Archive for the Cancer category.
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These are the characteristics of malignancy: fixed, hard, non-tender, matted, etc. I always ask the patient. If they do say, “Yeah, it changed. It’s bigger now it’s smaller, and it’s getting bigger.” Try to get a time. When does it happen. When you wake up in the morning is it bigger? Does it get bigger throughout the day? Does it get bigger when you are eating or when you are preparing food, or when you walk in the house and you smell food and get ready to eat? Anything that might indicate a salivary gland obstruction then of course you could be thinking stones, chronic infections, strictures, those kinds of things. Tumors can also cause it but those would be the things from a salivary gland standpoint. Other generalized adenopathy in the axilla and throughout. Mono, cat scratch, lymphoma, certainly sarcomas, TB, atypical TB, those kinds of things may make you want to get a chest x-ray, get other titers, get other studies prior to taking that patient to the operating room and doing an open biopsy. Color: certainly if you have pigmented lesions you can always ask the patient – especially for nodes in the parotid region and the external jugular, these are superficial nodes very frequently associated with skin cancer. So you need to ask the patient, “have you had any lesions removed? Any lesions burned off? Have you ever had any skin cancers?” and keep that in mind. Again, if you have them strain, do they blush like a hemangioma would.
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What do you do when faced with a patient with a unilateral, asymptomatic, neck mass? You’ll be the first one to see them. The patient comes in and says, “I noticed this when I was shaving.” How long ago? It’s always two weeks. I don’t care how many months. You know it’s been there for eight months, it’s always two weeks. And then what do you do? Well, a complete head and neck exam is the first thing that needs to be done. You need to look at the oral cavity, oropharynx if you’ve got a mirror or a scope, otherwise you need to look at that. These patients need to have an indirect exam so you can evaluate the larynx and the hypopharynx. You need to feel their thyroid and their salivary glands. And then you need to look at their skin. Did they have a lesion taken off? These skin cancers can go bad and can go to lymph nodes, so you need to look their skin over a little bit as well. Do they have a melanoma, do they have something that’s suspicious that you may need to biopsy first before you go to a fine needle.
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The next step, I believe, is if you have fine needle capacity in your office, is to go ahead and get a fine needle on it. While you are waiting for a fine needle – if you are talking to a 65-year-old who smokes two packs a day and is also hoarse – then I think it’s reasonable to go ahead and assume this is going to be cancer and go ahead and get your workup going. All these patients need chest x-rays. A high percentage of them are smokers and you need to know what’s going on in the lungs. That’s a good time to get them. These things are low yield and I don’t usually order them until after I have a diagnosis and I don’t have a primary and I’m looking for a primary. I don’t get sinus films or an esophagram unless the patient presents with an obstruction, a unilateral obstruction of the nose and a lymph node. Then it’s reasonable. Probably at that point you are going to go straight to a CT scan. Viagra super active at our pharmacy shop.
Then we get the fine needle aspiration. When the fine needle comes back, what do we do with it? If it’s adenocarcinoma then that’s a problem. They will usually say, “It’s malignant. Looks like it’s an adenocarcinoma.” Well, before we take them to the operating room and try to figure out what’s going on, we need to make sure if it’s in the upper neck, then you are thinking salivary glands. You need to feel that base of the tongue. Probably going to have to put the patient to sleep to do all this. If it’s lower, then they need to have a good breast exam. Probably a mammogram, GI studies, etc. and again, of course, a good chest x-ray. If there is any suspicion whatsoever, probably a CT of the chest as well. If they think it’s lymphoma, then they are going to get all their studies but we’re going to have to get some tissue for them. They won’t type them and stage them on fine needle, so that patient is going to need an open neck biopsy. But you don’t want to find out that they were wrong and it’s not lymphoma and you took out a squamous cell node and then you look in their mouth and find that they have a 4 cm base of tongue lesion. It happens all the time and it’s something that needs to be avoided.
