|Year : 2013 | Volume
| Issue : 1 | Page : 90-93
A retrospective study of incidence of bone metastasis in head and neck cancer
Virendra Bhandari1, Ravi Kant Jain2
1 Department of Radiotherapy, Sri Aurobindo Institute of Medical Sciences, Indore Ujjain Highway, Gram Bhawrasala, Indore, Madhya Pradesh, India
2 Department of Orthopaedics, Sri Aurobindo Institute of Medical Sciences, Indore Ujjain Highway, Gram Bhawrasala, Indore, Madhya Pradesh, India
|Date of Web Publication||10-Apr-2013|
401, Samyak Towers, 16/3, Old Palasia, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
The incidence of bone metastasis in head and neck Squamous cell carcinoma is very uncommon.
Aim: This retrospective study was done to identify the frequency, clinical presentation, and the clinical course of the metastatic disease to bone from head and neck primary.
Material and Methods: Out of 624 patients of head and neck cancers seen in our clinic 6 patients developed metastasis to solitary or multiple bones during the course of the disease.
Results: Postoperative patients had multiple bone involvement whereas others had solitary bone involvement. Main bones involved were parietal bone of skull, shaft of humerus and femur, sacrum, and ribs. All the patients had survival of few months only after developing metastasis.
Conclusion: Improvement in technology has resulted in improved results in advanced head and neck cancer patients; hence measures should be taken for complete responders to diagnose this metastasis early and treat them appropriately.
Keywords: Bone metastasis, head and neck cancer, Incidence
|How to cite this article:|
Bhandari V, Jain RK. A retrospective study of incidence of bone metastasis in head and neck cancer. J Can Res Ther 2013;9:90-3
| > Introduction|| |
Cancer is a leading health problem in India with approximately one million new cases occurring every year. Out of this, two lakhs occur in head and neck compared to 30,000 new cases in the United States. India has six times more head and neck cancers probably because of poor socio economic condition, oral consumption of tobacco in its various forms, use of lime with betel leaves and nuts, alcohol, and smoking habits. In India two-third of the head and neck cancer cases present in an advance nodal stage at the time of reporting at a tertiary care center.
The incidence of bone metastasis varies significantly depending on the primary site, with breast and prostate cancer accounting for up to 70% of patients.  Other primary sites with propensity for bone metastasis include thyroid, melanoma, and kidney. Primary gastrointestinal malignancies give rise to bone metastasis in 3-15% patients.  Some hematological malignancies including myeloma and lymphoma can also cause bone involvement.
The incidence of distance metastasis in head and neck squamous cell carcinoma is relatively small in comparison to other malignancies. Distant metastasis adversely impacts the survival and may significantly affect the treatment planning. Carcinoma of head and neck is an uncommon primary source of bone metastasis. But development in chemotherapy and radiotherapy techniques has lead to increased duration of survival in these patients and however has increased the probability of bone involvement.  The incidence of distant metastasis is influenced by location of the primary tumor, initial T and N stage of neoplasm, and the presence or absence of regional control above the clavicle. Patients with advanced nodal disease have a high incidence of distant metastasis, particularly in the presence of jugular vein invasion or extensive soft tissue disease in the neck. 
The objective of this study is to identify the frequency, clinical presentation, and the clinical course of the metastatic disease to bone from head and neck cancers.
| > Materials and Methods|| |
A retrospective review of all the cases of head and neck cancers presented in the last 10 years was made. Out of the total registered cases (2183) in the hospital head and neck cancer was 28.6% (624) and 72.7% cases of head and neck cancers presented in stage III and IV. [Table 1]. A total of 60% of patients whose primary disease was in buccal mucosa and anterior tongue presented post operatively and were squamous cell carcinoma with nodal metastasis. The patients with primary in base of tongue, palate, and tonsil also had presented with nodal metastasis. All of these patients were squamous cell carcinoma and were treated with concurrant chemotherapy and radiotherapy either as post-operative or as primary mode of treatment.
| > Results|| |
Out of all squamous cell carcinoma patients who had good local control at 1 year we found that six patients, i.e., 0.96% of all head and neck cancers developed bone metastasis for which they were treated. All patients presented with severe pain and swelling over the involved bone and on getting the X-Ray done an osteolytic lesion was found in the involved bone. One patient presented with a pathological fracture in the shaft femur. The bones involved in these patients were parietal bone of the skull in two, shaft of radius in one, sacrum in two, and shaft of femur in one [Figure 2]. Two patients on screening were found to have multiple bony lesions primarily involving the sacrum, pubic bone, shaft of femur, and rib [Figure 1]. FNAC from the involved site was done and metastasis from squamous cell carcinoma was confirmed in all before going on for any treatment. One patient with sacral involvement also had soft tissue mass along with osteolytic destruction of multiple bones [Figure 3]. FNAC from this mass also confirmed metastasis.
