{"paper_id":"03702972-e094-442c-b87d-048c54dfa1ec","body_text":"Incidental Pulmonary Nodules in Oral Squamous Cell Carcinoma – A retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Incidental Pulmonary Nodules in Oral Squamous Cell Carcinoma – A retrospective cohort study Matthew Gilmore, Aleeza Baker, Omar Breik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9376080/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Purpose Incidental pulmonary nodules are frequently identified on staging imaging for oral cavity squamous cell carcinoma (SCC). These may represent metastases, lung primaries, or benign lesions. Existing risk stratification guidelines are not specific to head and neck cancer. This retrospective cohort study evaluated survival differences between patients with and without pulmonary nodules and explored the impact of follow-up imaging. Methods This single-centre retrospective cohort study included adults with oral mucosal SCC managed with curative intent between 2011 and 2018. Clinical, demographic, and radiographic data, including nodule characteristics and follow-up imaging, were extracted from electronic records. Primary outcomes were overall survival and metastatic disease–related death, analysed using Fisher’s exact test, Kaplan–Meier survival with log-rank testing, and multivariable Cox regression. Results Of 4563 clinic patients screened, 372 met inclusion criteria (mean age 58.3 years, 62.9% male). Pulmonary imaging was available in 84.1%; nodules were present in 21.2%, predominantly < 6 mm and radiographically indeterminate. Pulmonary nodules, including size and multiplicity, were not associated with metastatic death, overall survival, or increased mortality. Older age, advanced T stage, and nodal metastasis were independently associated with poorer survival. Conclusion Pulmonary nodules were common but did not independently predict overall survival or metastatic mortality. Established oncologic factors remained the dominant prognostic determinants. Small incidental nodules on staging imaging should not, in isolation, alter curative treatment intent, however there is a trend for increased survival in those who have appropriate timed follow-up imaging, underscoring the need for larger prospective studies on follow-up imaging strategies. Pulmonary nodules lung metastases computed tomography chest oral cancer head and neck cancer Figures Figure 1 Figure 2 Introduction The lungs are a common site for distant metastatic disease in head and neck cancer [ 1 ]. The presence of pulmonary metastases or synchronous pulmonary tumours can change clinical management, and thus needs adequate and thorough clinical screening [ 2 – 4 ]. Chest computed tomography (CT) has surpassed the posterior-anterior chest radiograph in the staging algorithm for head and neck cancer [ 4 ]. The technological increase in the spatial resolution of chest CT has led to the increased detection of smaller incidental lesions [ 5 – 7 ]. Current data estimates that 14% to 30% of head and neck cancer patients have pulmonary nodules diagnosed at initial imaging [ 8 , 9 ]. Pulmonary nodules are focal lung parenchymal lesions found on imaging and are surrounded by aerated lung; they are traditionally 3cm or less in diameter [ 7 ]. Pulmonary nodules may be due to benign causes such as granulomatous or inflammatory diseases, or healed infections, all unrelated to malignancy [ 6 ]. There is currently no clear algorithm regarding the management of pulmonary nodules specific to the head and neck cancer cohort [ 9 ]. Most centres use generalised guidelines (such as the British Thoracic Society Guideline [ 5 , 10 ]) that are not specific to the head and neck population. Despite shared risk factors between head and neck cancer and primary lung cancer, many pulmonary nodules are benign [ 11 ]. Increased CT utilisation has led to more incidental pulmonary nodules, and distinguishing benign from malignant disease remains clinically challenging with important management implications [ 9 ]. Management of incidental pulmonary nodules has been addressed in the broader respiratory and thoracic imaging literature [ 5 , 7 ]. Contemporary regional clinical guidelines emphasise structured risk stratification of pulmonary nodules based on radiographic characteristics, patient risk factors, and interval change [ 12 ]. This approach recognises that most incidentally detected nodules, particularly small lesions, are benign and should not automatically be assumed to represent malignancy [ 7 ]. Uncertainty remains regarding the true prognostic significance of incidental pulmonary nodules in patients with oral cavity squamous cell carcinoma. It is unclear whether the presence of nodules at staging imaging is associated with increased risk of metastatic disease or decreased survival, and whether specific radiographic features of nodules can reliably identify patients at higher risk of adverse outcomes [ 13 ]. This retrospective cohort study aims to determine the incidence and clinical significance of incidental pulmonary nodules detected on staging imaging in patients with oral cavity squamous cell carcinoma. The primary objective is to evaluate whether the presence of pulmonary nodules was associated with death from metastases or reduced overall survival. Secondary objectives include describing the radiographic characteristics of pulmonary nodules and assessing whether follow-up imaging practices influence patient outcomes. Methods Patient Selection This single-centre retrospective cohort study was conducted at a tertiary institution in Brisbane, Australia. Patients were identified from the Royal Brisbane and Women’s Hospital (RBWH) Head and Neck Multidisciplinary Team clinic's (MDT) appointment scheduling records. All patients presented as a “new case” or “new case discussion” at the RBWH Head and Neck MDT during the study period were considered for inclusion. Eligible patients included those with a documented squamous cell carcinoma of the oral mucosa, managed through the RBWH Head and Neck MDT and treated with curative intent. The study included patients presenting between 1 July 2011 and 31 December 2018, allowing a full 60 months of follow-up to be observed. Patients were excluded if they were: i. younger than 18 years; ii. treated with palliative intent; or, iii. pregnant at the time of diagnosis or initial MDT discussion. Data Collection Clinical and radiographic data were extracted from electronic medical records, radiology reports, and multidisciplinary team documentation. Demographic variables collected included age at diagnosis, gender, smoking status, alcohol use, Aboriginal or Torres Strait Islander status, and relevant comorbidities. Tumour-related variables included primary tumour site, T stage, N stage, pathological adverse features and treatment modalities. Radiographic reports from staging imaging were reviewed to determine the presence or absence of pulmonary nodules. When nodules were identified, additional data were recorded regarding nodule size, number, and anatomical location within the lungs. Nodule size was categorised by maximal diameter and grouped into clinically relevant categories (< 6 mm, 6–8 mm, and > 8 mm), consistent with commonly used pulmonary nodule risk stratification frameworks. Follow-up imaging data were also recorded where available. Repeat chest CT imaging was considered ‘appropriate follow-up’ if performed within six months of the initial detection of a pulmonary nodule, or as suggested by contemporaneous clinical documentation. Imaging performed beyond this interval or in the absence of documented clinical intent to monitor the nodule was classified as ‘non-appropriate follow-up’. Outcome Measures The primary outcome of interest were overall survival and death attributable to metastatic disease. Overall survival was defined as the time from primary treatment to death or last clinical review. Survival time was calculated in 28-day months to maintain consistency across the dataset. Cause of death was classified as either death due to metastatic disease or due to other causes based on available clinical documentation. Secondary outcomes included radiographic characteristics of pulmonary nodules and the relationship between follow-up imaging and clinical outcomes. Statistical Analysis Associations between pulmonary nodules and death due to metastatic disease were examined using contingency tables. Due to the relatively small sample sizes in some subgroup analyses, Fisher’s exact test was used to assess statistical significance. Overall survival was analysed using Kaplan–Meier survival analysis, and differences between groups were assessed using the log-rank test. To evaluate independent predictors of survival, a multivariable Cox proportional hazards model was constructed incorporating pulmonary nodules, patient age, primary tumour stage, and nodal stage. Statistical significance was defined as a p-value of less than 0.05. Data was collected into a de-identified Microsoft Excel (version 2602) RRID: SCR_016137 database; statistical analyses were performed using IBM SPSS Statistics Version 29.0.0.0 (241) RRID: SCR_016479 . This study was compliant with the guidelines as outlined in The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement [ 14 ]. Clinical