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How can you cure cervical cancer? Because you have a gross mass present, you only can give 4500 centigrade to 5000 centigrade to the pelvis, how do we give enough radiation to kill a cancer that is on the cervix. That is done by what we call brachy therapy and brachy therapy is giving a high dose of radiation directly to the cancer and these are the implants. Modern day implants are based on what we call the Manchester system. Historically what we used to do in Stockholm, we used to put two radiation sources right against the cervix at tandem and give very high doses of radiation therapy to the tumor over a day and then remove it and were able to cure the cancer. The only problem here was that the complication rate was extremely high. Because of that, the Manchester system was developed in England where we gave an implant where the implant would deliver a low dose of radiation over an extended period of time and with a tandem containing radiation sources in the uterus, thereby killed the cancer yet minimized the complications. Modern day implants are based on what we call the Fletcher Suit system, this is an implant and in the Fletcher Suit system, what we do is we place two ovoids, and a tandem in the uterus. Each of these ovoids have a radiation source in them, the tandem have anywhere from two to three sources in them, but to calculate the dose, what you have to realize is that the radiation dose falls what we call by inverse square, so subsequently what happens is that if you look at 2 cm lateral to the cervix, what we call point A, the dose delivered from an implant is only one-fourth or inverse square of the distance. If you look at point B, point B is 3 cm further than point A or 5 cm from the external os, the dose delivered is 1/25th the dose of the implant. What is significant about point A is point A is the perimetria and that’s where the parametrial nodes are. Those are the most common nodes that are positive with a cervical cancer. Point B is the obturator nodes. Anatomically, what’s important about point A, is that’s where the uterine artery goes over the ureter, and that’s the reason often you can see a ureteral stricture secondary to an implant.
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The radiation sources used for an implant nowadays are cesium, cesium 137 is used and has a half life of 30 years, so it’s not necessary to calculate the dose with regard to the radiation implant every year, because these are long lived isotopes. We used to use radium or radium 226, the problem with radium 226, it has a very long half life of 1620 years, but in addition, in it’s decay, gave off radon gas and when the sources would crack, radon gas would be given off and became a health hazard to the personnel in the hospital, causing lung cancers. This is a Fletcher Suit implant, what you see here, is the ovoids which fit into the fornices and the tandem which contains radiation sources that are placed within the uterine cavity. To determine whether an implant is in it’s right position, x-ray films are taken and here you can see the ovoids as well as the tandem. The problem you have here, is you don’t know if it’s placed correctly. To determine that, a lateral film is taken and as you can see here, here is the tandem and here are the ovoids, what you are concerned about is that tandem is right angle to the ovoids, its not twisted which causes complications, secondly, is that each of these radiation sources in the tandem do not cross the sources in the ovoids because if that does happen, what your doing to the patient, is causing a hot spot and thereby having the possibility of causing either a rectovaginal or vesicovaginal fistula, so if you get called and the radiation oncologist isn’t around and this tandem is twisted or you see it pulled back, the proper thing is to call the radiation oncologist, have the sources taken out and take the implant out. When you have an indentation, what you are basically doing is you have the potential of the cancer recurring. Cheap soma without prescription.
Occasionally, in a morbidly obese patient, who has endometrial cancer, what the radiation oncologist will do is place Hayman capsules. What Hayman capsules are, are small radiation sources that usually contain cesium that are 5 to 10 mg of cesium, they place the sources actually into the uterus to radiate the surface of the uterus. The problem here clinically is that the ability to cure the cancer decreases about 15 to 20%. So when we give radiation therapy, our goal is to give external beam radiation therapy 4000 to 4500 centigrade and implant given to point A, an additional 40 to 45 gray or 4000 to 4500 giving a total dose, when you get the total dose you will add the external beam radiation therapy, the intracavitary implant and you get 80 to 85 gray to point A or 8000 to 8500 centigrade to point A. That is the dose you will would like to achieve to point A. With ovarian cancer occasionally, usually with an early stage ovarian cancer we’ll go ahead and use P32. What P32 is, is an isotope that is a colloidal suspension, or a fine particulate matter that is given into the peritoneal cavity, what P32 does, is it radiates the entire pelvic and abdominal cavity but with very low energy radiation, it delivers what we call a gamma ray as you have with x-ray and implants, it delivers beta energy. The problem with P32, it doesn’t distribute adequately and secondly, it’s depth of penetration, unlike x-ray therapy is very low, it penetrates only 1 to 3 mm in depth and that’s the reason it’s good only for microscopic disease.
