NON-HODGKIN'S LYMPHOMA

Non-Hodgkin's lymphoma is cancer of the lymphoid tissue, which includes the lymph nodes, spleen, and other organs of the immune system. Causes, incidence, and risk factors White blood cells called lymphocytes are found in lymph tissues. They help prevent infections. Most lymphomas start in a type of white blood cells called B lymphocytes, or B cells. For most patients, the cause of this cancer is unknown. However, lymphomas may develop in people with weakened immune systems. For example, the risk of lymphoma increases after an organ transplant or in people with HIV infection. There are many different types of non-Hodgkin's lymphoma (NHL). It is grouped according to how fast the cancer spreads.

The cancer may be low grade (slow growing), intermediate grade, or high grade (fast growing). Burkitt's lymphoma is an example of a high-grade lymphoma. Follicular lymphoma is a low-grade lymphoma The cancer is further grouped by how the cells look under the microscope, for example, if there are certain proteins or genetic markers present.

According to the American Cancer Society, a person has a 1 in 50 chance of developing nonHodgkin's lymphoma. NHL most often affects adults. However, children can get some forms of lymphoma. You are more likely to get lymphoma if you have a weakened immune system or have had an organ transplant. This type of cancer is slightly more common in men than in women. Symptoms Symptoms depend on what area of the body is affected by the cancer and how fast the cancer is growing. Symptoms may include:

Night sweats (soaking the bedsheets and pajamas even though the room temperature is not too hot) Fever and chills that come and go Itching Swollen lymph nodes in the neck, underarms, groin, or other areas Weight loss

Coughing or shortness of breath may occur if the cancer affects the thymus gland or lymph nodes in the chest, which may put pressure on the windpipe (trachea) or other airways.

Some patients may have abdominal pain or swelling, which may lead to a loss of appetite, constipation, nausea, and vomiting. If the cancer affects cells in the brain, the person may have a headache, concentration problems, personality changes, or seizures. Signs and tests The doctor will perform a physical exam and check body areas with lymph nodes to feel if they are swollen. The disease may be diagnosed after:

Biopsy of suspected tissue, usually a lymph node biopsy Bone marrow biopsy

Other tests that may be done include:

Blood test to check protein levels, liver function, kidney function, and uric acid level Complete blood count (CBC) CT scans of the chest, abdomen and pelvis Gallium scan PET (positron emission tomography) scan

If tests reveal you do have cancer, additional tests will be done to see if it has spread. This is called staging. Staging helps guide future treatment and follow-up and gives you some idea of what to expect in the future. Treatment Treatment depends on:

The type of lymphoma The stage of the cancer when you are first diagnosed Your age and overall health Symptoms, including weight loss, fever, and night sweats

Common treatments:

Radiation therapy may be used for disease that is confined to one body area. Chemotherapy is the main type of treatment. Most often,multiple different drugs are used in combination together. Another drug, called rituximab (Rituxan), is often used to treat B-cell non-Hodgkin's lymphoma.

Radioimmunotherapy may be used in some cases. This involves linking a radioactive substance to an antibody that targets the cancerous cells and injecting the substance into the body. People with lymphoma that returns after treatment or does not respond to treatment may receive high-dose chemotherapy followed by a bone marrow transplant (using stem cells from yourself). Additional treatments depend on other symptoms. They may include:

Transfusion of blood products, such as platelets or red blood cells Antibiotics to fight infection, especially if a fever occurs

During treatment, you and your health care team may need to manage other concerns. See also:

Being at home during chemotherapy

Support Groups The stress of illness may be eased by joining a support group whose members share common experiences and problems. Expectations (prognosis) Low-grade non-Hodgkin's lymphoma usually cannot be cured by chemotherapy alone. However, the low-grade form of this cancer progresses slowly, and it may take many years before the disease gets worse or even requires any treatment. Chemotherapy can often cure many types of high-grade lymphoma. However, if the cancer does not respond to chemotherapy drugs, the disease can cause rapid death. Complications

Autoimmune hemolytic anemia Infection Side effects of chemotherapy drugs

BRAIN CANCER
Also called: Glioma, Meningioma Quick Facts - Brain tumors are the second leading cause of cancer death among children and young adults.1 - Each year in the United States, more than 35,000 people are told they have a tumor that started in the brain.