trial number: not applicable. Results Table 1 – PULMONARY NODULES STRATIFIED BY PATIENT DEMOGRAPHICS, DISEASE CHARACTERISTICS Characteristic No Nodules (n = 233) Nodules Present (n = 80) p-value Age, mean ± SD 58.5 ± 14.2 61.6 ± 14.2 p = 0.090 Male gender, n (%) 143 (61.4%) 49 (61.3%) p = 0.984 Smoking status Never 39 (28.1%) 11 (22.4%) p = 0.516 Former 42 (30.2%) 19 (38.8%) Current 58 (41.7%) 19 (38.8%) Any History of Smoking 100 (71.9%) 38 (77.6%) p = 0.445 Alcohol Use None 40 (29.4%) 13 (27.7%) p = 0.892 Light 38 (27.9%) 12 (25.5%) Moderate 18 (13.2%) 8 (17.0%) Heavy 35 (27.2%) 14 (29.8%) Primary tumour site Tongue 109 (46.8%) 42 (52.5%) p = 0.139 Floor of mouth 38 (16.3%) 17 (21.3%) Buccal mucosa 20 (8.6%) 4 (5.0%) Mandibular alveolus 22 (9.4%) 7 (8.8%) Maxillary alveolus 23 (9.9%) 2 (2.5%) Retromolar trigone 11 (4.7%) 8 (10.0%) Palate 3 (1.3%) 0 (0%) Intraosseous mandible 3 (1.3%) 0 (0%) T stage group T1–T2 130 (56.8%) 43 (53.8%) p = 0.640 T3–T4 99 (43.2%) 37 (46.3%) N stage group N0 182 (78.4%) 57 (71.3%) p = 0.190 N+ 50 (21.6%) 23 (28.8%) Follow-up duration (months), median Median follow-up duration calculated using reverse Kaplan–Meier: 60 months (95% CI 59.99–60.01) Statistical tests used include t-test / Mann-Whitney for continuous variables and Chi-square or Fisher for categorical variables. Percentages are column percentages based available data for each variable: Smoking data available for 188 patients, Alcohol data available for 183 patients. Clinical records of all 4563 new patients of the RBWH Head and Neck MDT during the study inclusion period between 1 July 2011 and 31 December 2018 were reviewed. 15 patients were excluded due to expired or unavailable medical records, 44 were excluded as they had definitive metastatic disease, 213 were excluded due to some/or all of their treatment occurring at another facility, and a vast majority were excluded due to having either a non-squamous cell carcinoma diagnosis, or having cancer outside the oral cavity. This yielded 372 patients treated for oral squamous cell carcinoma. The cohort had a mean age of 58.3 years and was predominantly male (62.9%). Baseline characteristics of the study population are summarised in Table 1 . Pulmonary imaging was available in 84.1% of patients. Imaging was more frequently performed in older patients (mean age 59.3 vs 53.3 years, p = 0.017) and those with advanced primary tumours (T3/T4) (χ² = 9.45, p = 0.002) but was not associated with sex or nodal stage. Pulmonary nodules were found in 80 patients on baseline imaging, corresponding to an incidence of 25.6%. The majority of nodules identified were either small and radiographically indeterminate or lacked clinical characterisation. Radiographic characteristics of identified pulmonary nodules are presented in Table 2 . Table 2 – RADIOGRAPHIC CHARACTERISTICS OF PULMONARY NODULES Nodule characteristic n (%) Total patients with nodules 80 Number of nodules Single 43 (57.3%) Multiple 32 (42.7%) Nodule size <6 mm 57 (82.6%) 6–8 mm 9 (13.0%) >8 mm 3 (4.3%) Lobar location Right Upper Lobe 21 (30.4%) Right Middle lobe 5 (7.2%) Right Lower Lobe 21 (30.4%) Left Upper Lobe 13 (18.8%) Left Lower Lobe 9 (13.0%) Radiographic appearance Solid - Ground-glass 1 (5.9%) Calcified 16 (94.1%) Follow-up CT performed Performed 47 (58.8%) Not performed 33 (41.3%) Percentages were calculated using available data for each variable. Among patients with available radiographic measurements, most nodules measured less than 6 mm in maximal diameter. Specifically, 82.6% of nodules were smaller than 6 mm, 13.0% were between 6 and 8 mm, and 4.5% were greater than 8 mm. In terms of number, nodules were present as a single lesion in 57.3% of patients and as multiple nodules in 42.7%. The anatomical distribution of nodules demonstrated a predominance in the upper lobes versus the lower lobes (49.2% and 43.4%, respectively). Nodules arising within the middle lobe were uncommon and accounted for 7.2% of cases. During the follow-up period, 107 patients had a recurrence of cancer, of which 25 patients (6.7%) had pulmonary recurrence as the primary site of recurrence; 72 deaths occurred, representing 19.4% of the study population. Cause of death data were available for a subset of patients and were categorised as ‘death due to metastatic disease’ or ‘death from other causes’. The median follow-up duration for surviving patients was approximately 48 months. Among patients with pulmonary nodules who subsequently died (and for whom cause of death information was available) ( n = 33), death from metastatic disease occurred in 10 patients (30.3%). In comparison, 23 patients (69.7%) died from other causes. The presence of pulmonary nodules was not associated with an increased likelihood of death from metastatic disease. When radiographic characteristics of nodules were examined, neither nodule size nor multiplicity demonstrated a statistically significant association with metastatic mortality. When nodules were stratified by size, death from metastases occurred in 5 of 16 patients (31.3%) of those with nodules measuring 8 mm or less, whereas no metastatic deaths were observed among the 3 patients with nodules greater than 8 mm. This difference did not reach statistical significance using Fisher’s exact testing (p = 0.53). Similarly, the number of nodules was not associated with death from pulmonary metastases (Table 3 ). Among patients with single nodules, metastatic disease accounted for death in two of ten patients (20.0%), compared to three of nine patients (33.3%) with multiple nodules (Fisher’s exact test p = 0.63. These findings suggest that radiographic features of pulmonary nodules identified at staging imaging did not predict metastatic mortality in this cohort. Table 3 – ASSOCIATION BETWEEN NODULE CHARACTERISTICS AND DEATH FROM METASTATIC DISEASE Variable Metastatic Death n (%) Other Cause n (%) p-value Nodule size ≤8mm 5 (31.3%) 11 (68.8%) 0.53 Nodule size > 8 mm 0 (0.0%) 3 (100.0%) Single nodule 2 (20.0%) 8 (80.0%) 0.63 Multiple nodules 3 (33.3%) 6 (66.7%) Follow-up CT performed 7 (33.3%) 14 (66.7) 0.71 No follow-up CT 3 (25.0%) 9 (75.0%) Appropriate timing of follow-up imaging 0 (0.0%) 4 (58.8%) 0.26 Inappropriate timing of follow-up Imaging 7 (41.2%) 10 (100%) Percentages were calculated using available data for each variable. Of all participants, mean overall survival was 49.5 months for those with pulmonary nodules, and 50.7 months for those without nodules (Fig. 1 ). When survival was stratified by size for those with nodules, mean overall survival was 49.4 months for patients with nodules measuring 8 mm or less and 37.0 months for patients with nodules greater than 8 mm (Fig. 2 ). Despite this numerical difference, survival curves did not differ significantly between groups according to the log-rank test (p = 0.212). These results indicate that incidental pulmonary nodules detected during staging imaging did not significantly influence overall survival in patients with oral cavity SCC. To further evaluate predictors of survival, a multivariable Cox proportional hazards model was constructed incorporating pulmonary nodules, age at treatment, tumour stage, and nodal stage (Table 4 ). The presence of pulmonary nodules was not associated with increased mortality. The estimated hazard ratio for pulmonary nodules was 0.91 (95% confidence interval 0.54–1.55, p = 0.739). Table 4 – MULTIVARIABLE COX PROPORTIONAL HAZARDS MODEL FOR OVERALL SURVIVAL Variable Hazard Ratio 95% CI p-value Pulmonary nodules 0.91 0.54–1.55 0.739 Age (per year) 1.05 1.03–1.07 < 0.001 T stage (T3–T4 vs T1–T2) 2.75 1.64–4.64 < 0.001 N stage (N + vs N0) 1.99 1.17–3.36 0.011 In contrast, several established oncologic prognostic factors demonstrated statistically significant associations with survival. Increasing age was independently associated with a higher risk of mortality, with a hazard ratio of 1.05 per year (95% confidence interval 1.03–1.07, p < 0.001). Advanced primary tumour stage was also associated with significantly reduced survival, with patients presenting with T3–T4 tumours demonstrating a hazard ratio of 2.75 compared with those with T1–T2 disease (95% confidence interval 1.64–4.64, p < 0.001). Similarly, nodal metastasis was independently associated with poorer survival outcomes. Patients with nodal disease demonstrated a hazard ratio of 1.99 compared with node-negative patients (95% confidence interval 1.17–3.36, p = 0.011). These findings confirm that tumour stage and nodal disease remain the dominant predictors of survival, while incidental pulmonary nodules identified on staging imaging do not independently influence prognosis. CT chest imaging after initial staging was performed in 47 patients, representing 58.8% of patients with pulmonary nodules. Among patients with pulmonary nodules who subsequently died and had a documented cause of death (n = 33), follow-up imaging was performed in 21 patients (63.6%); 12 patients (36.4%) did not undergo follow-up imaging. Death from metastases occurred in seven of the 21 patients (33.3%) who underwent follow-up imaging and in three of the 12 patients (25.0%) who did not undergo follow-up imaging. This difference was not statistically significant (Fisher’s exact test p = 0.71). Only a small number of patients met criteria for their