1. 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

2. Background

3. 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.

4. 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

5. Background

6. 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

7. 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

8. Methods

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

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

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

12. Results

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

14. 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)

15. 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

16. 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%)

17. 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

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

19. 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)

20. Conclusion

21. 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.

22. Thankyou