- In the past thirty years, ONLY four brain cancer treatments have been approved by the FDA. - There are more than 120 different types of brain tumors, making effective treatment extremely complicated. - Brain tumors cannot be prevented because their causes are currently unknown.
1

- Central Brain Tumor Registry of the United States (CBTRUS) www.cbtrus.org

The following information is reproduced with permission from the National Cancer Institute (NCI) booklet entitled, "What You Need to Know About (TM) Brain Tumors. About The Brain The brain is a soft, spongy mass of tissue. It is protected by: - The bones of the skull - Three thin layers of tissue (meninges) - Watery fluid (cerebrospinal fluid) that flows through spaces between the meninges and through spaces (ventricles) within the brain The brain directs the things we choose to do (like walking and talking) and the things our body does without thinking (like breathing). The brain is also in charge of our senses (sight, hearing, touch, taste, and smell), memory, emotions, and personality. A network of nerves carries messages back and forth between the brain and the rest of the body. Some nerves go directly from the brain to the eyes, ears, and other parts of the head. Other nerves run through the spinal cord to connect the brain with the other parts of the body. Within the brain and spinal cord, glial cells surround nerve cells and hold them in place. The three major parts of the brain control different activities: - Cerebrum: The cerebrum uses information from our senses to tell us what is going on around us and tells our body how to respond. It controls reading, thinking, learning, speech, and emotions. The cerebrum is divided into the left and right cerebral hemispheres. The right hemisphere controls the muscles on the left side of the body. The left hemisphere controls the muscles on the right side of the body. - Cerebellum: The cerebellum controls balance for walking and standing, and other complex actions. - Brain stem: The brain stem connects the brain with the spinal cord. It controls breathing, body temperature, blood pressure, and other basic body functions.

Tumor Grades and Types When most normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor. Primary brain tumors can be benign or malignant: Benign brain tumors do not contain cancer cells: - Usually, benign tumors can be removed, and they seldom grow back. - Benign brain tumors usually have an obvious border or edge. Cells from benign tumors rarely invade tissues around them. They don't spread to other parts of the body. However, benign tumors can press on sensitive areas of the brain and cause serious health problems. - Unlike benign tumors in most other parts of the body, benign brain tumors are sometimes life threatening. - Benign brain tumors may become malignant. Malignant brain tumors (also called brain cancer) contain cancer cells: - Malignant brain tumors are generally more serious and often are a threat to life. - They are likely to grow rapidly and crowd or invade the nearby healthy brain tissue. - Cancer cells may break away from malignant brain tumors and spread to other parts of the brain or to the spinal cord. - They rarely spread to other parts of the body. Tumor Grade Doctors group brain tumors by grade. The grade of a tumor refers to the way the cells look under a microscope: - Grade I: The tissue is benign. The cells look nearly like normal brain cells, and they grow slowly. - Grade II: The tissue is malignant. The cells look less like normal cells than do the cells in a Grade I tumor. - Grade III: The malignant tissue has cells that look very different from normal cells. The abnormal cells are actively growing (anaplastic).

