Cancer information Cancer treatment

So needle biopsy

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So needle biopsy. At that point, if you are looking at a squamous cell or something that looks like epithelial, then they probably need some form of directed scope. Whether it’s a panendoscopy, which applies a rigid bronchoscopy, esophagoscopy and direct laryngoscopy, or whether you go just to direct laryngoscopy – which we do more and more – depending again on the physical exam. Whether you do biopsies or not, this is kind of becoming. I think most people do not do random or blind or guided biopsies unless you have a real high suspicion. So if we are faced with this patient, that we’ve got a fine needle they say is malignant, they’ve got a unilateral lymph node, what do we do with them? We take them to the operating room and we do a direct laryngoscopy. If we find something at the base of the tongue, hypopharynx, we biopsy it and we are done. We wake the patient up and then we need to have a discussion about what are your options, how can you be treated etc. Of course, this all has to be done ahead of time. If you don’t find anything then we proceed with an open neck biopsy and I draw out an incision for a neck dissection and then make that biopsy along the lines of my incision, make a small incision. If it’s epidermoid, if it’s a squamous cell carcinoma, then you are dealing with: you’ve done your direct laryngoscopy, you’ve looked at all the other sites, you’ve got your chest x-ray ahead of time and you’ve ruled those common things, then I go ahead and do a neck dissection on that patient. There’s no point in waking them up, giving them a second anesthetic, talking to them and bringing them back for a neck dissection because that’s what they are going to need. Then they are going to need radiation for an unknown primary. So we prepare our patients and do a neck dissection right at the time of the open biopsy. Get a frozen on it and proceed. If it’s lymphoma, then of course that’s not a surgical disease. You’ve got your tissue for stains and you close and wake the patient up.
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If it’s adenocarcinoma, then we never know what to do and we always hate them because if you’ve gotten your GI workup, your mammogram, all of those things ahead of time, then do you do a neck dissection assuming it’s an unknown primary salivary gland? You know, I usually do some form of modified neck dissection but I certainly wouldn’t fault anybody that just closed because it’s hard to know what to do at that point. Of course, if it’s inflammation granuloma then you press on. If they say it’s a lot of granuloma and infection and don’t see any specific organisms, you have them look for TB and those kinds of things. Sometimes you have to remove all those lymph nodes. Atypical TB, that’s still the treatment of choice in the patient who has had a chest x-ray that’s clear, that’s got only disease in the neck. And we’ll see one, maybe two of these a year and we conservatively remove those nodes. There are some better drugs for them now and they are being used more and more, but I think the more you get the disease out – if you are doing a very conservative modified neck where you are not doing anything too radical – that’s probably reasonable.
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CT and MRI should only be done when it’s going to change the management of that disease. So you really should know before you get the scan, exactly what you are dealing with. This is an oral cavity primary with a lymph node. I don’t need a CT. It’s money that’s wasted. Because I’m not going to do anything any different just based on the CT. If it’s a Larynx cancer then that’s different. I need a CT ahead of time because whether they have cartilage invasion or not is going to partially direct how we treat the patient. But I always say, only if it is going to change how you are going to manage that patient.

Characteristics of malignancy

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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.

Change over days can be inflammatory

Degree of change: change over days can be inflammatory. You can see tumors that grow that actually physically will increase in size extremely rapidly. Frequently it’s a matter of obstruction. Perhaps it’s a central necrosis that’s gotten secondarily infected. But for the most part things that oscillate in size or grow very rapidly are probably not tumors. Enlarging with straining, of course you are going to think of these other entities.
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The next thing, when you’ve outlined the history you may ask the patient, if it looks like an enlarged mass – it doesn’t feel like cancerous, it’s not rock hard. It’s a little bit spongy, it could be lymphoma. You’ve asked them about night sweats, fevers, chills, weight loss, those kinds of things and you’ve asked them, “Have you been exposed to TB? Do you have a cat? Do you clean the litter box?” you know, for toxoplasmosis. We see these things occasionally, but after you’ve kind of gone through those things then it’s time to start looking a little bit more at the mass itself. Number one, where is it located? Anterior border of the sternocleidomastoid could basically be anything. You know, that’s where your branchial clefts occur, that’s where your nodes are, so you could have inflammatory nodes and then that’s also the primary area where we are going to find metastatic disease from the upper digestive tract.

