The Clinical Utility and Cost of Routine Staging Exam under Anesthesia for Oral Cavity Squamous Cell Carcinoma

Osama A Hamdi; Michael I Dougherty; Jk J Rasamny; Mark A Greyson; John J Christophel; David C Shonka Jr; Katherine L Fedder; Mark J Jameson; Jonathan C Garneau

doi:10.1159/000526283

The Clinical Utility and Cost of Routine Staging Exam under Anesthesia for Oral Cavity Squamous Cell Carcinoma

ORL J Otorhinolaryngol Relat Spec. 2023;85(2):72-79. doi: 10.1159/000526283. Epub 2022 Dec 13.

Authors

Osama A Hamdi¹, Michael I Dougherty², Jk J Rasamny², Mark A Greyson², John J Christophel², David C Shonka Jr², Katherine L Fedder², Mark J Jameson², Jonathan C Garneau²

Affiliations

¹ Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA, osamahamdi851@gmail.com.
² Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.

PMID: 36513031
DOI: 10.1159/000526283

Abstract

Introduction: The standard complete evaluation of patients with head and neck squamous cell carcinoma (HNSCC) has included a staging exam under anesthesia (EUA) since the 1970s. The EUA for all sites of HNSCC has historically consisted of panendoscopy for the purpose of diagnostic biopsy, accurate staging of primary disease, and identification of second primary tumors. However, due to the accessibility of the oral cavity, the sole purpose of EUA for tumors of this site is to identify second primary tumors. Since the EUA became the gold standard for evaluation of HNSCC, there have been significant advancements in less invasive technologies such as CT, PET-CT, MRI, and fiberoptic examination. In this study, we sought to determine the value to patient care and cost-effectiveness of EUA in patients with oral cavity squamous cell carcinoma (OCSCC).

Methods: A retrospective chart review identified 77 patients who underwent EUA for OCSCC.

Results: The most common subsites were the oral tongue and floor of mouth (59.7% and 24.7% respectively). All underwent direct laryngoscopy, 94.8% underwent esophagoscopy, and 20.8% underwent flexible transnasal examination in clinic prior to EUA. For 90.9% of patients, the EUA did not change initial T-staging based on clinical examination and imaging. The remaining 9.1% of patients were upstaged after EUA, however this change did not impact the treatment plan. Second primary tumors were identified in 3.9% of patients, all were found in either the oral cavity or oropharynx, and were also identified with clinical examination or imaging. Analysis of patient charges determined an average cost of $8,022.93 per patient under the current paradigm involving EUA, however with a new algorithm eliminating mandatory EUA average cost decreases to $1,448.44.

Conclusion: Formal EUA has historically been the gold standard for all HNSCC tumors. However, when performed for cases of oral cavity carcinoma, it is safe and cost effective to limit its use to select clinical scenarios.

Keywords: Head and neck cancer; Head and neck squamous cell carcinoma; Oral cancer management; Oral cavity tumor.

MeSH terms

Anesthesia*
Carcinoma, Squamous Cell* / pathology
Esophagoscopy
Head and Neck Neoplasms* / diagnostic imaging
Head and Neck Neoplasms* / pathology
Humans
Mouth Neoplasms* / diagnostic imaging
Mouth Neoplasms* / pathology
Neoplasm Staging
Neoplasms, Second Primary* / pathology
Positron Emission Tomography Computed Tomography / methods
Retrospective Studies
Squamous Cell Carcinoma of Head and Neck / pathology