Distant Metastasis

Diagnosing Distant Metastasis

The diagnosis of distant metastases of a head and neck cancer is most likely to be made at initial diagnosis or during follow-up treatment.

  • Initial cancer diagnosis, prior to starting treatment: Metastases can be found during a pretreatment chest X-ray that shows a nodule, a PET scan that shows an active area somewhere in the body, a CT scan that includes the lungs and identifies a nodule or sometimes even in laboratory tests (such as liver function tests or LDH levels).
  • During follow-up after treatment: More commonly, after you have completed treatment, you will continue being monitored to see if the cancer has come back or spread. If at some point you have a new symptom that raises the concern for a metastasis (e.g., new onset bone pain, coughing up blood), your doctor will look to see if a tumor is causing the problem. Even if you do not have any symptoms, your doctor should perform routine chest X-rays, imaging tests, PET scans or lab work to look for any evidence of metastases for several years after you complete treatment for head and neck cancer.

Once there is some imaging concern for a distant metastasis, in many cases your doctors will recommend obtaining a biopsy to confirm the diagnosis. Not only does this confirm the diagnosis as cancer, but pathologists can also look at the cells under the microscope and do some special stains to help determine if the cancerous cells are similar to the cancerous cells in the head and neck tumor. There is always the possibility that a cancerous nodule in the lung (for example) is actually a new lung cancer totally different from a previously treated head and neck cancer. This can have implications for staging and treating the disease.

There are a few different methods of performing a biopsy, depending on where the suspicious lesion is located. Before undergoing a biopsy, your doctor will ask if you have any medical problems or if you take any medications that might increase the risk associated with biopsies (such as bleeding).

Lung and chest biopsy: This is the removal of cells or tissues from either the lungs or lymph nodes in the chest. There are several ways to perform a lung or thoracic biopsy.

  • Sputum cytology: This involves spitting up mucous brought up from the lungs and analyzing the cells within the sputum. This is the easiest method for patients, but it has the lowest chance of achieving a correct diagnosis.
  • Transthoracic image-guided needle biopsy: This biopsy is done with a needle inserted through the skin of the chest. Imaging methods such as CT scan, fluoroscopy or ultrasound can all be used to guide the needle into the area of concern prior to taking a biopsy. This has a high yield, but it does carry a higher risk of air trapping around the lungs (pneumothorax) than biopsies done from the inside.
  • Endobronchial lung biopsies: For this technique, you will receive some sedation and numbing medicine inside your throat. A camera will then be placed through your mouth and into your lungs. The camera will be threaded toward the suspicious area, and then one of a few different techniques of biopsy will be performed (see below). This can be done with or without fluoroscopy at the same time. Also, it can be done with or without an endobronchial or esophageal ultrasound. It can be difficult to get to lesions on the outer parts of the lung with this method. The different methods of obtaining cells through an endobronchial route include:
  • Biopsy: A piece of tissue will be picked off the lesion using a forceps and analyzed under a microscope.
  • Transbronchial needle aspiration: A needle will be inserted into the lesion and some cells will be sucked out and analyzed.
  • Brush biopsy: The lesion will be swabbed, and cells from the surface of the lesion will be analyzed.
  • Bronchioalveolar lavage (BAL): Saline will be flushed into the area and then sucked back up. Cells will be picked up in the fluid and analyzed.
  • Video assisted thoracoscopic surgery (VATS) or mediastinoscopy with biopsy: In this technique, a camera is inserted through a small incision near the area of concern (either a lung or lymph nodes in central chest area). This technique also requires you be put to sleep with general anesthesia in an operating room. If less invasive techniques do not find the diagnosis, but the suspicion for cancer is high, your doctor might recommend you undergo this technique. As in an open surgical biopsy, if there is only a single area of concern, this technique (particularly VATS) can remove the entire lesion, thereby finding a diagnosis and removing the metastasis at the same time.
  • Open surgical biopsy (thoracotomy): Putting you to sleep with general anesthesia and opening your chest to remove the part of the lung with the suspicious lesion is best for reaching a diagnosis. However, it is the most difficult way to biopsy a suspicious lesion. In reality, this method is reserved for a single isolated lesion in the lung that is highly suspicious for cancer. Not only can it find a diagnosis, but if it is the only lesion, it can also remove the metastasis at the same time.

Liver biopsy: This is the removal of cells or tissue from a suspicious lesion in the liver. There are several ways to perform a liver biopsy.

