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Original article
Risk of Onset of Second Neoplasms and Successive Neoplasms in Patients With a Head and Neck Index Tumour
Riesgo de aparición de segundas neoplasias y neoplasias sucesivas en pacientes con un tumor índice de cabeza y cuello
Xavier Leóna,b,
Corresponding author
xleon@santpau.cat

Corresponding author.
, Jacinto Garcíaa, Montserrat Lópeza, Camilo Rodrigueza, Alfons Gutierreza, Miquel Quera
a Servicio de Otorrinolaringología. Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
b Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Throughout the last decades and as a consequence of improvements in irradiation techniques&#44; the use of new chemotherapy drug&#44; the inclusion of targeted therapies and an optimization in surgical and reconstruction techniques there has been an increase in the locoregional control in patients with head and neck squamous cell carcinomas &#40;HNSCC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; this increase has not led to a parallel increase in the patients&#8217; final survival&#46; Among the elements involved in this divergence is the onset of distant metastases and second neoplasms in those patients with HNSCC who achieve an appropriate locoregional control of the disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 1999 we conducted a study in which the rate of onset of second neoplasms was analysed in a cohort of 1845 patients with HNSCC who had been treated in our centre during the period between 1984&#8211;1995&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In accordance with the results obtained&#44; the annual rate of onset of a second neoplasm for patients with an initial tumour in the head and neck was 4 &#37;&#44; and this incidence remained practically constant over the 10<span class="elsevierStyleHsp" style=""></span>year follow-up period analysed in this study&#46; After this&#44; in 2010&#44; we published a study in which the risk of onset of second neoplasms and successive neoplasms in a group of 3631 patients with HNSCC was studied&#46; This was able to demonstrate how the risk of onset of another neoplasm gradually increased as the patients found they had a new tumour&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to update the data on the incidence of onset of second neoplasms and successive neoplasms in patients with HNSCC in a cohort of patients monitored prospectively over a period of 30 years&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The data used in this study was obtained retrospectively from a data base which prospectively collected information relating to the clinical characteristics&#44; treatment and follow-up of patients with HNSCC treated in our centre since 1985&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We analysed patients with a squamous carcinoma in the oral cavity&#44; the oro and hypopharynx or the larynx who had been treated in our centre between 1985&#8211;2016 and whose minimum follow-up to treatment had been at least one year&#46; Out of the total of 4506 patients with tumours in these locations 48 patients were excluded who&#44; in absence of the onset of a second neoplasm&#44; did not have the required minimum follow-up period&#46; A total of 4458 patients met with the inclusion criteria and comprised the study base</p><p id="par0030" class="elsevierStylePara elsevierViewall">For this study an index tumour was considered to be the first squamous carcinoma diagnosed from 1985 in the named locations and a second or successive neoplasm was any malignant tumour in any location&#44; excluding the cutaneous carcinomas diagnosed posterior to the index tumour&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the definition of the second neoplasm or successive neoplasm the criteria established by Warren and Gates<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> were followed&#58; having histological confirmation of both tumours&#44; ruling out the possibility that one of the tumours being metastasis or a relapse of a previous tumour and in adjacent locations of tumours&#44; ruling out the existence of submucosal connections between both tumours&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The protocol usually followed in our centre consisted in the performing of controls every 3 months for the first 2 years of follow-up&#44; every 4&#8211;6 months between the third and fifth year&#44; and then annually from then onwards&#46; The control check-ups consisted of an exhaustive review of all upper aerodigestive tract pathway mucus membranes&#44; including a study by pulmonary imaging&#44; usually a chest X-ray&#44; annually&#46; Depending on the findings or symptoms of the patients these imaging tests or additional examinations were requested when considered appropriate&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A frequency analysis and location of second neoplasms and successive neoplasms was carried out depending on the age and sex of the patients&#44; the background of tobacco and alcohol consumption and the location of the index tumour in the head and neck&#46; Given the interaction of tobacco and alcohol consumption&#44; a combined variable of toxic substances was created with 3 categories&#58; non consumption&#59; moderate consumption &#40;&#60;20 cigarettes per day and&#47;or 80<span class="elsevierStyleHsp" style=""></span>g alcohol&#47;day&#41;&#59; and severe consumption &#40;&#8805;20 cigarettes per day or &#8805;80<span class="elsevierStyleHsp" style=""></span>g alcohol&#47;day&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Second neoplasm free survival was calculated for all patients included in the study&#46; For those patients who presented with a second neoplasm&#44; the third neoplasm free survival was calculated&#44; considering the diagnosis of the second neoplasm as the initial date of the actuarial calculation&#46; For patients with a third neoplasm the fourth neoplasm free survival was calculated&#44; considering the diagnosis of the third neoplasm as the initial date of the actuarial calculation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Comparison of the