A rational approach to pulmonary screening in newly diagnosed head and neck cancer

BACKGROUND: The purpose of this study was to determine the detection rate of lung metastasis or a synchronous lung primary tumor in patients with newly diagnosed head and neck mucosal squamous cell carcinoma (SCC) and to determine factors that are associated with positive findings. METHODS: This was a prospective cohort study of 102 patients with head and neck mucosal SCC diagnosed in a tertiary cancer center. Chest x-rays and a CT scan of the thorax were performed. An indeterminate nodule on CT scan was followed with either a repeat scan to assess progression or a CT-guided needle biopsy. Metastasis or synchronous lung primary tumor were determined by CT scan. The findings were correlated with age, sex, duration of symptoms, site of primary tumor, grade of tumor, T classification, and N classification. RESULTS: A CT scan of the thorax showed abnormalities or suspicious nodules in 20 patients (19.6%). With either follow-up scans or CT-guided biopsy, 10 patients were eventually proven to have pulmonary metastasis and one a synchronous lung primary tumor. Of those eleven patients (10.8%), seven had normal chest x-ray. Eight (72.7%) of 11 patients with a positive CT scan had N2 or N3 disease in contrast to 32 (35.2%) of 91 patients with a normal CT scan (p = .02). Seven patients (63.6%) with a positive CT scan had T4 disease, whereas 34 (37.4%) with a normal CT scan had T4 disease (p = .08). Primary tumors arising in the oropharynx, hypopharynx, and supraglottis had a greater risk of a positive CT scan than tumors arising in the oral cavity, glottis, or unknown sites (OR = 5.4; 95% CI, 1.3-21.9). Age, sex, duration of symptoms, and grade of disease did not predict a positive CT scan. CONCLUSIONS: The detection rate of lung metastasis or a synchronous lung primary tumor by CT scan is 10.8%. We recommend the use of CT scans of the thorax in screening the lungs of newly diagnosed patients with T4 and/or N2 or N3 oropharyngeal, hypopharyngeal, and supraglottic SCC.