  • Transabdominal (or percutaneous): This method uses a small needle placed through the skin (after it is cleaned and numbed). In situations where the doctor is looking to get cells from a specific part of the liver (as in liver metastases), an ultrasound or low-dose CT scan will usually be used to confirm that the needle enters the suspicious area before removing the cells. Be prepared to lie still on your side with your right arm up toward your head and to hold your breath while the biopsy is being done.
  • Transvenous: In this method, a specialist inserts a tiny catheter into the jugular vein and, using fluoroscopy, threads it back through the system of veins into the liver. A small biopsy can then be taken through the catheter and the cells can be examined under a microscope. This is not typically used for cancer diagnosis because it is difficult to get into a specific lesion.
  • Laparoscopically: This method requires general anesthesia and an operating room. You will be put to sleep, and a small camera will be placed through the abdomen, along with a few other ports to help with the procedure. Once the liver and the suspicious growth are in view, a piece of tissue can be removed and sent for analysis.

Bone biopsy: In this procedure, some cells or a piece of abnormal-appearing bone is removed and analyzed under a microscope. There are two ways to do this.

  • Percutaneous needle biopsy: In this method, a tiny needle is placed through the skin (after cleaning and numbing it) and placed into the bone. This is usually done with the guidance of a CT scan or fluoroscopy to make sure the needle gets into the right place. Cells are then drawn out and analyzed under a microscope.
  • Open biopsy: In this method, you will receive some type of anesthesia that will either numb an entire area (regional anesthesia) or put you to sleep completely (general anesthesia). A small incision is made through the skin, the bone lesion is identified and cells are removed for analysis.

Skin biopsy: Biopsies of the skin are more straightforward than other sites, mainly because the skin is easiest to access. Typically, you will get a tiny injection of numbing medicine before the procedure.

  • Incisional biopsy: In this technique, a piece of a suspicious lesion is removed. The goal is NOT to remove it all but to get a good enough piece that a pathology doctor can evaluate to make a diagnosis. The second step will be removing it all and treating it. One or two sutures (stitches) might be required to close up the skin.
    • Punch biopsy: This is a type of incisional biopsy in which a special circular forceps penetrates into the skin, then a quick little snip releases a cylinder of tissue. This is usually done at the edge of normal skin and an abnormal-appearing lesion on your skin. The advantage of this method is that it can determine the depth of an invasive cancer.
  • Excisional biopsy: In this technique, the entire lesion is removed and then analyzed under a microscope later to find out what it is. A rim of normal tissue is removed along with the lesion. The problem with this technique is that if additional treatment is required (for example, the need to take even more normal tissue), it can sometimes be difficult for your surgeon to see exactly where the lesion was. A few sutures might be required to close up the skin, and you will have a scar.
  • Shave biopsy: In this procedure, usually performed by a dermatologist who has a low suspicion for cancer, a very thin layer of cells is removed using a sharp blade. A shave biopsy should typically not be used if there is suspicion for cancer because it does not give good information about how deep the cancer goes into the skin. Knowing the depth of the cancer can determine the best type of treatment.

1 Ferlito A, Shaha AR, Silver CE, Rinaldo A, Mondin V. Incidence and sites of distant metastases from head and neck cancer. O RL J Otorhinolaryngol Relat Spec. 2001;63(4):202-207.

2 Allen CT, Law JH, Dunn GP, Uppaluri R. Emerging insights into head and neck cancer metastasis. Head Neck. 2012 doi: 10.1002/hed.23202. [Epub ahead of print].

3 Merino OR, Lindberg RD, Fletcher GH. An analysis of distant metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer. 1977;40:145-151.

4 Spector JG, Sessions DG, Haughey BH, et al. Delayed regional metastases, distant metastases, and second primary malignancies in squamous cell carcinomas of the larynx and hypopharynx. Laryngoscope. 2001;111:1079-1087.

5 Nishijima W, Takooda S, Tokita N, Takayama S, Sakura M. Analyses of distant metastases in squamous cell carcinoma of the head and neck and lesions above the clavicle at autopsy. Arch Otolaryngol Head Neck Surg. 1993;119:65-68.

6 Zbaren P, Lehmann W. Frequency and sites of distant metastases in head and neck squamous cell carcinoma: an analysis of 101 cases at autopsy. Arch Otolaryngol Head Neck Surg. 1987;113:762-764.

7 Kotwall C, Sako K, Razack MS, Rao U, Bakamjian V, Shedd DP. Metastatic patterns in squamous cell cancer of the head and neck. Am J Surg. 1987;154:439-442.

8 Carvalho AL, Nishimoto IN, Califano JA, Kowalski LP. Trends in incidence and prognosis for head and neck cancer in the United States: a site-specific analysis of the SEER database. International Journal of Cancer. 2004;114(5), 806-816.

9 Leemans CR, Tiwari R, Nauta JJ, van der Waal I, Snow GB. Regional lymph node involvement and its significance in the development of distant metastases in head and neck carcinoma. Cancer. 1993;71(2):452-456.

10 Alvi A, Johnson JT. Development of distant metastasis after treatment of advanced-stage head and neck cancer. Head Neck. 1997;19(6):500-505.