follow-up imaging to be deemed to be within appropriate timeframes. Within this subgroup, death from metastatic disease occurred in seven of seventeen patients (41.2%) who did not undergo appropriate follow-up imaging. In contrast, no deaths from metastases occurred among the four patients who underwent appropriate follow-up imaging within 6 months. Although this observation suggests a possible association between timely follow-up imaging and improved outcomes, the difference did not reach statistical significance (p = 0.26), most likely due to the limited number of patients undergoing appropriate follow-up imaging. Discussion Pulmonary nodules are common and were identified in approximately one-quarter of oral cavity SCC patients undergoing staging imaging in this study. This study found that they were not associated with reduced overall survival or a higher risk of death from distant metastatic disease. Furthermore, within the subgroup of patients with nodules, radiographic features such as nodule size and multiplicity were not significantly associated with death from metastatic disease. These findings suggest most nodules were incidental rather than biologically aggressive. Kaplan–Meier survival analysis showed no significant difference in survival between patients with and without nodules, and this finding persisted after adjustment for age, T stage, and N stage in a multivariable Cox proportional hazards model. In contrast, increasing age, advanced primary tumour stage, and nodal disease were independently associated with poorer survival. This is consistent with the established natural history of oral cavity squamous cell carcinoma, in which tumour burden and regional nodal spread remain the major determinants of prognosis [ 3 ]. The fact that pulmonary nodules were not independently prognostic after controlling for these factors supports the interpretation that they are, in most cases, incidental findings rather than a marker of occult systemic disease [ 11 ]. Unfortunately, morphological descriptors such as ‘solid’ and ‘subsolid’ were often omitted in the current study’s radiology reports before 2016/17, thereby preventing morphological characterisation in the analysis. The analysis of death from metastases produced a similar conclusion. Although the proportion of metastatic deaths was numerically higher among patients with nodules than among those without nodules, the difference was small and not statistically significant, and logistic regression did not demonstrate an independent association between pulmonary nodules and metastatic death. The calculated positive predictive value of nodules for metastatic death was modest (PPV = 30.3), which again argues against assuming that nodules detected on staging imaging are malignant by default. These findings suggest pulmonary nodules alone should not alter curative treatment intent. An interesting secondary finding relates to follow-up imaging. Only a minority of patients with nodules underwent what was defined as appropriate interval follow-up imaging. Although timely follow-up imaging was not significantly associated with deaths from metastases, there was a numerical pattern suggesting fewer metastatic deaths among those who underwent appropriate follow-up. However, the small subgroup size renders this observation underpowered and vulnerable to type II error. The safest interpretation is that the study did not show a statistically significant effect of follow-up imaging on outcome, but that the observed pattern justifies further investigation in larger cohorts. Contemporary management of pulmonary metastases has evolved considerably, with increasing consideration of surgical resection for selected patients, particularly those with p16-positive disease, and the emergence of immunotherapy as an additional treatment modality. These developments suggest earlier detection through interval imaging may offer clinical benefit. Larger prospective studies in modern treatment cohorts are therefore required to determine whether routine follow-up imaging may improve survival outcomes [ 15 , 16 ]. Limitations of this study include incomplete or poorly filed documentation and the relatively small sample size. The study lost a significant number of participants due to part of their care being handled in other facilities (including their initial CT imaging occurring in external facilities). Radiology reports were of variable quality. Radiographic interpretation was not based on standardised reporting characteristics, which may introduce some heterogeneity; similarly, reporting was from a varied array of clinicians rather than uniform central review by a subspecialist thoracic radiologist. Several of the more clinically interesting subgroup analyses, particularly those relating to nodule size, multiplicity, and follow-up imaging, were based on small numbers and therefore lack statistical power. Histological diagnosis is also a pitfall of this study: at index imaging, there were very few pulmonary nodules biopsied (n = 2). Due to the difficulty in differentiating lung SCC from oral SCC, those patients with histologically proven squamous cell carcinoma within lung parenchyma could have either metastatic oral or primary lung disease. Despite limitations, findings were consistent and clinically informative. Pulmonary nodules were common, but they were not associated with reduced overall survival, and their radiographic features did not reliably identify a subgroup at markedly higher risk of death from metastatic disease. The factors that did predict survival were the expected oncologic variables of age, tumour stage, and nodal disease. This suggests that clinicians should continue to prioritise established prognostic markers when counselling patients and planning treatment, rather than placing disproportionate emphasis on small incidental pulmonary nodules detected at staging. Declarations Funding The authors declare that no funds, grants or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions Matthew Gilmore and Omar Breik contributed to study design. Data collection was performed by Matthew Gilmore and Aleeza Baker. Data analysis was performed by Matthew Gilmore. The first draft of the manuscript was written by Matthew Gilmore and all authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript. Compliance with Ethical Standards This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Metro North Health Human Research Ethics Committee (HREC/2024/MNH/114937). Consent to Participate & Consent to Publish Metro North Health Human Research Ethics Committee granted a waiver of consent as this study was deemed low/negligible risk (HREC/2024/MNH/114937). References Probert JC, Thompson RW, Bagshaw MA (1974) Patterns of spread of distant metastases in head and neck cancer. Cancer 33(1):127–133 Lewis-Jones H, Colley S, Gibson D Imaging in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. 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BMJ. https://doi.org/10.1136/bmj.39335.541782.AD Shiono S et al (2021) The role of pulmonary metastasectomy for pulmonary metastasis from head and neck cancer. J Thorac Dis. https://doi.org/10.21037/jtd-20-1154 Sharon S et al (2022) Immunotherapy in head and neck squamous cell carcinoma. Front Oncol. https://doi.org/10.3389/fonc.2022.842316 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 06 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers invited by journal 06 May, 2026 Editor assigned by journal 15 Apr, 2026 Submission checks completed at journal 15 Apr, 2026 First submitted to journal 10 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9376080\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":636862571,\"identity\":\"7bb31558-8914-4930-a3bc-575f12d833ce\",\"order_by\":0,\"name\":\"Matthew Gilmore\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Griffith University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Matthew\",\"middleName\":\"\",\"lastName\":\"Gilmore\",\"suffix\":\"\"},{\"id\":636862572,\"identity\":\"963514c2-e860-4859-a828-6210a048dc4b\",\"order_by\":1,\"name\":\"Aleeza Baker\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Royal Brisbane and Women's Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Aleeza\",\"middleName\":\"\",\"lastName\":\"Baker\",\"suffix\":\"\"},{\"id\":636862573,\"identity\":\"1020f63d-dbf1-41a6-8074-c0a2b86b77f6\",\"order_by\":2,\"name\":\"Omar Breik\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Royal Brisbane and Women's Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Omar\",\"middleName\":\"\",\"lastName\":\"Breik\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-04-10 07:38:58\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9376080/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9376080/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":109286753,\"identity\":\"2f621ef5-9dc3-4d80-8fe7-6328a2b5fc4b\",\"added_by\":\"auto\",\"created_at\":\"2026-05-15 02:36:41\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":20624,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eKAPLAN-MEIER SURVIVAL – PULMONARY NODULES VS NO NODULES\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9376080/v1/64cb27e02c5dc79905b3b2c3.png\"},{\"id\":109286752,\"identity\":\"4747e1b7-feb9-4275-9a2f-eea7203f71b2\",\"added_by\":\"auto\",\"created_at\":\"2026-05-15 02:36:41\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":17595,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eKAPLAN-MEIER SURVIVAL – SURVIVAL BY NODULE SIZE (≤8mm vs \\u0026gt;8mm)\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9376080/v1/8717c999a91fa2fe2ad00c10.png\"},{\"id\":109296364,\"identity\":\"7b83f71d-17bd-46ea-bdf2-db7ea8cbdf4d\",\"added_by\":\"auto\",\"created_at\":\"2026-05-15 08:46:39\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":281759,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9376080/v1/8ca39497-92a3-418d-9a92-0ce7f5e1a6fe.