onset frequency of second and successive neoplasms depending on the different categorical variables was carried out using the Chi square method&#46; Second neoplasm free survival and successive neoplasms were calculated using the Kaplan&#8211;Meier method&#46; The comparison between the survival curves was made with the log-rank test&#46; A multivariate analysis was undertaken using the Cox proportional risk model&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study had the approval of the Institutional Review Committee of the centre and was conducted in accordance with the principles established by the Declaration of Helsinki&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">During the follow-up period a total of 1203 patients 27&#46;0 &#37;&#41; presented with a second neoplasm&#44; 242 &#40;5&#46;4 &#37;&#41; with a third neoplasm&#44; 58 &#40;1&#46;3 &#37;&#41; with a fourth and 8 &#40;&#46;2 &#37;&#41; with 5 or more malignant tumours&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the second neoplasm free survival curve after diagnosis of the index head and neck tumour for the patients included in the study&#46; It is of note that there is an approximately 3&#46;5 &#37; annual rate of second neoplasm onset&#44; and this incidence remained practically constant throughout the whole follow-up period of the patients&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the location of the second&#44; third and fourth neoplasms of the patients included in the study&#46; The second neoplasms and successive neoplasms were grouped together depending on their epidemiological relationships with tobacco and alcohol consumptions&#46; On the one hand&#44; the tumours were considered to have an intense relationship with tobacco and alcohol consumptions including those of HNSCC&#44; lung&#44; oesophagus and bladder&#44; and on the other&#44; with the other locations&#46; 78&#46;0 &#37; of second and 88&#46;0 &#37; of third and 89&#46;6 &#37; of fourth tumours appeared in locations epidemiologically related to the consumption of tobacco and alcohol&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> of the supplementary material appendix shows the distribution of the location of the second and successive neoplasms depending on the location of the index tumour&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the percentage of patients who presented with a second neoplasm and those with a second neoplasm in locations connected to tobacco and alcohol depending on age and sex of the patients&#44; the background of tobacco and alcohol consumption and the location of the index neoplasm&#46; Male patients&#44; under 65 and with a background of toxic substance consumption had a higher frequency of second neoplasms and second neoplasm in locations related to tobacco and alcohol consumption&#46; The location of the index tumour did not appear as a variable related to the frequency of appearance of second neoplasm in the univariate study&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">On analysis of the risk factors associated with the appearance of a second neoplasm with the multivariate study &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; the results obtained were slightly different&#46; In accordance with the study results&#44; the male sex and consumption of toxic substances was significantly related to the appearance of second neoplasm&#46; Patients with tumours located in the larynx were at lower risk of second tumour onset&#46; With regard to age&#44; the risk of the presentation of second tumours and second tumours in locations related to tobacco and alcohol significantly increased with ageing of the patients&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the second neoplasm free survival rate for all of the patients included in the study&#44; the third neoplasm free survival rate for the patients affected by a second neoplasm and the fourth neoplasm free survival rate for the patients affected by a third neoplasm&#46; After initial diagnosis of the index tumour of the head and neck&#44; the patients had an annual incidence between 3&#46;1&#37;&#8211;4&#46;0 &#37; of second neoplasm onset&#59; for patients who had a second neoplasm&#44; the rate of a third neoplasm onset was between 5&#46;0 &#37;&#8211;6&#46;8 &#37; annually&#59; and finally&#44; for patients with a third neoplasm&#44; the rate of a fourth tumour onset was between 6&#46;6 &#37;&#8211;8&#46;1 &#37; annually&#46; There were significant differences in the risk of a second neoplasm onset and of successive neoplasms &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; The onset of the second neoplasm and of successive neoplasms remained practically constant throughout the whole period studied&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the values of the second neoplasm free survival rate at 5&#44; 10 and 15 years for all patients included in the study&#44; the third neoplasm free survival rate for the patients with a second neoplasm and the fourth neoplasm free survival rate for the patients with a third neoplasm&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">With regard to the general population&#44; patients with a background of HNSCC were at increased risk of onset of new neoplasms and these new tumours had a tendency to appear in epidemiologically related locations to tobacco and alcohol&#44; the main promoters of the appearance of index tumours of the head and neck&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">One of the contributions of our study was to verify that the onset of second neoplasms after an index tumour of the head&#44; neck maintained a constant rate&#44; even over a long period&#44; in a cohort of patients followed up prospectively throughout a prolonged period of time&#46; In keeping with our results obtained after follow-up of over 30 years&#44; the rate of onset of second neoplasms following diagnosis of the index head&#44; neck tumour was approximately 3&#46;5 &#37; annually&#44; this rate of onset remained practically constant throughout the whole follow-up period&#46; Other authors in the studies in patients with more limited follow-up periods