- Grade IV: The malignant tissue has cells that look most abnormal and tend to grow quickly. Cells from low-grade tumors (grades I and II) look more normal and generally grow more slowly than cells from high-grade tumors (grades III and IV). Over time, a low-grade tumor may become a highgrade tumor. However, the change to a highgrade tumor happens more often among adults than children. Types of Primary Brain Tumors There are many types of primary brain tumors. Primary brain tumors are named according to the type of cells or the part of the brain in which they begin. For example, most primary brain tumors begin in glial cells. This type of tumor is called a glioma. Among adults, the most common types are: Astrocytoma: The tumor arises from star-shaped glial cells called astrocytes. It can be any grade. In adults, an astrocytoma most often arises in the cerebrum. - Grade I or II astrocytoma: It may be called a low-grade glioma. - Grade III astrocytoma: It's sometimes called a high-grade or an anaplastic astrocytoma. - Grade IV astrocytoma: It may be called a glioblastoma or malignant astrocytic glioma. Meningioma: The tumor arises in the meninges. It can be grade I, II, or III. It's usually benign (grade I) and grows slowly. Oligodendroglioma: The tumor arises from cells that make the fatty substance that covers and protects nerves. It usually occurs in the cerebrum. It's most common in middle-aged adults. It can be grade II or III. Among children, the most common types are: Medulloblastoma: The tumor usually arises in the cerebellum. It's sometimes called a primitive neuroectodermal tumor. It is grade IV. Grade I or II astrocytoma: In children, this lowgrade tumor occurs anywhere in the brain. The most common astrocytoma among children is juvenile pilocytic astrocytoma. It's grade I. Ependymoma: The tumor arises from cells that line the ventricles or the central canal of the spinal cord. It's most commonly found in children and young adults. It can be grade I, II, or III. Brain stem glioma: The tumor occurs in the lowest part of the brain. It can be a low-grade or high-grade tumor. The most common type is diffuse intrinsic pontine glioma.

You can find more information about types of brain tumors at http://www.cancer.gov/cancertopics/types/brain. Or, you can call the NCI Cancer Information Service at 1-800-4-CANCER (1-800-422-6237). Risk Factors When you're told that you have a brain tumor, it's natural to wonder what may have caused your disease. But no one knows the exact causes of brain tumors. Doctors seldom know why one person develops a brain tumor and another doesn't. Researchers are studying whether people with certain risk factors are more likely than others to develop a brain tumor. A risk factor is something that may increase the chance of getting a disease. Studies have found the following risk factors for brain tumors: Ionizing radiation: Ionizing radiation from high dose x-rays (such as radiation therapy from a large machine aimed at the head) and other sources can cause cell damage that leads to a tumor. People exposed to ionizing radiation may have an increased risk of a brain tumor, such as meningioma or glioma. Family history: It is rare for brain tumors to run in a family. Only a very small number of families have several members with brain tumors. Researchers are studying whether using cell phones, having had a head injury, or having been exposed to certain chemicals at work or to magnetic fields are important risk factors. Studies have not shown consistent links between these possible risk factors and brain tumors, but additional research is needed. Symptoms The symptoms of a brain tumor depend on tumor size, type, and location. Symptoms may be caused when a tumor presses on a nerve or harms a part of the brain. Also, they may be caused when a tumor blocks the fluid that flows through and around the brain, or when the brain swells because of the buildup of fluid. These are the most common symptoms of brain tumors: Headaches (usually worse in the morning) Nausea and vomiting Changes in speech, vision, or hearing Problems balancing or walking Changes in mood, personality, or ability to concentrate Problems with memory Muscle jerking or twitching (seizures or convulsions)

Numbness or tingling in the arms or legs Most often, these symptoms are not due to a brain tumor. Another health problem could cause them. If you have any of these symptoms, you should tell your doctor so that problems can be diagnosed and treated. Diagnosis If you have symptoms that suggest a brain tumor, your doctor will give you a physical exam and ask about your personal and family health history. You may have one or more of the following tests: Neurologic exam: Your doctor checks your vision, hearing, alertness, muscle strength, coordination, and reflexes. Your doctor also examines your eyes to look for swelling caused by a tumor pressing on the nerve that connects the eye and the brain. MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of areas inside your head. Sometimes a special dye (contrast material) is injected into a blood vessel in your arm or hand to help show differences in the tissues of the brain. The pictures can show abnormal areas, such as a tumor. CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your head. You may receive contrast material by injection into a blood vessel in your arm or hand. The contrast material makes abnormal areas easier to see. Your doctor may ask for other tests: Angiogram: Dye injected into the bloodstream makes blood vessels in the brain show up on an x-ray. If a tumor is present, the x-ray may show the tumor or blood vessels that are feeding into the tumor. Spinal tap: Your doctor may remove a sample of cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). This procedure is performed with local anesthesia. The doctor uses a long, thin needle to remove fluid from the lower part of the spinal column. A spinal tap takes about 30 minutes. You must lie flat for several hours afterward to keep from getting a headache. A laboratory checks the fluid for cancer cells or other signs of problems. Biopsy: The removal of tissue to look for tumor cells is called a biopsy. A pathologist looks at the cells under a microscope to check for abnormal cells. A biopsy can show cancer, tissue changes that may lead to cancer, and other conditions. A biopsy is the only sure way to diagnose a brain tumor, learn what grade it is, and plan treatment. Surgeons can obtain tissue to look for tumor cells in two ways: However, if the tumor is in the brain stem or certain other areas, the surgeon may not be able to remove tissue from the tumor without harming normal brain tissue. In this case, the doctor uses MRI, CT, or other imaging tests to learn as much as possible about the brain tumor.