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Incidental Pulmonary Nodules in Oral Squamous Cell Carcinoma – A retrospective cohort study\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe lungs are a common site for distant metastatic disease in head and neck cancer [\\u003cspan class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. The presence of pulmonary metastases or synchronous pulmonary tumours can change clinical management, and thus needs adequate and thorough clinical screening [\\u003cspan class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e–\\u003cspan class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Chest computed tomography (CT) has surpassed the posterior-anterior chest radiograph in the staging algorithm for head and neck cancer [\\u003cspan class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. The technological increase in the spatial resolution of chest CT has led to the increased detection of smaller incidental lesions [\\u003cspan class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e–\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eCurrent data estimates that 14% to 30% of head and neck cancer patients have pulmonary nodules diagnosed at initial imaging [\\u003cspan class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Pulmonary nodules are focal lung parenchymal lesions found on imaging and are surrounded by aerated lung; they are traditionally 3cm or less in diameter [\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Pulmonary nodules may be due to benign causes such as granulomatous or inflammatory diseases, or healed infections, all unrelated to malignancy [\\u003cspan class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThere is currently no clear algorithm regarding the management of pulmonary nodules specific to the head and neck cancer cohort [\\u003cspan class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Most centres use generalised guidelines (such as the British Thoracic Society Guideline [\\u003cspan class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]) that are not specific to the head and neck population. Despite shared risk factors between head and neck cancer and primary lung cancer, many pulmonary nodules are benign [\\u003cspan class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Increased CT utilisation has led to more incidental pulmonary nodules, and distinguishing benign from malignant disease remains clinically challenging with important management implications [\\u003cspan class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eManagement of incidental pulmonary nodules has been addressed in the broader respiratory and thoracic imaging literature [\\u003cspan class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Contemporary regional clinical guidelines emphasise structured risk stratification of pulmonary nodules based on radiographic characteristics, patient risk factors, and interval change [\\u003cspan class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. This approach recognises that most incidentally detected nodules, particularly small lesions, are benign and should not automatically be assumed to represent malignancy [\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eUncertainty remains regarding the true prognostic significance of incidental pulmonary nodules in patients with oral cavity squamous cell carcinoma. It is unclear whether the presence of nodules at staging imaging is associated with increased risk of metastatic disease or decreased survival, and whether specific radiographic features of nodules can reliably identify patients at higher risk of adverse outcomes [\\u003cspan class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThis retrospective cohort study aims to determine the incidence and clinical significance of incidental pulmonary nodules detected on staging imaging in patients with oral cavity squamous cell carcinoma. The primary objective is to evaluate whether the presence of pulmonary nodules was associated with death from metastases or reduced overall survival. Secondary objectives include describing the radiographic characteristics of pulmonary nodules and assessing whether follow-up imaging practices influence patient outcomes.\\u003c/p\\u003e \"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003ePatient Selection\\u003c/p\\u003e\\u003cp\\u003eThis single-centre retrospective cohort study was conducted at a tertiary institution in Brisbane, Australia. Patients were identified from the Royal Brisbane and Women’s Hospital (RBWH) Head and Neck Multidisciplinary Team clinic's (MDT) appointment scheduling records. All patients presented as a “new case” or “new case discussion” at the RBWH Head and Neck MDT during the study period were considered for inclusion. Eligible patients included those with a documented squamous cell carcinoma of the oral mucosa, managed through the RBWH Head and Neck MDT and treated with curative intent. The study included patients presenting between 1 July 2011 and 31 December 2018, allowing a full 60 months of follow-up to be observed.\\u003c/p\\u003e\\u003cp\\u003ePatients were excluded if they were: i. younger than 18 years; ii. treated with palliative intent; or, iii. pregnant at the time of diagnosis or initial MDT discussion.\\u003c/p\\u003e\\u003cp\\u003eData Collection\\u003c/p\\u003e\\u003cp\\u003eClinical and radiographic data were extracted from electronic medical records, radiology reports, and multidisciplinary team documentation. Demographic variables collected included age at diagnosis, gender, smoking status, alcohol use, Aboriginal or Torres Strait Islander status, and relevant comorbidities. Tumour-related variables included primary tumour site, T stage, N stage, pathological adverse features and treatment modalities.\\u003c/p\\u003e\\u003cp\\u003eRadiographic reports from staging imaging were reviewed to determine the presence or absence of pulmonary nodules. When nodules were identified, additional data were recorded regarding nodule size, number, and anatomical location within the lungs. Nodule size was categorised by maximal diameter and grouped into clinically relevant categories (\\u0026lt; 6 mm, 6–8 mm, and \\u0026gt; 8 mm), consistent with commonly used pulmonary nodule risk stratification frameworks.\\u003c/p\\u003e\\u003cp\\u003eFollow-up imaging data were also recorded where available. Repeat chest CT imaging was considered ‘appropriate follow-up’ if performed within six months of the initial detection of a pulmonary nodule, or as suggested by contemporaneous clinical documentation. Imaging performed beyond this interval or in the absence of documented clinical intent to monitor the nodule was classified as ‘non-appropriate follow-up’.\\u003c/p\\u003e\\u003cp\\u003eOutcome Measures\\u003c/p\\u003e\\u003cp\\u003eThe primary outcome of interest were overall survival and death attributable to metastatic disease. Overall survival was defined as the time from primary treatment to death or last clinical review. Survival time was calculated in 28-day months to maintain consistency across the dataset. Cause of death was classified as either death due to metastatic disease or due to other causes based on available clinical documentation.\\u003c/p\\u003e\\u003cp\\u003eSecondary outcomes included radiographic characteristics of pulmonary nodules and the relationship between follow-up imaging and clinical outcomes.\\u003c/p\\u003e\\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e\\u003cp\\u003eAssociations between pulmonary nodules and death due to metastatic disease were examined using contingency tables. Due to the relatively small sample sizes in some subgroup analyses, Fisher’s exact test was used to assess statistical significance.\\u003c/p\\u003e\\u003cp\\u003eOverall survival was analysed using Kaplan–Meier survival analysis, and differences between groups were assessed using the log-rank test. To evaluate independent predictors of survival, a multivariable Cox proportional hazards model was constructed incorporating pulmonary nodules, patient age, primary tumour stage, and nodal stage. Statistical significance was defined as a p-value of less than 0.05.\\u003c/p\\u003e\\u003cp\\u003eData was collected into a de-identified Microsoft Excel (version 2602) \\u003cb\\u003eRRID: SCR_016137\\u003c/b\\u003e database; statistical analyses were performed using IBM SPSS Statistics Version 29.0.0.0 (241) \\u003cb\\u003eRRID: SCR_016479\\u003c/b\\u003e.\\u003c/p\\u003e\\u003cp\\u003eThis study was compliant with the guidelines as outlined in The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement [\\u003cspan class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. Clinical trial number: not applicable.