computed tomography (CT) in its management. Of 116 consecutive patients who were identified prospectively 81(70%) had oral and 35 (30%) oropharyngeal SCC. Ten patients (9%) had suspicious thoracic CT findings. After investigation or follow up, four (3.5%) of these patients were shown to have coincident thoracic malignancies. This large prospective series of newly diagnosed oral and oropharyngeal SCC had a lower incidence of coincident thoracic malignancy than had previously been shown.

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.

The surgical management of pulmonary metastasis: current concepts

Lung metastases have been found in 25-30% of all patients with cancer at autopsy. Those patients satisfying criteria for surgical resection represent a much smaller subgroup. Given the potentially curative nature of pulmonary metastasectomy in the absence of disseminated disease, it has become widely accepted as an important treatment option for a variety of malignancies with metastasis to the lungs. A standardized approach remains unfounded however, given limited numbers of patients, various histologic subtypes and few published studies utilizing randomized prospective methodology.Ultimately, the development of metastasis represents a major determinant of survival for patients with cancer. Pulmonary metastasectomy is an important treatment modality for patients with metastatic pulmonary disease. The indications for pulmonary metastasectomy and the surgeon's role in pulmonary metastatic disease continue to evolve. Future prospective studies and the compilation of comparable data yielding prognostic factors for specific histologies will better define indications for resection.

The role of thorax imaging in staging head and neck squamous cell carcinoma

The overall survival rate for patients with head neck squamous cell carcinoma remains disappointingly static despite improved locoregional control. This has been attributed to the development of distant metastases and second primary malignancies in these patients, a large proportion of which occur in the thorax. We retrospectively analysed the incidence of thoracic malignancies in 138 patients presenting with newly diagnosed (n = 107) or recurrent (n = 31) cancer of the head and neck over a 4-year period. All 138 patients had undergone both computerised tomography of the thorax (CT) and conventional chest radiography within one month of presenting with biopsy proven squamous cell carcinoma. Seventeen percent of these were found to have simultaneous thoracic malignancies. CT thorax was more sensitive in detecting simultaneous thoracic malignancies compared with standard chest X-ray (24/138 versus 9/138, odds ratio of 3:1 in favour of CT). All thoracic malignancies detected by chest X-ray were also detected by CT thorax. Patients presenting with recurrent tumors were significantly more likely to have simultaneous thoracic malignancies than those with newly diagnosed cancer (11/31 versus 13/107, chi2 test with Yates correction, chi2 = 4.66, p = 0.03). The primary site (laryngeal, oral or pharyngeal) or presence of nodal disease did not have an effect on the incidence of simultaneous thoracic malignancies. The presence of distant metastases and second primary malignancies has major implications in the management and prognosis of patients presenting with head and neck squamous cell carcinoma, with a large proportion of such patients succumbing to their disease within one year of diagnosis. As CT scanning of the thorax was a more effective screening investigation than standard chest X-ray in the detection of simultaneous thoracic malignancy, we recommend it for use in the staging of patients presenting with cancer of the head and neck.