Biopsy at the same time as treatment: The surgeon takes a tissue sample when you have surgery to remove part or all of the tumor. Stereotactic biopsy: You may get local or general anesthesia and wear a rigid head frame for this procedure. The surgeon makes a small incision in the scalp and drills a small hole (a burr hole) into the skull. CT or MRI is used to guide the needle through the burr hole to the location of the tumor. The surgeon withdraws a sample of tissue with the needle. A needle biopsy may be used when a tumor is deep inside the brain or in a part of the brain that can't be operated on. A person who needs a biopsy may want to ask the doctor the following questions: - Why do I need a biopsy? How will the biopsy results affect my treatment plan? - What kind of biopsy will I have? - How long will it take? Will I be awake? Will it hurt? - What are the chances of infection or bleeding after the biopsy? Are there any other risks? - How soon will I know the results? - If I do have a brain tumor, who will talk with me about treatment? When? Treatments People with brain tumors have several treatment options. The options are surgery, radiation therapy, and chemotherapy. Many people get a combination of treatments. The choice of treatment depends mainly on the following: - The type and grade of brain tumor - Its location in the brain - Its size - Your age and general health For some types of brain cancer, the doctor also needs to know whether cancer cells were found in the cerebrospinal fluid. Your doctor can describe your treatment choices, the expected results, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your medical and personal needs.

You may want to talk with your doctor about taking part in a clinical trial, a research study of new treatment methods. Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat brain tumors include neurologists, neurosurgeons, neuro-oncologists, medical oncologists, radiation oncologists, and neuroradiologists. Your health care team may also include an oncology nurse, a registered dietitian, a mental health counselor, a social worker, a physical therapist, an occupational therapist, a speech therapist, and a physical medicine specialist. You may want to ask your doctor these questions before you begin treatment: - What type of brain tumor do I have? - Is it benign or malignant? - What is the grade of the tumor? - What are my treatment choices? Which do you recommend for me? Why? - What are the expected benefits of each kind of treatment? - What can I do to prepare for treatment? - Will I need to stay in the hospital? If so, for how long? - What are the risks and possible side effects of each treatment? How can side effects be managed? - What is the treatment likely to cost? Will my insurance cover it? - How will treatment affect my normal activities? What is the chance that I will have to learn how to walk, speak, read, or write after treatment? - Would a research study (clinical trial) be appropriate for me? - Can you recommend other doctors who could give me a second opinion about my treatment options? - How often should I have checkups? Surgery Surgery is the usual first treatment for most brain tumors. Before surgery begins, you may be given general anesthesia, and your scalp is shaved. You probably won't need your entire head shaved. Surgery to open the skull is called a craniotomy. The surgeon makes an incision in your scalp and uses a special type of saw to remove a piece of bone from the skull. You may be awake