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u0026ndash; PULMONARY NODULES STRATIFIED BY PATIENT DEMOGRAPHICS, DISEASE CHARACTERISTICS\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo Nodules\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;233)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eNodules Present (n\\u0026thinsp;=\\u0026thinsp;80)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge, mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e58.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;14.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e61.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;14.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.090\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale gender, n (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e143 (61.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e49 (61.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.984\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmoking status\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNever\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e39 (28.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11 (22.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.516\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFormer\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e42 (30.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e19 (38.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCurrent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e58 (41.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e19 (38.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAny History of Smoking\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e100 (71.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e38 (77.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.445\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAlcohol Use\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNone\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e40 (29.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13 (27.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.892\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLight\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e38 (27.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e12 (25.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e18 (13.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (17.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHeavy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e35 (27.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14 (29.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePrimary tumour site\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTongue\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e109 (46.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e42 (52.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.139\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFloor of mouth\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e38 (16.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17 (21.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBuccal mucosa\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20 (8.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (5.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMandibular alveolus\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e22 (9.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (8.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaxillary alveolus\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e23 (9.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (2.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRetromolar trigone\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11 (4.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (10.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePalate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (1.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0 (0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIntraosseous mandible\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (1.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0 (0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT stage group\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT1\\u0026ndash;T2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e130 (56.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e43 (53.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.640\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT3\\u0026ndash;T4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e99 (43.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e37 (46.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN stage group\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e182 (78.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e57 (71.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep\\u0026thinsp;=\\u0026thinsp;0.190\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN+\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e50 (21.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e23 (28.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFollow-up duration (months), median\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c4\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eMedian follow-up duration calculated using reverse Kaplan\\u0026ndash;Meier: 60 months (95% CI 59.99\\u0026ndash;60.01)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eStatistical tests used include t-test / Mann-Whitney for continuous variables and Chi-square or Fisher for categorical variables.\\u003c/p\\u003e \\u003cp\\u003ePercentages are column percentages based available data for each variable: Smoking data available for 188 patients, Alcohol data available for 183 patients.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eClinical records of all 4563 new patients of the RBWH Head and Neck MDT during the study inclusion period between 1 July 2011 and 31 December 2018 were reviewed. 15 patients were excluded due to expired or unavailable medical records, 44 were excluded as they had definitive metastatic disease, 213 were excluded due to some/or all of their treatment occurring at another facility, and a vast majority were excluded due to having either a non-squamous cell carcinoma diagnosis, or having cancer outside the oral cavity. This yielded 372 patients treated for oral squamous cell carcinoma. The cohort had a mean age of 58.3 years and was predominantly male (62.9%). Baseline characteristics of the study population are summarised in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003ePulmonary imaging was available in 84.1% of patients. Imaging was more frequently performed in older patients (mean age 59.3 vs 53.3 years, p\\u0026thinsp;=\\u0026thinsp;0.017) and those with advanced primary tumours (T3/T4) (χ\\u0026sup2; = 9.45, p\\u0026thinsp;=\\u0026thinsp;0.002) but was not associated with sex or nodal stage.\\u003c/p\\u003e \\u003cp\\u003ePulmonary nodules were found in 80 patients on baseline imaging, corresponding to an incidence of 25.6%. The majority of nodules identified were either small and radiographically indeterminate or lacked clinical characterisation. Radiographic characteristics of identified pulmonary nodules are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u0026ndash; RADIOGRAPHIC CHARACTERISTICS OF PULMONARY NODULES\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNodule characteristic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003en (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal patients with nodules\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e80\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNumber of nodules\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSingle\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e43 (57.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMultiple\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e32 (42.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNodule size\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026lt;6 mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e57 (82.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e6\\u0026ndash;8 mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9 (13.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026gt;8 mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (4.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLobar location\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRight Upper Lobe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e21 (30.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRight Middle lobe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5 (7.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRight Lower Lobe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e21 (30.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLeft Upper Lobe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13 (18.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLeft Lower Lobe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9 (13.