When we speak about radiation oncology, on the biological level. What we’re trying to do is kill a cancer cell. What one has to realize is radiation is effective only in microscopic disease for the most part, and it’s not effective during the entire time period that the radiation is being given. The reason is, if you look at the biology of cancer, and you think about the dividing cell, the majority of a cancer mass does not divide at any one time, only about 10% of the cancer is dividing, so if you look at the cell cycle, what you see is that the majority of cells are what we call the G0 phase in a tumor mass, 90% of the cells are actually resting. For radiation to be effective, these cells have to be recruited out of their resting phase and have to be actually dividing because radiation will kill a cell when it’s either in the mitotic phase or beginning from the resting phase or the G2 phase.
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The clinical implication of this is that one sees the maximum effect of radiation, not during the time of radiation but within three to four weeks after a patient completed radiation therapy. The reason we give a small dose initially of 180 to 200 rads is that lower doses, the cell has the ability to repair the damage of the radiation and that is called the sublethal effect. That is this little slope you see here. As you get over 200 centigrade, you begin to see the higher the dose, the more likely the cancer cell will be killed. Radiation therapy is based upon what we call the Compton effect, what the Compton effect is, is that when a photon or an x-ray hits a cell, it will go ahead and eject the nucleus from the outer shell of the cell of the atom producing what we call a scatter photon, and what you have to remember is x-rays are like energy or photons. This is the way radiation works. Radiation doesn’t work in large masses because the majority of cancers have a hypoxic out nucleus or have necrosis.
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When angiogenesis takes place, and there is a vascularity, what happens is the vasculature oxygenates the center of the tumor mass and what we have found over the years, is the more oxygenated the cancer mass is, the greater the likelihood the cancer will die and here you have a comparison of what happens when cell are in a toxic background or no oxygen and when there is oxygen present. As you can see, treating cells with radiation what you will see is that there is a greater ability to kill the cancer cell when oxygen is present. This is important clinically because when a patient goes for radiation therapy, we like the patient not to anemic and to be transfused with a hematocrit over 30. This is the basis for it. When you send a patient to radiation oncology, they always give you a dose, 10 years ago what we used to report is dose in rads, and what rads was radiation absorbed dose. A patient would get for example, 4 to 5 thousand rads of external beam radiation therapy. However, the terminology has changed and what we now talk about rather than rads is centigrade and centigrade is if you pick up an older chart, you convert rads to centigrade by remembering that one rad is equivalent to one centigrade, 100 centigrade is equivalent to one grade, so if a patient receives 40 grade, they have received 5,000 centigrade or 5000 rads, they are all equivalent. Herbal xanax.
Posted on November 7th, 2007 by Canadian Health in
Cancer The entity of microinvasive carcinoma of the cervix, is not always as easy to correctly diagnose as you may think, and there are a few rules that need to observed before this diagnosis is made. First of all, it rests on a cone biopsy specimen that needs to adequate with negative margins. If there is a cone with positive margins that show microinvasive carcinoma of the cervix, that does not rule out the possibility that there may be a larger or more invasive lesion somewhere else in the cervix
The diagnosis of microinvasive carcinoma of the cervix also supposes the availability of expert pathology services. These two requirements have world wide not always been present and have led to the continuing kind of confusion and lack of general agreement on what the ideal treatment for these lesions should be. It was recognized shortly after the second world war that there was an entity of invasive carcinoma of the cervix, where the tumors are so small, that more likely than not, less than radical or less than conventional treatment would be sufficient to obtain a cure. You are familiar with this data, but I would like to review them with you here, in the depth of invasion, less than 3 mm are equal to 3 mm, the incidents of positive lymph node metastases is very low, it’s substantially less than 1%, however, if the invasion is between 3 and 5 mm, which is stage IAII category, then the lymph node metastases rate is approximately 5.3%. When you look at recurrences, the recurrence rate is very low with these lesions less than 3 mm invasive, it’s approximately 5.3% when invasion is somewhere between 3 and 5 mm. So one can say that indeed, there are lesions here where the pelvis lymph node metastases rate is very small, where the recurrence rate is very small, but you can also look at it the other way and say well, there are subset of patient’s here who are clearly at a higher risk of having either no disease, or having recurrences, and can we identify them. The issue of lymphovascular space involvement is clearly more controversial as well. This is a compilation of the data here on lesions either less than 3 mm or 3 to 5 mm. Vascular space involvement is very uncommon in these circumstances, but one present in lesions than 3 mm might be associated with an increased risk of pelvic lymph node metastases, although not significant as well as increased risk of recurrences.