Midline masses are almost always benign. You can get some thyroid cancers that will present to a delphian node, but for the most part these are all benign thyroglossal duct cysts, dermoids, etc. And the age of your patient, smoking history, etc. If it’s a child you are going to be thinking more of the congenital things. Dermoid cysts, etc. Close to the border of the sternocleidomastoid you can get metastatic disease from the nasal pharynx and that’s the classic spot for that, but usually those are inflammatory nodes. Especially in a kid they are invariably inflammatory and even in adults, those are much less likely to be a cancer. You can see lymphomas there but again that’s much less likely. Basically what we are trying to do is get the original Gestalt as to how we are going to follow this patient up. Should I get a CAT scan first? Should I get a fine needle? Should I get a barium swallow? What’s the first thing? Order cialis super active online at canadian pharmacy. Does somebody need to put them to sleep and look? Where do we need to go? Supraclavicular masses – although cystic hygromas in kids – but usually, in about 90% of supraclavicular that are malignant you are looking at a malignancy below the clavicles. The classic is stomach and GI tract, but the most common in a woman is either breast or lung and most common in a man is lung by far. Almost all of them.

We talked about size. Size over 2 cm rarely inflammatory except in some of these stranger diseases that we don’t see very often. Consistency is important to some degree. Cancer nodes, especially squamous cell – which is 95% of head and neck cancers – are usually rock hard. They are fixed to things. They are non-tender of course and patients – virtually every patient that I have will tell me – “Well, I had this mass but I didn’t get too concerned about it because it didn’t hurt.” Well, those are the ones that you get concerned about, the ones that don’t hurt, because those are the ones that are tumors. If they are attached to the skin you need to think about the things that occur in the skin. The inclusion cysts etc. but also tumors can fixate to the skin. Again, that’s a late effect and usually the patient is in trouble. If they are deep to the skin but non-tender, soft, very very soft spongy, discreet, certainly lipomas, fibromas, neurofibromas, those things can all occur there as well.
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Congenital lesions: frequently cystic. They are all non-tender. They can sometimes transilluminate. I haven’t found that to be too useful. If they are pulsatile or if you have a bruit, and again we have to remember to do this occasionally – especially when you get a high jugular node – I will always tell them that when you are feeling it, to have the residents or whoever is examining a patient. To just pause for a second when you are feeling that node. Every once in awhile you’ll find somebody with a carotid – a thin person that has a high node that you are sent in for – the first thing you want to do is, you’ve done your exam and you are ready to do your fine needle, just put your finger on it and pause for a second. Every once in awhile you’ll find it pulsating. It can be a carotid body tumor, can be the carotid bulb itself and you get a surprise when you put a needle in those and that’s something you don’t want to happen. We have that happen a couple of times a year. Glomus tumors will also do that too. Red, tender, warm, of course you are thinking inflammatory.

