Kirklin Clinic Head & Neck Cancer Support Group, Birmingham, AL
distributed by American Cancer Society
Pat Sanders, Editor
Recurrence Or Another Primary?
Recently there was a discussion on the Larynx-C email list about discovering cancer again and a number of us mentioned having cancer twice, sometimes in a totally different area from the first time. Thanks to Dr. David Myssiorek, we now understand a little more of what goes on with cancer cells and how the doctors can know what is going on in our bodies. He gave me permission to use his answer in HeadLines.
Some of what I've been reading here is confusing and confused regarding second primaries. First, some basic definitions. Cancer cells ARE named from the cells that make up the organ that is affected. Hence, thyroid cancer is made up of cells that would be found in the thyroid. There are about 7 different cell types in the thyroid and (you guessed it!) there are about 7 different thyroid cancers with seven different behavior problems.
The timing of the "second primary" can be simultaneous (occurring at the same time as the first cancer), synchronous (within 6 months of the first cancer) or metachronous (at some time in the life of the patient before or after the index cancer).
Since the larynx, pharynx, mouth and sinuses are lined with squamous cells, the most common cancer in these areas is the squamous cell cancer (SCC). Second primaries can refer to any coincident cancer (i.e. a person with a tongue cancer and prostate cancer has two primaries). However, the situation becomes a little unclear when the second primary is another SCC, got it? Since the brain, bones and liver don't contain squamous cells, a SCC cannot arise in these organs. If SCC is found in these organs, it must be a metastasis, not a second primary.
During the workup for laryngeal cancer, we investigate the esophagus, lungs, nasopharynx, oral cavity and oropharynx to rule out second primary cancers. Occasionally we run into a patient with a SCC of the larynx and a lung nodule. Squamous cells are found in the lung so the lung can make a second primary SCC. It shouldn't surprise anyone since the usual source of laryngeal cancer is smoking and the same goes for the lung. If the lung lesion is at the periphery of the lung, it is likely to be a second primary lung cancer. If it occurs 5 years or more after the larynx cancer it is likely to be a second primary. You can have metastasis to the lungs without lymph node involvement so the lymph nodes don't help determine what you've got. Sometimes, the laryngeal cancer and the second primary are both SCC but one is better differentiated than the other - this is a clue that it is a second primary, not a met from the larynx. My guess is that the molecular markers used in labs will be the next technical step in separating second primaries from tumor recurrences.
David Myssiorek, M.D.,
Long Island Jewish Medical Center
Q&A for a medical professional:
Some people notice they have more "gas" and feel bloated on days when they talk a lot. Why does this happen and would you have some hints on what to do?
Answer by Katie Dietrich Burns:
Excessive gas is a problem for many laryngectomees. Although it is more commonly reported by patients with a TEP, it can occur regardless of preferred communication mode. Most laryngectomees who have excessive stomach gas or flatulence have problems in one or more of the following categories: unintentionally injecting air into the esophagus, and anatomic problems of the pharyngoesophageal (PE) segment.
When the larynx is removed, the upper portions of trachea and esophagus are surgically separated. However, both the lower airway and the body of the esophagus are still paired together within the thorax. Therefore, as the lungs expand during inhalation, the pressure within the esophagus becomes more negative, creating a “Vacuum”. This “Vacuum” in conjunction with other controlled movements of the mouth and tongue allow esophageal speakers to inject air into the throat. This trapped air creates vibration of the PE segment during speech as air is ejected. Esophageal speakers may have difficulties with gas as they are learning to control their muscles if more air is taken into the esophagus than is ejected out during speech. Typically over-the-counter medications or home remedies for gas such as drinking carbonated beverages or walking, help relieve discomfort during this period.
In TEP users, negative pressure within the esophagus may inadvertently open the valve. Although it rarely happens, some TEP speakers may draw air into the esophagus every time he or she inhales. Typically this can be observed. This may be resolved by switching from a low resistance prosthesis (e.g. Bivona Ultra Low Resistance) to a higher resistance model. (e.g. duckbills). Valve resistance is determined by diameter of the prosthesis and the configuration of the valve mechanism (flap or V. slit).