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Actually in lesions between 3 and 5 mm, you can see that when vascular space involvement was absent, there was actually a higher pelvic lymph node metastases rate than when it was present. On the other hand, recurrences were more frequent when vascular space involvement was present rather than absent. This remains a controversial issue, most gynecologic oncologists in this country continue to feel that lymphovascular space involvement is a factor to be reckoned with at least at the present time, but this may change, is certainly challenged. What are the treatment options, well the treatment options remain as they were before in stage IAI, carcinoma of the cervix, one has the option to perform a simple hysterectomy or a cone biopsy. In stage IAII, one would conduct at least a simple hysterectomy, preferably a modified radical hysterectomy and one should address at the present time, the pelvic lymph node, so a pelvic lymphadenectomy needs to be done. There is a whole host of surgical alternatives that are being proposed in many parts of the world that are actually being tried out in microinvasive carcinoma of the cervix, and they all center on limited resections of the tumor, for instance a cone biopsy for stage IAII, cone combined with a pelvic lymphadenectomy and this pelvic lymphadenectomy can be done through the laparoscope, it can be done in a conventional way. One needs to understand that there are really no good data at the present time to support any of these approaches, and the sad forecast is that because of problems with pathology and with the correct diagnosis of microinvasive carcinoma of the cervix, there is no real expectation that there is going to be any large amount of data in the foreseeable future. In patient’s who are nonsurgical candidates, and who have microinvasive carcinoma, radiation therapy, is then the treatment of choice.
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Posted on November 6th, 2007 by Canadian Health in
Cancer What is the workup before we go ahead with treatment of cervical cancer? Well obviously a history and a physical examination which includes a pelvic and a rectal examination, a complete blood count, blood chemistry with attention to the patient’s creatinine, then consider HIV testing, cervical cancer is an AIDS defining illness and patient’s at risk. The treatment of the cervical cancer will be positively influenced and affected by treatment of their HIV status and their AIDS at the same time, so this is important to consider. A chest x-ray is important, an IVP, skeletal x-rays and barium enema are helpful in patient’s with advanced disease. These are the studies that are also allowed for clinical staging purposes.
Examination under anesthesia, in my opinion, remains an important component of the pretreatment workup because it allows one to examine a relaxed patient, to have a better understanding of the local extent of the disease, it also allows examinations with multiple examiners including radiation oncologist at that time. Cystoscopy, proctoscopy again are useful in patient’s with locally advanced disease where there is a positive finding to be expected.
Other studies which are increasingly used are imaging studies such as CT scan, MRI scan, in order to more accurately try to determine the extent of the disease, if one finds that findings are accessible to fine needle aspiration and that should be attempted under CT guidance. As a reminder, the staging of cervical cancer is purely clinical and information is allowed from the following sources, from the clinical examination preferably conducted under anesthesia, x-rays of the chest, the kidneys, the bone, no information of the CT scan or the MRI scan is allowed, so if you do a CT scan basically for clinical staging purposes, only the information with respect to the presence or absence of hydronephrosis can be used for clinical staging, not the presence of an enlarged, periaortic node for instance. Biopsy of suspected bladder or rectal invasion, it can further be used to complete the clinical staging.