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRadiographic appearance\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSolid\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGround-glass\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (5.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCalcified\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e16 (94.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFollow-up CT performed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePerformed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e47 (58.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNot performed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e33 (41.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003ePercentages were calculated using available data for each variable.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eAmong patients with available radiographic measurements, most nodules measured less than 6 mm in maximal diameter. Specifically, 82.6% of nodules were smaller than 6 mm, 13.0% were between 6 and 8 mm, and 4.5% were greater than 8 mm. In terms of number, nodules were present as a single lesion in 57.3% of patients and as multiple nodules in 42.7%. The anatomical distribution of nodules demonstrated a predominance in the upper lobes versus the lower lobes (49.2% and 43.4%, respectively). Nodules arising within the middle lobe were uncommon and accounted for 7.2% of cases.\\u003c/p\\u003e \\u003cp\\u003eDuring the follow-up period, 107 patients had a recurrence of cancer, of which 25 patients (6.7%) had pulmonary recurrence as the primary site of recurrence; 72 deaths occurred, representing 19.4% of the study population. Cause of death data were available for a subset of patients and were categorised as \\u0026lsquo;death due to metastatic disease\\u0026rsquo; or \\u0026lsquo;death from other causes\\u0026rsquo;. The median follow-up duration for surviving patients was approximately 48 months.\\u003c/p\\u003e \\u003cp\\u003eAmong patients with pulmonary nodules who subsequently died (and for whom cause of death information was available) (\\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;33), death from metastatic disease occurred in 10 patients (30.3%). In comparison, 23 patients (69.7%) died from other causes. The presence of pulmonary nodules was not associated with an increased likelihood of death from metastatic disease.\\u003c/p\\u003e \\u003cp\\u003eWhen radiographic characteristics of nodules were examined, neither nodule size nor multiplicity demonstrated a statistically significant association with metastatic mortality. When nodules were stratified by size, death from metastases occurred in 5 of 16 patients (31.3%) of those with nodules measuring 8 mm or less, whereas no metastatic deaths were observed among the 3 patients with nodules greater than 8 mm. This difference did not reach statistical significance using Fisher\\u0026rsquo;s exact testing (p\\u0026thinsp;=\\u0026thinsp;0.53).\\u003c/p\\u003e \\u003cp\\u003eSimilarly, the number of nodules was not associated with death from pulmonary metastases (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). Among patients with single nodules, metastatic disease accounted for death in two of ten patients (20.0%), compared to three of nine patients (33.3%) with multiple nodules (Fisher\\u0026rsquo;s exact test p\\u0026thinsp;=\\u0026thinsp;0.63. These findings suggest that radiographic features of pulmonary nodules identified at staging imaging did not predict metastatic mortality in this cohort.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u0026ndash; ASSOCIATION BETWEEN NODULE CHARACTERISTICS AND DEATH FROM METASTATIC DISEASE\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMetastatic Death n (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOther Cause n (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNodule size \\u0026le;8mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5 (31.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11 (68.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.53\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNodule size\\u0026thinsp;\\u0026gt;\\u0026thinsp;8 mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (100.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSingle nodule\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (20.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (80.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMultiple nodules\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (33.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6 (66.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFollow-up CT performed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (33.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14 (66.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.71\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNo follow-up CT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (25.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9 (75.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAppropriate timing of follow-up imaging\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (58.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.26\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInappropriate timing of follow-up Imaging\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (41.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10 (100%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003ePercentages were calculated using available data for each variable.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eOf all participants, mean overall survival was 49.5 months for those with pulmonary nodules, and 50.7 months for those without nodules (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). When survival was stratified by size for those with nodules, mean overall survival was 49.4 months for patients with nodules measuring 8 mm or less and 37.0 months for patients with nodules greater than 8 mm (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Despite this numerical difference, survival curves did not differ significantly between groups according to the log-rank test (p\\u0026thinsp;=\\u0026thinsp;0.212). These results indicate that incidental pulmonary nodules detected during staging imaging did not significantly influence overall survival in patients with oral cavity SCC.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eTo further evaluate predictors of survival, a multivariable Cox proportional hazards model was constructed incorporating pulmonary nodules, age at treatment, tumour stage, and nodal stage (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). The presence of pulmonary nodules was not associated with increased mortality. The estimated hazard ratio for pulmonary nodules was 0.91 (95% confidence interval 0.54\\u0026ndash;1.55, p\\u0026thinsp;=\\u0026thinsp;0.739).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u0026ndash; MULTIVARIABLE COX PROPORTIONAL HAZARDS MODEL FOR OVERALL SURVIVAL\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHazard Ratio\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e95% CI\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePulmonary nodules\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.91\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.54\\u0026ndash;1.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.739\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge (per year)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.05\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.03\\u0026ndash;1.07\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT stage (T3\\u0026ndash;T4 vs T1\\u0026ndash;T2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2.75\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.64\\u0026ndash;4.64\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN stage (N\\u0026thinsp;+\\u0026thinsp;vs N0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.99\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.17\\u0026ndash;3.36\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.011\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn contrast, several established oncologic prognostic factors demonstrated statistically significant associations with survival. Increasing age was independently associated with a higher risk of mortality, with a hazard ratio of 1.05 per year (95% confidence interval 1.03\\u0026ndash;1.07, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Advanced primary tumour stage was also associated with significantly reduced survival, with patients presenting with T3\\u0026ndash;T4 tumours demonstrating a hazard ratio of 2.75 compared with those with T1\\u0026ndash;T2 disease (95% confidence interval 1.64\\u0026ndash;4.64, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Similarly, nodal metastasis was independently associated with poorer survival outcomes. Patients with nodal disease demonstrated a hazard ratio of 1.99 compared with node-negative patients (95% confidence interval 1.17\\u0026ndash;3.36, p\\u0026thinsp;=\\u0026thinsp;0.011). These findings confirm that tumour stage and nodal disease remain the dominant predictors of survival, while incidental pulmonary nodules identified on staging imaging do not independently influence prognosis.