when the surgeon removes part or all of the brain tumor. The surgeon removes as much tumor as possible. You may be asked to move a leg, count, say the alphabet, or tell a story. Your ability to follow these commands helps the surgeon protect important parts of the brain. After the tumor is removed, the surgeon covers the opening in the skull with the piece of bone or with a piece of metal or fabric. The surgeon then closes the incision in the scalp. Sometimes surgery isn't possible. If the tumor is in the brain stem or certain other areas, the surgeon may not be able to remove the tumor without harming normal brain tissue. People who can't have surgery may receive radiation therapy or other treatment. You may have a headache or be uncomfortable for the first few days after surgery. However, medicine can usually control pain. Before surgery, you should discuss the plan for pain relief with your health care team. After surgery, your team can adjust the plan if you need more relief. You may also feel tired or weak. The time it takes to heal after surgery is different for everyone. You will probably spend a few days in the hospital. Other, less common problems may occur after surgery for a brain tumor. The brain may swell or fluid may build up within the skull. The health care team will monitor you for signs of swelling or fluid buildup. You may receive steroids to help relieve swelling. A second surgery may be needed to drain the fluid. The surgeon may place a long, thin tube (shunt) in a ventricle of the brain. (For some people, the shunt is placed before performing surgery on the brain tumor.) The tube is threaded under the skin to another part of the body, usually the abdomen. Excess fluid is carried from the brain and drained into the abdomen. Sometimes the fluid is drained into the heart instead. Infection is another problem that may develop after surgery. If this happens, the health care team will give you an antibiotic. Brain surgery may harm normal tissue. Brain damage can be a serious problem. It can cause problems with thinking, seeing, or speaking. It can also cause personality changes or seizures. Most of these problems lessen or disappear with time. But sometimes damage to the brain is permanent. You may need physical therapy, speech therapy, or occupational therapy. You may want to ask your doctor these questions about surgery: - Do you suggest surgery for me? - How will I feel after the operation? - What will you do for me if I have pain? - How long will I be in the hospital? - Will I have any long-term effects? Will my hair grow back? Are there any side effects from using metal or fabric to replace the bone in the skull?

- When can I get back to my normal activities? - What is my chance of a full recovery? Radiation Therapy Radiation therapy kills brain tumor cells with high-energy x-rays, gamma rays, or protons. Radiation therapy usually follows surgery. The radiation kills tumor cells that may remain in the area. Sometimes, people who can't have surgery have radiation therapy instead. Doctors use external and internal types of radiation therapy to treat brain tumors: External radiation therapy: You'll go to a hospital or clinic for treatment. A large machine outside the body aims beams of radiation at the head. Because cancer cells may invade normal tissue around a tumor, the radiation may be aimed at the tumor and nearby brain tissue, or at the entire brain. Some people need radiation aimed at the spinal cord also. The treatment schedule depends on your age, and the type and size of the tumor. Fractionated external beam therapy is the most common method of radiation therapy used for people with brain tumors. Giving the total dose of radiation over several weeks helps to protect healthy tissue in the area of the tumor. Treatments are usually 5 days a week for several weeks. A typical visit lasts less than an hour, and each treatment takes only a few minutes. Some treatment centers are studying other ways of delivering external beam radiation therapy: Intensity-modulated radiation therapy or 3-dimensional conformal radiation therapy: These types of treatment use computers to more closely target the brain tumor to lessen the damage to healthy tissue. Proton beam radiation therapy: The source of radiation is protons rather than x-rays. The doctor aims the proton beam at the tumor. The dose of radiation to normal tissue from a proton beam is less than the dose from an x-ray beam. Stereotactic radiation therapy: Narrow beams of x-rays or gamma rays are directed at the tumor from different angles. For this procedure, you wear a rigid head frame. The therapy may be given during a single visit (stereotactic radiosurgery) or over several visits. Internal radiation therapy (implant radiation therapy or brachytherapy): Internal radiation isn't commonly used for treating brain tumors and is under study. The radiation comes from radioactive material usually contained in very small implants called seeds. The seeds are placed inside the brain and give off radiation for months. They don't need to be removed once the radiation is gone. Some people have no or few side effects after treatment. Rarely, people may have nausea for several hours after external radiation therapy. The health care team can suggest ways to help you cope with this problem. Radiation therapy also may cause you to become very tired with each

