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Department of General and Oncologic Surgery, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010
(Email: fgrannis{at}coh.org).
This article from the Metastatic Lung Tumor Study Group of Japan [1] raises important questions regarding surveillance after treatment of disease caused by tobacco products, which in this case was squamous cell carcinoma of the head and neck. After treatment of the squamous cell carcinoma of the head and neck, recurrence and death can result from any of the following: (1) local recurrence at the margin of the prior resection, (2) local recurrence in regional lymph nodes, (3) distant metastasis, and (4) second primary neoplasms caused by tobacco carcinogens.
The clinician, therefore, is left with a number of important responsibilities. First, the clinician should offer the patient smoking cessation counseling and treatment. Second, a close clinical examination follow-up is necessary for early detection of recurrence of squamous cancer in the mouth, oropharynx, larynx, and esophagus. Third, consideration needs to be given to early detection of both lung metastasis and second primary lung cancer.
In the absence of surveillance by roentgenogram, second primary cancers in the lung after squamous cell carcinoma of the head and neck are associated with an advanced stage at diagnosis, limited curative treatment options, and significantly diminished survival. A chest roentgenogram has been found to be of limited benefit in surveillance.
In 1996, based on the striking results of computerized tomographic cancer screening in Japan and later in the International Early Lung Cancer Action Program (I-ELCAP) experience, we began to perform annual computed tomographic scans in our surveillance of patients with lung cancer and other neoplasms caused by tobacco carcinogens at City of Hope National Medical Center. We have published our experience with annual computed tomographic scan surveillance in patients with lung cancers and demonstrated a 20% incidence of a second lung cancer in the decade after treatment. Systematic follow-up of nonsmall cell lung cancer, including annual computed tomographic scanning, detected second primary lung cancer in stage IA in most cases. Curative pulmonary resections were often feasible.
A new pulmonary nodule detected after treatment of a squamous cell carcinoma of the head and neck is frequently neoplastic, a metastasis in approximately half the cases, and a second tobacco-caused lung cancer in the other half. If pathology reports are not squamous, a diagnosis of second primary lung cancer is established; if the lung neoplasm is squamous, then it may represent either a second lung cancer or a metastasis. This differentiation has clinical importance, because optimal treatment of a primary lung cancer would involve a lobectomy and mediastinal lymph node dissection, whereas a lung metastasis would be acceptably treated by wedge or segmental resection. Molecular methods of differentiation between lung metastasis and second primary tumor yield conflicting evidence. This problem offers an important research question to young thoracic surgeons with research skills in molecular medicine.
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