I will review the stages of cervical cancer with you. Stage I is confined to the cervix and then identified microinvasive carcinoma as follows: These are invasive lesions which by definition can only be identified under the microscope. Stage IAI includes lesions with invasion up to 3 mm and with a width not exceeding 7 mm, when invasion reads more than 3 mm, the stage is IAII, less than 5 mm width not exceeding 7 mm. Stage IB are clinically visible lesions or preclinical tumors which are more than 5 mm invasive. They are in terms further subdivided in lesions than are less than 4 cm or equal to 4 cm stage IBI or tumors that are larger than 4 cm in diameter, stage IBII. Stage II tumors involve either the vagina or the parametrium, stage IIA extends into the upper vagina, not in the lower one-third and not in the parametrium, stage IIB remains parametrium extension, but not to the side wall. Stage III disease, stage IIIA lower third of the vagina, stage IIIB is extension to the pelvic side wall and the presence of hydronephrosis. Stage IV disease is extension outside the reproductive tract, either involving the mucosa of the bladder or rectum, stage IVA or distant metastases outside the pelvis stage IVB. These stages do correlate with survival, this is experience of Anderson which are still very applicable in patient’s with invasive carcinoma of the cervix treated with radiation therapy, five year survival in stage I cases, 91% is excellent, stage IIA 83%, stage IIB 66.5%, and approximately 45% for patient’s with stage IIIA. In carcinoma of the cervix, treatment controversies continue to persist and they predictably continues to exist at both ends of the spectrum, so there are still substantial difficulties at the present time in finding the correct and ideal treatment for patient’s with either very small tumors or the patient with very large tumors. I will go over that in the next couple of minutes.
Posted on November 5th, 2007 by Canadian Health in
Cancer Carcinoma of the cervix continues to occur, although the incidence is clearly decreasing; what we are talking about are predominantly squamous cell carcinomas which are the most common variety, accounting for approximately 80% of all cervical cancers, adenocarcinoma represents approximately 20%, other cell types are much less common. There are currently approximately 14,000 cases a year, and the clinical spectrum is changing, cervical carcinoma has traditionally been a big topic in gynecology for understandable reasons, it is still important for us as gynecologists to be leaders in this field in our ability to recognize the disease and suggest appropriate treatment.
At the present time in the United States, approximately one-half of the cases of invasive carcinoma of the cervix are advanced at the time of diagnosis. What is the cause of death? It is either uncontrolled disease in the pelvis, or distant metastasis and I will come back to these issues. The pattern of spread is something you are familiar with, and something we want to keep in mind when we talk about treatment. There is first of all, local expansion in the pelvis, lymphatic spread through the regional and more distant lymph nodes, hematogenous spread is of importance predominantly in the late stages of the disease. What are the symptoms of cervical carcinoma? As a reminder, patient’s traditionally present with either abnormal vaginal bleeding or discharge. I want to share with you that not recognizing this continues to occur, and is not infrequently a cause or a reason for not timely diagnosing sometimes advanced cervical carcinoma. Most of the symptoms, are symptoms of advanced disease, pain, typical lumbosacral pain, pain in the gluteal area, hematuria, rectal bleeding. A lot of patient’s with cervical cancer of course, will have no symptoms because the disease will be diagnosed in the workup of an abnormal PAP smear.
The diagnosis typically relies on the biopsy of any gross lesion of the cervix. Workup of an abnormal PAP smear in a number of cases will lead to the diagnosis of an invasive cancer of the cervix, and this will include colposcopy and biopsy or cone biopsy. As a reminder, the cervix is grossly abnormal as in this case, the first thing to do is to biopsy here, this lesion is not approached by doing a PAP smear, and again, maybe with decreasing incidents of cervical cancer and the fact that we are more adapt in working up abnormal PAP smears and doing colposcopy, one needs to be reminded of the fact that lesions such as these need to be biopsied, and the answer will be obvious.