The anatomic problems of the PE segment contributing to gas problems include muscle hypertonicity, muscle hypotonicity, and scarring (stricture). Tone problems may be observed during a modified barium swallow if voicing tasks are presented.
If the PE segment (esophageal inlet) is hypotonic (low tone), air may unintentionally move into the esophagus during relaxed inhalation. Signs of hypotonicity include weak and breathy TEP and esophageal voice. Treatment may include external compression bands or surgery.
If the PE segment (pharyngeal constrictors) is hypertonic (high tone), air may be trapped within the esophagus as the constrictor muscles spasm in response to air. Symptoms include spontaneous voice breaks and “tight sound”. If a stricture is present it too may restrict the egress of airflow over the PE segment and out of the mouth. Consequently air is forced into the stomach. Strictures are generally accompanied with difficulties swallowing solids. Typically hypertonic muscle spasms are treated with either a surgical or chemical (Botox) myotomy. Strictures are most frequently treated with dilation.
If you are experiencing persistent difficulties with gas, please discuss it with your medical team. Your surgeon and speech pathologist will work with you to pinpoint the cause of your difficulties and prescribe an individualized treatment.
Katie Dietrich-Burns M.S. CCC-SLP
Speech Language Pathologist; Clinical Specialist- Head & Neck
The Milton J. Dance Jr. Head & Neck Rehab Center
How Are Laryngeal and Hypopharyngeal Cancer Staged?
From the American Cancer Society Website
T Stages Common to Laryngeal and Hypopharyngeal Cancers
TX: Cannot be staged (information not available).
T0: No evidence of tumor.
Tis: Carcinoma in situ. The cancer cells are limited to the epithelium, without invasion into the connective tissue of the larynx or hypopharynx. (Very few hypopharyngeal and larynx cancers are found at this early stage.)
T Stages of Supraglottic Cancer The T stage of cancer of the supraglottis is based on how many subsites (different parts of the larynx) are involved and how far outside the larynx the cancer has spread. The five subsites of the supraglottic part of the larynx are the ventricular bands (also called false vocal cords), arytenoids, suprahyoid epiglottis, infrahyoid epiglottis and aryteno-epiglottic folds.
T1: Tumor is limited to one subsite of the supraglottis and there is normal vocal cord movement.
T2: Tumor invades more than one subsite of the supraglottis and there is normal vocal cord movement.
T3: Tumor is limited to the larynx and there is vocal cord fixation or invasion of the post cricoid area, medial wall of pyriform sinus, or pre-epiglottic (in front of the epiglottis) tissues.
T4: Tumor invades through thyroid cartilage (firm tissue that separates the thyroid gland from the front of the larynx) and/or extends to tissues beyond the larynx
T Stages of Glottic Cancer
T1: Tumor is limited to the vocal cord(s) and there is normal vocal cord mobility.
T1a: Tumor is limited to one vocal cord.
T1b: Tumor is on both vocal cords.
T2: Tumor extends to the supraglottis and/or subglottis and/or there is impaired vocal cord movement
T3: Tumor limited to larynx with vocal cord fixation.
T4: Tumor invades the laryngeal cartilage or extends to tissues beyond the larynx
T Stages of Subglottic Cancer
T1: Tumor is limited to the subglottis.
T2: Tumor extends to the vocal cords with or without impaired vocal cord movement.
T3: Tumor is limited to the larynx with vocal cord fixation.
T4: Tumor invades through the cricoid or thyroid cartilage and/or extends to tissues beyond the larynx.
T Stages of Hypopharyngeal Cancer
Spread of cancer within the hypopharynx is described according to the size of the tumor and how many subsites (areas of the hypopharynx) are involved by cancer. The 3 subsites of the hypopharynx are the pharyngo-esophageal junction, pyriform sinus, and posterior pharyngeal wall.