\\u003c/p\\u003e \\u003cp\\u003eCT chest imaging after initial staging was performed in 47 patients, representing 58.8% of patients with pulmonary nodules. Among patients with pulmonary nodules who subsequently died and had a documented cause of death (n\\u0026thinsp;=\\u0026thinsp;33), follow-up imaging was performed in 21 patients (63.6%); 12 patients (36.4%) did not undergo follow-up imaging. Death from metastases occurred in seven of the 21 patients (33.3%) who underwent follow-up imaging and in three of the 12 patients (25.0%) who did not undergo follow-up imaging. This difference was not statistically significant (Fisher\\u0026rsquo;s exact test p\\u0026thinsp;=\\u0026thinsp;0.71).\\u003c/p\\u003e \\u003cp\\u003eOnly a small number of patients met criteria for their follow-up imaging to be deemed to be within appropriate timeframes. Within this subgroup, death from metastatic disease occurred in seven of seventeen patients (41.2%) who did not undergo appropriate follow-up imaging. In contrast, no deaths from metastases occurred among the four patients who underwent appropriate follow-up imaging within 6 months. Although this observation suggests a possible association between timely follow-up imaging and improved outcomes, the difference did not reach statistical significance (p\\u0026thinsp;=\\u0026thinsp;0.26), most likely due to the limited number of patients undergoing appropriate follow-up imaging.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003ePulmonary nodules are common and were identified in approximately one-quarter of oral cavity SCC patients undergoing staging imaging in this study.\\u003c/p\\u003e \\u003cp\\u003eThis study found that they were not associated with reduced overall survival or a higher risk of death from distant metastatic disease. Furthermore, within the subgroup of patients with nodules, radiographic features such as nodule size and multiplicity were not significantly associated with death from metastatic disease. These findings suggest most nodules were incidental rather than biologically aggressive.\\u003c/p\\u003e \\u003cp\\u003eKaplan\\u0026ndash;Meier survival analysis showed no significant difference in survival between patients with and without nodules, and this finding persisted after adjustment for age, T stage, and N stage in a multivariable Cox proportional hazards model. In contrast, increasing age, advanced primary tumour stage, and nodal disease were independently associated with poorer survival. This is consistent with the established natural history of oral cavity squamous cell carcinoma, in which tumour burden and regional nodal spread remain the major determinants of prognosis [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. The fact that pulmonary nodules were not independently prognostic after controlling for these factors supports the interpretation that they are, in most cases, incidental findings rather than a marker of occult systemic disease [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Unfortunately, morphological descriptors such as \\u0026lsquo;solid\\u0026rsquo; and \\u0026lsquo;subsolid\\u0026rsquo; were often omitted in the current study\\u0026rsquo;s radiology reports before 2016/17, thereby preventing morphological characterisation in the analysis.\\u003c/p\\u003e \\u003cp\\u003eThe analysis of death from metastases produced a similar conclusion. Although the proportion of metastatic deaths was numerically higher among patients with nodules than among those without nodules, the difference was small and not statistically significant, and logistic regression did not demonstrate an independent association between pulmonary nodules and metastatic death. The calculated positive predictive value of nodules for metastatic death was modest (PPV\\u0026thinsp;=\\u0026thinsp;30.3), which again argues against assuming that nodules detected on staging imaging are malignant by default. These findings suggest pulmonary nodules alone should not alter curative treatment intent.\\u003c/p\\u003e \\u003cp\\u003eAn interesting secondary finding relates to follow-up imaging. Only a minority of patients with nodules underwent what was defined as appropriate interval follow-up imaging. Although timely follow-up imaging was not significantly associated with deaths from metastases, there was a numerical pattern suggesting fewer metastatic deaths among those who underwent appropriate follow-up. However, the small subgroup size renders this observation underpowered and vulnerable to type II error. The safest interpretation is that the study did not show a statistically significant effect of follow-up imaging on outcome, but that the observed pattern justifies further investigation in larger cohorts.\\u003c/p\\u003e \\u003cp\\u003eContemporary management of pulmonary metastases has evolved considerably, with increasing consideration of surgical resection for selected patients, particularly those with p16-positive disease, and the emergence of immunotherapy as an additional treatment modality. These developments suggest earlier detection through interval imaging may offer clinical benefit. Larger prospective studies in modern treatment cohorts are therefore required to determine whether routine follow-up imaging may improve survival outcomes [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eLimitations of this study include incomplete or poorly filed documentation and the relatively small sample size. The study lost a significant number of participants due to part of their care being handled in other facilities (including their initial CT imaging occurring in external facilities). Radiology reports were of variable quality. Radiographic interpretation was not based on standardised reporting characteristics, which may introduce some heterogeneity; similarly, reporting was from a varied array of clinicians rather than uniform central review by a subspecialist thoracic radiologist. Several of the more clinically interesting subgroup analyses, particularly those relating to nodule size, multiplicity, and follow-up imaging, were based on small numbers and therefore lack statistical power. Histological diagnosis is also a pitfall of this study: at index imaging, there were very few pulmonary nodules biopsied (n\\u0026thinsp;=\\u0026thinsp;2). Due to the difficulty in differentiating lung SCC from oral SCC, those patients with histologically proven squamous cell carcinoma within lung parenchyma could have either metastatic oral or primary lung disease.\\u003c/p\\u003e \\u003cp\\u003eDespite limitations, findings were consistent and clinically informative. Pulmonary nodules were common, but they were not associated with reduced overall survival, and their radiographic features did not reliably identify a subgroup at markedly higher risk of death from metastatic disease. The factors that did predict survival were the expected oncologic variables of age, tumour stage, and nodal disease. This suggests that clinicians should continue to prioritise established prognostic markers when counselling patients and planning treatment, rather than placing disproportionate emphasis on small incidental pulmonary nodules detected at staging.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch3\\u003eFunding\\u003c/h3\\u003e\\n\\u003cp\\u003eThe authors declare that no funds, grants or other support were received during the preparation of this manuscript.\\u003c/p\\u003e\\n\\u003ch3\\u003eCompeting Interests\\u003c/h3\\u003e\\n\\u003cp\\u003eThe authors have no relevant financial or non-financial interests to disclose.\\u003c/p\\u003e\\n\\u003ch3\\u003eAuthor Contributions\\u003c/h3\\u003e\\n\\u003cp\\u003eMatthew Gilmore and Omar Breik contributed to study design. Data collection was performed by Matthew Gilmore and Aleeza Baker. Data analysis was performed by Matthew Gilmore. The first draft of the manuscript was written by Matthew Gilmore and all authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3\\u003eCompliance with Ethical Standards\\u003c/h3\\u003e\\n\\u003cp\\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Metro North Health Human Research Ethics Committee (HREC/2024/MNH/114937).\\u003c/p\\u003e\\n\\u003ch2\\u003eConsent to Participate \\u0026amp; Consent to Publish\\u003c/h2\\u003e\\n\\u003cp\\u003eMetro North Health Human Research Ethics Committee granted a waiver of consent as this study was deemed low/negligible risk (HREC/2024/MNH/114937).\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eProbert JC, Thompson RW, Bagshaw MA (1974) Patterns of spread of distant metastases in head and neck cancer. Cancer 33(1):127\\u0026ndash;133\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLewis-Jones H, Colley S, Gibson D Imaging in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1017/S0022215116000396\\u003c/span\\u003e\\u003cspan address=\\\"10.1017/S0022215116000396\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePfister DG, Spencer S, Adelstein D, Adkins D, Anzai Y, Brizel DM et al Head and neck cancers, version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.6004/jnccn.2020.0031\\u003c/span\\u003e\\u003cspan address=\\\"10.6004/jnccn.2020.0031\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTan L, Greener CC, Seikaly H, Rassekh CH, Calhoun KH Role of screening chest computed tomography in patients with advanced head and neck cancer. Otolaryngol Head Neck Surg. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1053/hn.1999.v120.a91767\\u003c/span\\u003e\\u003cspan address=\\\"10.1053/hn.1999.v120.a91767\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCallister MEJ, Baldwin DR, Akram AR, Barnard S, Cane P, Draffan J, Thorax et al \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1136/thoraxjnl-2015-207168\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/thoraxjnl-2015-207168\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP et al Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1378/chest.12-2351\\u003c/span\\u003e\\u003cspan address=\\\"10.1378/chest.12-2351\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMacMahon H, Naidich DP, Goo JM, Lee KS, Leung ANC, Mayo JR et al Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1148/radiol.2017161659\\u003c/span\\u003e\\u003cspan address=\\\"10.1148/radiol.2017161659\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHsu YB, Chu PY, Liu JC, Lan MC, Chang SY, Tsai TL et al Role of chest computed tomography in head and neck cancer. Arch Otolaryngol Head Neck Surg. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1001/archotol.134.10.1050\\u003c/span\\u003e\\u003cspan address=\\\"10.1001/archotol.134.10.1050\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTsai HH, Ali M, Mohindra A, Parmar S, Breik O Outcomes of incidental pulmonary nodules detected in oral and oropharyngeal cancer patients. Br J Oral Maxillofac Surg. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.bjoms.2024.09.011\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.bjoms.2024.09.011\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGreen R, King M, Reid H, Murchison JT, Evans A, Nixon IJ Management of pulmonary nodules in head and neck cancer patients\\u0026mdash;our experience and interpretation of the British Thoracic Society Guidelines. Surgeon. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.surge.2016.10.002\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.surge.2016.10.002\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZammit-Maempel I, Kurien R, Paleri V Outcomes of synchronous pulmonary nodules detected on computed tomography in head and neck cancer patients: 12-year retrospective review of a consecutive cohort. J Laryngol Otol. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1017/S0022215116000736\\u003c/span\\u003e\\u003cspan address=\\\"10.1017/S0022215116000736\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBrims F, McWilliams A, Williamson J, Siemienowicz M, Leong TL et al The TSANZ practical guide for clinicians in the management of screen- and incidentally-detected nodules. Respirology. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1111/resp.70065\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/resp.70065\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlford RE, Fried DV, Huang BY, Weissler M, Shores C, Shockley W et al Clinical significance of indeterminate pulmonary nodules in patients with locally advanced head and neck squamous cell carcinoma. Head Neck. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1002/hed.23294\\u003c/span\\u003e\\u003cspan address=\\\"10.1002/hed.23294\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\\u0026oslash;tzsche PC, Vandenbroucke JP Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1136/bmj.39335.541782.AD\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/bmj.39335.541782.AD\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eShiono S et al (2021) The role of pulmonary metastasectomy for pulmonary metastasis from head and neck cancer. J Thorac Dis. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.21037/jtd-20-1154\\u003c/span\\u003e\\u003cspan address=\\\"10.21037/jtd-20-1154\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSharon S et al (2022) Immunotherapy in head and neck squamous cell carcinoma. Front Oncol. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3389/fonc.2022.842316\\u003c/span\\u003e\\u003cspan address=\\\"10.3389/fonc.2022.842316\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"oral-and-maxillofacial-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"omfs\",\"sideBox\":\"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)\",\"snPcode\":\"10006\",\"submissionUrl\":\"https://submission.nature.com/new-submission/10006/3\",\"title\":\"Oral and Maxillofacial Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Pulmonary nodules, lung metastases, computed tomography chest, oral cancer, head and neck cancer\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9376080/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9376080/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eIncidental pulmonary nodules are frequently identified on staging imaging for oral cavity squamous cell carcinoma (SCC). These may represent metastases, lung primaries, or benign lesions. Existing risk stratification guidelines are not specific to head and neck cancer. This retrospective cohort study evaluated survival differences between patients with and without pulmonary nodules and explored the impact of follow-up imaging.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThis single-centre retrospective cohort study included adults with oral mucosal SCC managed with curative intent between 2011 and 2018. Clinical, demographic, and radiographic data, including nodule characteristics and follow-up imaging, were extracted from electronic records. Primary outcomes were overall survival and metastatic disease\\u0026ndash;related death, analysed using Fisher\\u0026rsquo;s exact test, Kaplan\\u0026ndash;Meier survival with log-rank testing, and multivariable Cox regression.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eOf 4563 clinic patients screened, 372 met inclusion criteria (mean age 58.3 years, 62.9% male). Pulmonary imaging was available in 84.1%; nodules were present in 21.2%, predominantly\\u0026thinsp;\\u0026lt;\\u0026thinsp;6 mm and radiographically indeterminate. Pulmonary nodules, including size and multiplicity, were not associated with metastatic death, overall survival, or increased mortality. Older age, advanced T stage, and nodal metastasis were independently associated with poorer survival.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003ePulmonary nodules were common but did not independently predict overall survival or metastatic mortality. Established oncologic factors remained the dominant prognostic determinants. Small incidental nodules on staging imaging should not, in isolation, alter curative treatment intent, however there is a trend for increased survival in those who have appropriate timed follow-up imaging, underscoring the need for larger prospective studies on follow-up imaging strategies.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Incidental Pulmonary Nodules in Oral Squamous Cell Carcinoma – A retrospective cohort study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-15 02:36:37\",\"doi\":\"10.21203/rs.3.rs-9376080/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-16T11:57:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"262613962209807952702724118247257565198\",\"date\":\"2026-05-08T11:56:11+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-06T12:25:16+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"254290964454054035843979936060694985085\",\"date\":\"2026-05-06T09:11:40+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-05-06T06:47:52+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-04-15T05:50:44+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-04-15T05:50:21+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Oral and Maxillofacial Surgery\",\"date\":\"2026-04-10T07:27:08+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"oral-and-maxillofacial-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"omfs\",\"sideBox\":\"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)\",\"snPcode\":\"10006\",\"submissionUrl\":\"https://submission.nature.com/new-submission/10006/3\",\"title\":\"Oral and Maxillofacial Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"846c6e82-853c-49be-a31e-92e22e2fe43c\",\"owner\":[],\"postedDate\":\"May 15th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-16T11:57:10+00:00\",\"index\":14,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"262613962209807952702724118247257565198\",\"date\":\"2026-05-08T11:56:11+00:00\",\"index\":13,\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-06T12:25:16+00:00\",\"index\":12,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"254290964454054035843979936060694985085\",\"date\":\"2026-05-06T09:11:40+00:00\",\"index\":11,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"3\",\"date\":\"2026-05-06T06:47:52+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-15T02:36:37+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-15 02:36:37\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9376080\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9376080\",\"identity\":\"rs-9376080\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}