These patients were treated with local radiotherapy followed by chemotherapy for the systemic disease. There was very good pain relief with local radiotherapy with 30 Gy in 10 fractions in 2 weeks. One patient was lost to follow-up and three patients died within 3 months of diagnosis of bone metastasis. Two patients who had multiple bone involvement survived 6 months and 11 months respectively. Both the patients with multiple bone metastases had undergone composite resection of buccal mucosa growth with conservative neck node dissection. On review it was seen that the local lesion was advancedT3 or T4 [Table 1] with the primaries in Tonsil, base of tongue, and buccal mucosa. Operated patients tend to have bone metastasis at multiple sites and the others had solitary bone metastasis.
| > Discussion|| |
Head and neck squamous cell carcinoma most commonly spreads with the lymphatics; clinical evidence of nonlymphatic distant spread accounts for approximately 10% of the cases and is typically found in the lungs, brain, bones, and skin.  Studies have been done on the risk factors for metastasis in head and neck cancer, and consensus has been reached regarding the increased risk with the higher stage of the tumor at the initial presentation, size of the primary lesion (T4), the grade of the tumor, and the site of the lesion - with the incidence being highest in the hypopharynx 60%, followed by the base of the tongue 53% and the anterior tongue 50%. 
Primary tumors of advanced T stages in the hypopharynx, oropharynx, and oral cavity are associated with the highest incidence of distant metastases. Pulmonary metastases are the most frequent in SCC, accounting for 66% of distant metastases. It may be difficult to distinguish pulmonary metastasis from a new primary tumor, particularly if solitary. Other metastatic sites include bone (22%), liver (10%), skin, mediastinum, and bone marrow. 
Our study also shows that most of the cases have high tumor and nodal stage at time of presentation and all the patients had primary in base of tongue, tonsil where solitary bone metastasis was seen and operated Buccal mucosa where the patient had multiple bony metastasis. In all the patients the neck nodes showed metastasis and in one there was extra-capsular spread.
Autopsy findings and case histories of 64 cases of epidermoid carcinoma of the head and neck at the Denver Veterans Administration Hospital between 1967 and 1977 were reviewed. Forty percent of these cases had metastases below the clavicles at autopsy. Incidence of metastasis was related to size of the primary lesion. Correlation with nodal involvement was equivocal. These data combined with that of similar studies done by O'Brien in 1970 and Gowen in 1963 resulted in a combined autopsy series of 247 cases. Overall, 47% had distant metastases at autopsy. 
A much stronger correlation has been found with the clinical and pathological lymph node status of the patient. Preoperative clinically palpable neck disease (N1-N3) with histological evidence of metastasis, extra-capsular spread, the presence of the lympho-vascular invasion, and three or more positive lymph nodes are an increased risk for the development of distant metastases. ,,
The axial skeleton is the most common site of bone metastasis involving the spine, pelvis, and ribs frequently. The lumbar spine is the single most frequent site of bone metastasis. ,, In the appendicular skeleton, the proximal femur is the most common site and humeral lesion also occurs frequently. Same bones have been found involved in this study also.
In a retrospective review of the radiographs and nuclear medicine studies for 363 cases of squamous cell carcinoma of the head and neck by Pietropaoli,  it was seen that approximately 1% of these patients had clinically demonstrable bone metastases. Eight sites of bone involvement were identified in five patients, including three pelvic, two femoral, and one each humeral, rib, and thoracic spine lesions. All lesions were purely lytic with moth-eaten or permeative borders. In our series also the main bones which showed metastasis are flat parietal bone of skull, ribs and sacrum, and long bones like shaft of femur and radius. Same bones have been seen involved in the other series by Pietropaoli. The lesion in all the bones was lytic or moth eaten appearance which appeared 3--12 months after the primary treatment was over. The observation regarding the site and duration in this study remains the same as other studies.
Time from primary tumor diagnosis to identification of metastatic disease ranged from being present at diagnosis to a maximum 3.5 years later. The ultimate prognosis for patients with bone metastasis is poor with a median survival of few months only. Time from identification of metastatic disease to patient death was no greater than 8 months.  In our series also the bone metastasis occurred 9 months to 3 years after achieving a complete response to the primary treatment. The patients with solitary bone metastasis survived 3--4 months and patients with multiple bone metastases survived 6--11 months after development of bone metastasis which is similar to the other studies.
| > Conclusions|| |
Despite the increasing overall survival of patients with advance head and neck carcinomas, distant bone metastases are infrequent, but should be considered a possibility in any patient with a concurrent or past diagnosis of head and neck carcinoma. The very short time from discovery of bone dissemination to death in most of these patients should be taken into consideration when contemplating operative intervention. The complete responders should get a bone scan or a PET CTScan to detect this metastasis and treat them earlier.
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[Figure 1], [Figure 2], [Figure 3]