T1: Tumor is limited to one subsite of hypopharynx
T2: Tumor involves more than one subsite of the hypopharynx or an adjacent site, without vocal cord fixation T3: Tumor involves more than one subsite of the hypopharynx or an adjacent site, with vocal cord fixation
T4: Tumor invades adjacent structures N (Regional Lymph Node) Stages of Laryngeal and Hypopharyngeal Cancer
The N staging is the same for all laryngeal and hypopharyngeal cancers.
The stages are as follows:
NX: Lymph nodes cannot be assessed (information not available).
N1: Cancer has metastasized (spread) to a single lymph node not larger than 3 cm (about 1 1/4 inch). The lymph node is on the same side of the neck of the origin of the laryngeal or hypopharyngeal cancer.
N2: Metastasis to one or more lymph node(s) between 3 cm (about 1 1/4 inch) and 6 cm (about 2 1/2 inches) in diameter.
N2a: Metastasis in one node between 3 cm and 6 cm, on the same side of the neck as the origin of the cancer. N2b: Metastasis in multiple nodes, none larger than 6 cm, and all on the same side of the neck as the origin of the cancer.
N2c: Metastasis to one or more nodes on both sides of neck or on the side opposite the origin of the cancer. None can be larger than 6 cm.
N3: Metastasis to one or more nodes larger than 6 cm.
M (Distant Metastasis) Stages of Laryngeal and Hypopharyngeal Cancer
The M staging for all head and neck cancers, including laryngeal and hypopharyngeal cancers, is the same. The stages are as follows:
MX: Information not available. Unable to tell if distant metastasis is present.
M0: No distant metastasis.
M1: Distant metastasis present.
Stage Grouping. Once the T, N, and M stages have been assigned, this information is combined (stage grouping) to assign an overall stage of 0, I, II, III, or IV. Stage grouping rules are the same for all cancers of the hypopharynx and the supraglottic, glottic, and infraglottic areas of the larynx.
Stage 0 Tis, N0, M0
Stage I T1, N0, M0
Stage II T2, N0, M0
Stage III T1, N1, M0 or T2, N1, M0 or T3, N0, M0 or T3, N1, M0
Stage IV Any cancer with T4 tumor stage, or any cancer with N2 or N3 lymph node metastasis, or any M1 cancer (with distant metastasis)
If you have any questions about the stage of your cancer or how it affects your treatment, do not hesitate to ask your doctor.
A Talk with my Massage Therapist
I saw Shari last week and as she started the massage with my head and neck, I remembered to ask a question that a new lary asked me recently. Why when we touch a place on the outside of the throat, not even putting pressure, do we sometimes feel a tickle, sting, or something like a little hot wire in the inside of the tissue? She answered that it was likely caused by the cut nerves attempting to regenerate themselves. This reminded me that I was told something similar by my doctor after breast cancer surgery. He said to expect little stabbing pains and that it would last several years. It actually lasted longer than that and I could not find anything I did to bring it on. I had these in my throat after my laryngectomy, particularly when I would start to eat, but I thought it was stitches that I was irritating as I swallowed and that still may be what caused part of it but, later, I still have mildly sensitive spots that seem to be referred from a touch on the outside.
Shari has given us another interesting article, this one on reflexology and it will be in HeadLines in a few months. Pat
An Educational Issue
The December 2002 HeadLines issue makes an even 7 years of articles, stories and advice and it is, in total, a little more technical than usual but these are professional answers to some of the questions we have. We will end up covering some of these items in simpler language at other times, but not as thoroughly or as well.
The January 2003 issue will start with a look back at some of the changes and some of the things that never seem to change in our world of the rehabilitation of the laryngectomee.
Remember that you can find past HeadLines issues on these sites:
SUPPORT YOUR LOCAL GROUP
Please attend your local group and share your knowledge with those who may need it. If you are new, go and ask questions. We will learn from each other.
If you have a computer, join WebWhispers http://webwhispers.org/
If you do not have a computer, use the one at the public library, or get a friend or family member to help. If you can’t join, see if you can get to the WebWhispers site and check all of the information online. There are a lot of hints and other information to help you solve your problems.