equally described a constant rate of diagnosis of second neoplasms in patients with an index tumour of the head&#44; neck&#44; with percentages which ranged between 2&#46;5 &#37;&#44; 5&#46;1 &#37; annually&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a> In Spain&#44; in a retrospective study with 579&#44; patients with an index tumour of the head&#44; neck&#44; Herranz Gonz&#225;lez-Botas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> found there was a rate of onset of second neoplasms of approximately 3&#46;3 &#37; annually&#44; this remained practically constant over the 10 year follow-up period to the study&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The variables relating to a higher risk of onset of second neoplasms in patients with an index tumour of the head and neck include&#58; male sex&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> the extralaryngeal location of the tumour&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;18&#44;19</span></a> a history of tobacco and alcohol consumption prior to diagnosis of the index tumour&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a> and the persistence of tobacco and alcohol consumption after diagnosis and treatment of the index tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> With regard to age at the time of index tumour diagnosis&#44; the results are contradictory&#44; with studies which have found a higher rate of onset of second neoplasms in younger patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> whilst for others the risk was higher for patients more advanced in years&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;17&#44;26</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition to these clinical factors&#44; a series of molecular factors have been described which would be related to the susceptibility of onset of second neoplasm after the diagnosis of an index tumour of the head and neck&#44; including sensitivity to the induction of mutations promoted by carcinogens&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> repair mechanisms of genetic damage<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and metabolisation processes of toxic substances&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In accordance with our results&#44; the frequency of onset of a second neoplasm was higher for male patients and those with a history of tobacco and alcohol consumption&#46; Regarding the other locations&#44; patients with index tumours located in the larynx were at lower risk of onset of second neoplasms&#46; The results of the multivariate study showed that the risk of onset of a second neoplasm was higher for patients who were more advanced in age&#46; Notwithstanding&#44; the percentage of patients with a second neoplasm in the univariate study was higher in the group aged under 65 years&#46; The rate of onset of tumours increased as the age rose&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and the results of the multivariate study are a reflection of this concept&#46; However&#44; the greater exposure time to onset of new tumours confirmed that the percentage of patients with a second neoplasm was higher in the group of those under 65 years in the univariate study&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The human papillomavirus &#40;HPV&#41; has emerged as the promoter of the onset of oropharyngeal carcinomas&#44; replacing tumours promoted by the carcinogenic action of tobacco and alcohol in certain geographical areas&#44; especially North America and Northern Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> In these areas it has been possible to confirm that the risk of onset of second neoplasms in patients with positive oropharyngal carcinomas for HPVE was lower than that of patients with negative tumours for HPV related to tobacco and alcohol&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#8211;34</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In one study conducted in our centre we were able to demonstrate the existence of a relationship between the carcinogenesis mechanism and the onset of second neoplasms in patients with oropharyngeal carcinomas&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Second neoplasm free survival at 5 and 10 years for patients with positive oropharyngeal carcinomas for HPV was 89&#46;0 &#37; and 78&#46;5 &#37;&#44; whilst for those with negative tumours for HPV it was 57&#46;0 and 35&#46;2 &#37;&#44; respectively&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">There is a very limited number of studies which analyse the rate of onset of third and successive neoplasms in patients who have had a second tumour after an index tumour of the head and neck&#46; In one previous study conducted in our centre with a sample of 3631 patients diagnosed between 1985&#8211;2007 we were able to confirm that the rate of onset of a third neoplasm for patients with a second neoplasm after an index tumour of the head and neck was higher than the rate of onset of a second neoplasm&#44; and the rate of onset of fourth neoplasms in patients with a third neoplasm was equally higher than the rate of onset of third neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In accordance with the results of this study&#44; conducted with a higher sample of patients and a longer follow-up period&#44; we can confirm the concept of the existence of an acceleration process in the carcinogenesis mechanisms as patients survive successive tumours&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">Following diagnosis and treatment of an index tumour of the head and neck patients are at an annual risk of onset of a second neoplasm of 3&#46;5 &#37; and this risk remains constant throughout the long term follow-up period&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Financing</span><p id="par0150" class="elsevierStylePara elsevierViewall">This study was financed with the State Plan grant of R&#43;D&#43;I of the Carlos III Health Institute &#40;co-financed by the European Regional Development Fund &#91;FEDER&#93;&#44; A Way to Build Europe&#59; FIS 14-01819 a XL&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            0 => "Second neoplasms"
