Analysis of the Incidence and Factors Predictive of Outcome in Head and Neck Cancer Patients with Pulmonary Nodules Richard Green MBBS, DOHNS1 Mark Macmillan2.

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Presentation transcript:

Analysis of the Incidence and Factors Predictive of Outcome in Head and Neck Cancer Patients with Pulmonary Nodules Richard Green MBBS, DOHNS1 Mark Macmillan2 Theofano Tikka3 MSc, MCh, PGDME, FHEA, MRCS (ENT) Lorna Bruce4 PhD John Murchison2 FRCR, PhD Iain J. Nixon1 MBChB, FRCS (ORL-HNS), PhD 1Edinburgh ENT department, 2Edinburgh radiology department, 3Glasgow ENT department, 4SCAN Cancer audit Edinburgh

Background

Background Pulmonary nodules can be challenging in their investigation and management Recent guidelines on the management of lung nodules from BTS. New guidelines address nodules in patients with known malignancy.

Background N Malignancy type Key Findings Keogan 1993 551 Lung cancer 70% of nodules benign Margolis, 1998 116 Oesophageal Solitary nodules unlikely to be metastasis Quint, 2000 149 Multiple Associated risk of malignancy with primary type Kim, 2002 141 44% had nodules, 3% were malignant Yuan, 2003 223 Metastases less likely in low stage disease Mery, 2004 1,104 History of cancer increases risk of nodule being malignant Khokhar, 2006 151 Smyth, 2012 221 Melanoma 69% biopsied nodules melanoma Hanamiya, 2012 308 Nodule size and distance from pleura associated with malignancy

Background https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-nodules/bts-guidelines-for-pulmonary-nodules/

Head and neck cancer Some evidence that type of primary determines risk No guidance for specific cancer types Currently head and neck cancer staging includes CT chest

Aims Investigate the incidence of pulmonary nodules in head and neck cancer Investigate whether clinical and radiological features can predict malignancy of pulmonary nodules in patients with known head and neck cancer

Methods

Recruitment Retrospective review of 400 patients with head and neck cancer Consecutive patients Jan 2010 to Jan 2012

Exclusions No staging CT (n=55) Primary lung malignancy or Metastasis at staging (n=10) Final cohort 335 patients

Evaluation Up to 3 nodules described in each patient Nodules were selected based on following features Calcification Size Distance from pleura

Results

Patient demographics 66% male 72% had a smoking history 92% SCC 42% stage IV disease

Nodule prevalence 193 (58%) patients had non calcified nodules 109 had multiple nodules Age over 64 was associated with increased risk of nodules (p=0.023)

Malignant change in nodules Patients were excluded if less than 1 year of nodule follow up Benign nodules were classified as such based on at least 1 year follow up without progression Final Cohort 172 patients

Pulmonary nodule malignant change (%) Table 1. Patient demographics and tumour characteristics, stratified by the evidence of malignancy. Pulmonary nodule malignant change (%) P-value No (n=161) Yes (n=11) Gender Male 111 (93.2%) 8 (7.8%) 0.545 Female 50 (94.3%) 3 (6.7%) Age Mean (SD) 62 (9.6) 64.6 (10.8) 0.431 Site Hypopharynx 15 (93.7%) 1 (6.3%) 0.727 Larynx 55 (93.2%) 4 (6.8%) Nasopharynx 1 (100.0%) 0 (0.0%) Oral 44 (95.7%) 2 (4.3%) Oropharynx 35 (94.6%) 2 (5.4%) Other 15 (88.2%) 2 (11.8%) Stage I+II 83 (98.8%) 1 (1.2%) 0.006 III+IV 78 (88.6%) 10 (11.4%) Histology 13 (86.7%) 2 (13.3%) 0.247 SCC 148 (94.2%) 9 (5.8%)

Pulmonary nodule malignant change (%) Table 2. Lung nodule characteristics stratified by the evidence of malignancy Pulmonary nodule malignant change (%) P-value No (n=161) Yes (n=11) Type of Nodule pGGN 13 (100%) 0 (0%) 0.2662 PSN 3 (75.0%) 1 (25.0%) Solid 145 (93.5%) 10 (5.8%) Size (mm) <5 97 (96.0%) 4 (4.0%) 0.1442 5-6 39 (92.9%) 3 (8.1%) >6 25 (86.2%) 4 (13.8%) Shape Irregular 14 (93.3%) 1 (6.6%) 0.6452 Oval 30 (93.8%) 2 (6.2%) Round 92 (94.8%) 5 (5.2%) Triangular 25 (89.3%) 3 (10.7%) <1mm from pleura Yes 136 (95.1%) 7 (4.9%) 0.0922 No

Graph 1. Nodule size vs malignant change on follow up depending on malignancy on follow up (p=0.076)

Table 3: Nodule characteristics Patient age (gender) Site Stage Malignant change Size max 71 (F) Other Stage IVA Metastasis 9mm 60 (M) Larynx 3mm 84 (M) Hypopharynx Stage III 6mm 63 (M) Stage II Lung Primary 19mm 65 (F) 14mm 67 (M) 53 (M) Oral cavity 4mm 58 (M) 54 (F) Oropharynx 52 (M) Stage IVC 13mm 55 (M)

Conclusion

Discussion No association between radiological findings and malignant change were identified in our study Clinical stage was associated with increased risk of malignancy in indeterminate pulmonary nodules.

Thankyou