When you look at all comers with nodes in the neck

When you look at all comers with nodes in the neck, you’ll find that about 90% of nodes in children are going to be benign. Vast, vast majority and that may even be an understatement. Almost always they are benign. Malignancy is the second thought when they don’t respond to antibiotics, when they don’t respond to all these other things that you are doing. But in adults that’s basically reversed. When you take all lymph nodes, and if you eliminate some of the younger adults, it’s probably higher than that. When you are talking about a unilateral node in a smoker, it’s probably in the mid 90%. So very, very high percentage of these are going to be malignant. So I think that you are going to be much less inclined to treat these people with several courses of antibiotics and probably quicker to go to a fine needle aspiration if you can’t find a primary in the mouth or oropharynx.
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Risk factors, of course, the number one risk factor that you have to know when a patient walks through the door with a neck mass, the first question that we ask them other than how long has I been there and these kind of things, is “Are you a cigarette smoker?” because then that increases the likelihood of that being cancer by a very very high percentage. And of course alcohol is synergistic with tobacco. The duration of the mass is also important. If the mass has been there for a couple of days, it may not be quite so significant as a mass that’s been there for a couple of months. Anything over a couple of weeks is probably significant. Something that’s been there for 10 years, 15 years, then of course that takes on a different significance. Then the size also. We talked about the size being relative. A mass greater than 2 cm is unlikely to be inflammatory. Some chronic infections – TB, histoplasmosis, toxoplasmosis – you’ll see bigger nodes in those patients but they are very very rare. For the most part, any node over 2 cm is significant. If it’s a family that you are taking care of and you know that other members have had melanomas, have had cancers, I think that raises your suspicion too. Certainly there are a number of syndromes that you see, and those are very very rare.
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Obviously associated symptoms, weight loss being the biggest one, but hoarseness, dysphasia, hemoptysis, those things guide you how you are going to look at that neck mass and also always ask them about fullness. Do they have fullness of the ear or pain in the ear, especially unilaterally. If it happens to be on the same side as the neck mass then those people are invariably going to have a cancer that you need to find. Visual changes for sinus cancers. Of course if you find those, they are in trouble. Fevers, chills that go along with your lymphomas can be important.
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A good history is going to outline what most of these people have if you just listen to the patients. Of course, you’ve heard that. Location, size, consistency, we’ll go through all these things in just a little more detail. Whether it’s fixed or not. A fixed mass is extremely ominous, with the exception of some infections, that’s going to mean malignancy in almost every patient. Variation in size. Although certain larger tumors, especially those that are necrotic, necrotic lymph nodes can respond to antibiotics, can get smaller, can fluctuate to some extent. For the most part, if they are fluctuating in size then that kind of goes away from malignancy and you may be looking at salivary glands and some of the other things. Then also whether they have associated masses or what color it is. If it blushes, if it looks like it might be fluid-filled close to the surface then of course those are all going to send you off on another tangent. Duration: less than … short period of time. Seven days is inflammatory, seven months is neoplastic, seven years is congenital.

Management of the Neck Mass

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About 5% of all cancer patients will present with neck masses. About 12% of head and neck cancer patients present with neck masses. So it is a fairly common presenting symptom.Unfortunately it just about has your prognosis for almost any site when you see a neck mass, but it is frequently the first symptom that we will see. Especially for head and neck cancers. If at all possible you should avoid an open biopsy of a neck mass. There are a lot of reasons oncologically. It does compromise where we can put our incisions if you have an incision in the neck. It does obstruct the lymphatics and it may indicate a poor prognosis for the patient who has had an open neck biopsy. It usually is not necessary. We almost always can find a primary site or we almost always can do it either with a fine needle aspiration or something like that, prior to an open neck biopsy. So try to do all these other things first, prior to an open neck biopsy.
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Any neck mass in an adult is malignant until proven otherwise. Some of the statistics as we go through them are really kind of shocking, at least they were to me. At what a high percentage of malignancies you will find in your adult patients. At biopsy, the primary site is always best and before we launch on any type of treatment, whether it’s chemotherapy, radiation or surgical approach, we have to have a diagnosis. So that patient is going to have to have a biopsy at some point. Again, the history and physical directs what we do. It really is the way that you go through it. And I won’t insult you by going through how to do a history and physical, but I will just emphasize those points that I think it is so tempting to overlook when you see somebody walk through the door with a 10 cm mass in their neck. You want to get that diagnosis, and we do the same thing too. We find primary sites in the oral cavity all the time in patients who have had open neck biopsies. It’s really best to avoid.
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The jugular nodes along the internal jugular vein, especially the junctional nodes up here are the most important nodes that you are going to find in them, and really from a head/neck oncologists standpoint, those nodes are involved in almost all cancers that we treat up there. Also lots of lymphomas as well. Submandibular nodes and then posterior triangle nodes, supraclavicular nodes and that’s the way I would break them down. Remember, when you get that patient in the chair when you are examining for a neck mass, those nodes lie right underneath the sternocleidomastoid muscle so I always keep my hand on the top of their head and kind of turn their head so that you kind of loosen up that muscle. You can really feel those nodes, in most patients, down to about a centimeter. That’s probably the point at which they become significant. When you start picking up nodes smaller than that we don’t know what to do with them anyway and they are frequently not significant. Don’t forget your bimanual palpation for anyplace that you can do it. When we put the patient to sleep for our direct laryngoscopes, you can get your hand clear down to the vallecula and you can feel, you can bimanually palpate nodes all the way down. It’s really a good technique and an easy way to feel them. Of course, it’s not too easy in the clinic but when you do feel the base of the tongue and those things, make sure it’s the last thing you do for the patient because they won’t let you do much else after you do that. Canadian pharmacy news