            1 => "Successive neoplasms"
            2 => "index tumour"
            3 => "Squamous carcinoma of head and neck"
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            0 => "Segundas neoplasias"
            1 => "Neoplasias sucesivas"
            2 => "Tumor &#237;ndice"
            3 => "Carcinoma escamoso de cabeza y cuello"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To analyse the incidence of appearance of second and successive neoplasms in a cohort of head and neck squamous carcinoma patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We conducted a retrospective study with 4458 patients with an index tumour located in the head and neck diagnosed during the 1985&#8211;2016 period&#46; We evaluated the incidence of appearance of second neoplasms and successive neoplasms over a period of 30 years&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">During the follow-up&#44; 1203 patients 27&#46;0 &#37;&#41; had a second neoplasm&#44; 242 patients &#40;5&#46;4 &#37;&#41; a third neoplasm&#44; 58 patients &#40;1&#46;3 &#37;&#41; a fourth neoplasm&#44; and 8 patients &#40;2 &#37;&#41; five or more successive neoplasms&#46; The incidence of appearance of second neoplasms was 3&#46;5 &#37; per year&#44; remaining relatively constant throughout the follow-up period&#46; The patients with a second neoplasm had a higher risk of appearance of a third neoplasm&#44; and those with a third neoplasm had a higher risk of a fourth&#46; Seventy-eight percent of the second neoplasms&#44; 88&#46;0 &#37; of the third neoplasms&#44; and 89&#46;6 &#37; of the fourth neoplasms appeared in locations epidemiologically related to tobacco and alcohol use&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Second neoplasms after a head and neck index tumour appeared at a constant rate of 3&#46;5 &#37; per year throughout the entire follow-up period&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Analizar la incidencia de aparici&#243;n de segundas neoplasias y neoplasias sucesivas en una cohorte de pacientes con un carcinoma escamoso de cabeza y cuello&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo realizado en 4&#46;458 pacientes con un tumor &#237;ndice localizado en cabeza y cuello diagnosticados durante el periodo 1985&#8211;2016&#46; Se llev&#243; a cabo una evaluaci&#243;n de la incidencia de aparici&#243;n de segundas neoplasias y neoplasias sucesivas a lo largo de un periodo de 30 a&#241;os&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Durante el seguimiento un total de 1&#46;203 pacientes &#40;27&#37;&#41; contaron con la aparici&#243;n de una segunda neoplasia&#44; 242 &#40;5&#46;4&#37;&#41; con una tercera neoplasia&#44; 58 &#40;1&#46;3&#37;&#41; con una cuarta&#44; y 8 &#40;0&#44;2&#37;&#41; con cinco o m&#225;s neoplasias&#46; La incidencia de aparici&#243;n de segundas neoplasias fue del 3&#46;5&#37; anual&#44; manteni&#233;ndose pr&#225;cticamente constante a lo largo del periodo de seguimiento&#46; Los pacientes que sufrieron la aparici&#243;n de una segunda neoplasia contaron con un riesgo aumentado de presentar una tercera neoplasia&#44; y los pacientes con una tercera neoplasia con un riesgo aumentado de presentar una cuarta neoplasia&#46; Un 78&#37; de las segundas&#44; un 88&#37; de las terceras&#44; y un 89&#46;6&#37; de las cuartas neoplasias aparecieron en localizaciones epidemiol&#243;gicamente relacionadas con los consumos de tabaco y alcohol&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Tras el diagn&#243;stico y tratamiento de un tumor &#237;ndice de cabeza y cuello los pacientes cuentan con un riesgo de aparici&#243;n de una segunda neoplasia del 3&#46;5&#37; anual&#44; y este riesgo permanece constante a lo largo del periodo de seguimiento a largo plazo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Le&#243;n X&#44; Garc&#237;a J&#44; L&#243;pez M&#44; Rodriguez C&#44; Gutierrez A&#44; Quer M&#46; Riesgo de aparici&#243;n de segundas neoplasias y neoplasias sucesivas en pacientes con un tumor &#237;ndice de cabeza y cuello&#46; Acta Otorrinolaringol Esp&#46; 2020&#59;71&#58;9&#8211;15&#46;</p>"
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                  \t\t\t\t" scope="col">Second Neoplasm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Fourth Neoplasm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t">Head and neck&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">421 &#40;35&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">114 &#40;47&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">367 &#40;30&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70 &#40;28&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;29&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oesophagus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;7&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">57 &#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prostate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;2&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Digestive&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128 &#40;10&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;2&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;203 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">242 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#44;029&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;133 &#40;28&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle">&#91;1&#44;0&#93;&#46;0001</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">883 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle">&#91;1&#44;0&#93;&#46;0001</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">429&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;92 &#40;&#46;72&#8211;1&#46;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t">47&#46;2 &#40;45&#46;8&#8211;49&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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Article information
ISSN: 21735735
Original language: English
DOI:10.1016/j.otoeng.2018.11.002
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