Board Review

A 68-year-old woman is evaluated for a 1-month history of a painful lump underneath the tongue. She has a 45-pack-year smoking history and continues to smoke.

On physical examination, vital signs are normal. An ulcerated lesion measuring approximately 1 cm is seen on the anterior floor of the mouth.

The lesion is resected. Pathology specimens identify poorly differentiated squamous cell carcinoma with negative margins.

The patient is encouraged to stop smoking. Following discussion of the benefits and risks, she is enrolled in a lung cancer screening program utilizing low-dose CT scanning.

Which of the following surveillance tests should also be recommended for this patient?

A) Biannual CT scans

B) PET/CT scan

C) Oral examinations and direct laryngoscopy

D) No additional follow-up

Answer: C - Oral examinations and direct laryngoscopy

Objective: Manage posttreatment surveillance following therapy for head and neck cancer.

Key Point

Posttreatment surveillance of patients with head and neck cancer should be directed toward identifying development of both locally recurrent cancer and a second primary cancer at a more distant site.

Periodic oral examinations and direct laryngoscopy are indicated for this patient. Following successful treatment of localized squamous cell carcinoma of the head and neck, patients remain at risk for developing both local cancer recurrence and second primary cancers, especially cancers due to tobacco and alcohol use. Tobacco and alcohol act as chemical carcinogens and induce genetic changes in the squamous mucosa of the head and neck that are not limited to the site involved with the cancer. These genetic changes expose patients to ongoing risk for development of second primary cancers. Therefore, surveillance must be directed at identifying both locally recurrent cancer and second primary cancers elsewhere in the head and neck. This is accomplished by assessment of the primary site (for example, in this patient by direct oral examination) and periodic assessment of the remaining squamous mucosa of the head and neck via direct laryngoscopy. In addition, this patient population is at high risk for non–small cell lung cancer, which represents the most commonly diagnosed second cancer in patients with head and neck cancer. This patient also meets the general criteria for lung cancer screening with low-dose CT as she is between the ages of 55 to 80 years with a smoking history of at least 30 pack-years within 15 years of quitting. Inclusion of low-dose CT surveillance for lung cancer should therefore be discussed with any patient being treated for tobacco-related head and neck cancer.

Within the first 6 months following treatment, imaging of the primary tumor site and neck is performed to establish a baseline for future reference. Imaging techniques, including CT, MRI, PET, and ultrasonography, have been used in posttreatment surveillance for locoregional recurrence. Subsequent imaging is generally based on the presence of signs or symptoms. Biannual CT scans are not indicated, and the additional radiation poses an unnecessary danger to the patient.

Providing no posttreatment surveillance is not recommended, as this patient should be evaluated periodically for development of both locally recurrent cancer and a second primary cancer.

Chuang SC, Scelo G, Tonita JM, et al. Risk of second primary cancer among patients with head and neck cancers: A pooled analysis of 13 cancer registries. Int J Cancer. 2008 Nov 15;123(10):2390-6. Link Out