Updated: May 2003
Squamous Cell Carcinoma
Curative treatment is still possible for many patients who develop recurrent disease either at the primary site or in the neck nodes. Therefore it is essential that patients with head and neck cancer are followed carefully after initial treatment. A large majority of recurrences will be detected in the first two years after treatment and therefore patients should be seen more frequently during this time, very few recurrences are found after three years. After five years the chance of recurrence of most squamous cell carcinomas is negligible, but the patients have a significant risk of developing a second primary in the upper aerodigestive tract. This risk is between 2 and 4% per year, and exceeds the risk of recurrence if patients are disease free more than three years after their initial treatment. It is important that patients are informed about possible symptoms – such as persistent hoarseness, pain, dysphagia or bleeding and or enlarged lymph nodes - and told to report them in a timely fashion rather than wait until their next appointment.
Patients should be followed by someone with the equipment and skills to examine the areas in question. This usually means that patients will be seen either in the head and neck clinic at a cancer centre, or by their otolaryngologist, or, preferably, alternate between the two.
Follow-up Schedules for Squamous Cell Carcinoma
Patients should be seen at monthly intervals until the acute radiation reaction has subsided and the epithelium has healed. If there is any residual mucosal abnormality or undue delay in resolution of the radiation reaction, biopsy should be considered.
Patients with nodal disease prior to treatment should have a CT scan approximately 6 weeks after the completion of radiotherapy.
When the mucosa has healed and, where apppropriate, a follow-up CT scan is negative, patients should be seen at 2 monthly intervals until 2 years after treatment. Thereafter they should be seen at 3 monthly intervals for the next year. There is no evidence that routine follow-up beyond three years improves prognosis, but it is most important that patients are told of the risk of a second primary tumour and encouraged to report any new symptoms. The risk of a second primary carcinoma is highest in those who continue to smoke.
Similar schedules to those for squamous carcinoma apply with the exception that late recurrence is more common in patients with nasopharyngeal cancer so follow-up is recommended for the first seven years after treatment.
Tumours of Major and Minor Salivary Glands
Once the radiation reaction has healed, patients should be seen 3 monthly for 2 years then 6 monthly to five years. Clinical examination is sufficient for most patients, but for patients with tumours that are not accessible for palpation – such as those in the deep lobe of the parotid and some minor salivary gland tumours – should have CT scans periodically. Some of these tumours – such adenoid cystic carcinomas – may recur many years after their initial treatment and symptoms should be investigated as appropriate for the individual circumstances.
Initial follow-up is usually undertaken by an endocrinologist or surgeon or at a cancer centre or on an alternating basis. Thereafter most patients are referred back to the care of their family doctor. The recommended schedule is a visit every three - four months for the first two years. If there is no evidence of recurrence, six monthly for the next two years, with annual visits thereafter. Iodine scanning is usually continued until there is no evidence of uptake in the neck or elsewhere and then only repeated if the thyroglobulin starts to rise or recurrence or metastasis is detected clinically. Examination should include the thyroid bed and the neck nodes and any other symptomatic areas.
Investigations should include Thyroglobulin and TSH. T4 should also be measured periodically to ensure that serum thyroxine levels are not significantly elevated as this is associated with excessive loss of mineral from the bones.
This is a useful marker in many patients with papillary or follicular carcinoma. After total thyroidectomy and
131Iodine ablation of any residual thyroid tissue, the thyroglobulin should be at or below the lower limit of the detectable range. The thyroglobulin assay may be affected by the presence of antithyroglobulin antibodies. If present, the level of these antibodies should fall slowly after thyroidectomy and ablation, a rising titre of antibodies should raise the suspicion of tumour recurrence.
Thyroglobulin is most sensitive when the TSH is very high (such as after thyroxine withdrawal prior to an iodine scan) and values above 10 suggest recurrent or metastatic disease. Thyroglobulin levels when the patient has a low TSH are not directly comparable to those taken when the TSH is significantly elevated, but rising values in specimens taken under the same conditions suggest recurrence and are an indication for an iodine scan.
The disease is known to progress rapidly and most patients are treated palliatively. In those who have been treated for cure, it is unlikely that recurrence will be curable. Follow-up schedules will depend on the individual circumstances.
The follow-up schedule will be the same as for those with differentiated carcinomas. Laboratory investigations should include serum calcitonin and the patient's relatives should be screened for multiple endocrine neoplasia. In some patients radionuclide scanning may be of benefit follow-up.