radiation treatment. Resting is important, but doctors usually advise people to try to stay as active as they can. Also, external radiation therapy commonly causes hair loss from the part of the head that was treated. Hair usually grows back within a few months. Radiation therapy also may make the skin on the scalp and ears red, dry, and tender. The health care team can suggest ways to relieve these problems. Sometimes radiation therapy causes brain tissue to swell. You may get a headache or feel pressure. The health care team watches for signs of this problem. They can provide medicine to reduce the discomfort. Radiation sometimes kills healthy brain tissue. Although rare, this side effect can cause headaches, seizures, or even death. Radiation may harm the pituitary gland and other areas of the brain. For children, this damage could cause learning problems or slow down growth and development. In addition, radiation increases the risk of secondary tumors later in life. You may want to ask your doctor these questions about radiation therapy: - Why do I need this treatment? - When will the treatments begin? When will they end? - How will I feel during therapy? Are there side effects? - What can I do to take care of myself during therapy? - How will we know if the radiation is working? - Will I be able to continue my normal activities during treatment? Chemotherapy Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat brain tumors. Drugs may be given in the following ways: By mouth or vein (intravenous): Chemotherapy may be given during and after radiation therapy. The drugs enter the bloodstream and travel throughout the body. They may be given in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, you may need to stay in the hospital. The side effects of chemotherapy depend mainly on which drugs are given and how much. Common side effects include nausea and vomiting, loss of appetite, headache, fever and chills, and weakness. If the drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. Some side effects may be relieved with medicine. In wafers that are put into the brain: For some adults with high-grade glioma, the surgeon implants several wafers into the brain. Each wafer is about the size of a dime. Over several

weeks, the wafers dissolve, releasing the drug into the brain. The drug kills cancer cells. It may help prevent the tumor from returning in the brain after surgery to remove the tumor. People who receive an implant (a wafer) that contains a drug are monitored by the health care team for signs of infection after surgery. An infection can be treated with an antibiotic. You may want to ask your doctor these questions about chemotherapy: - Why do I need this treatment? - What will it do? - Will I have side effects? What can I do about them? - When will treatment start? When will it end? - How will treatment affect my normal activities?

BLADDER CANCER
Bladder cancer is a cancer that starts in the bladder. The bladder is the body part that holds and releases urine. It is in the center of the lower belly area. Bladder cancer is a type of cancer that begins in your bladder a balloon-shaped organ in your pelvic area that stores urine. Bladder cancer begins most often in the cells that line the inside of the bladder. Bladder cancer typically affects older adults, though it can occur at any age. The great majority of bladder cancers are diagnosed at an early stage when bladder cancer is highly treatable. However, even early-stage bladder cancer is likely to recur. For this reason, bladder cancer survivors often undergo follow-up tests to look for bladder cancer recurrence for years after treatment Causes, incidence, and risk factors In the United States, bladder cancers usually start from the cells lining the bladder (called transitional cells). These tumors are classified based on the way they grow:

Papillary tumors have a wart-like appearance and are attached to a stalk. Nonpapillary (sessile) tumors are flat. They are much less common. However, they are more invasive and have a worse outcome.

The exact cause of bladder cancer is uncertain. However, several things may make you more likely to develop it:

Cigarette smoking. Smoking greatly increases the risk of developing bladder cancer. Up to half of all bladder cancers in men and several in women may be caused by cigarette smoke. Chemical exposure at work. About one in four cases of bladder cancer is caused by coming into contact with to cancer-causing chemicals at work. These chemicals are called carcinogens. Dye workers, rubber workers, aluminum workers, leather workers, truck drivers, and pesticide applicators are at the highest risk. Chemotherapy: The chemotherapy drug cyclophosphamide (Cytoxan) may increase the risk of bladder cancer. Your doctor may prescribe a medicine to reduce this risk. Radiation treatment: Women who had radiation therapy to treat cervical cancer have an increased risk of developing bladder cancer. Bladder infection: A long-term (chronic) bladder infection or irritation may lead to a certain type of bladder cancer.

Some research has suggested a link between artificial sweeteners and bladder cancer. The evidence is weak. Symptoms Symptoms of bladder cancer can include:

Abdominal pain Blood in the urine Bone pain or tenderness if the cancer spreads to the bone Fatigue Painful urination Urinary frequency Urinary urgency Urine leakage (incontinence) Weight loss

Note: Other diseases and conditions can cause similar symptoms. It is important to see a doctor to rule out all other possible causes. Signs and tests The health care provider will perform a physical examination, including a rectal and pelvic exam. Tests that may be done include:

Abdominal CT scan Abdominal MRI scan Bladder biopsy (usually performed during cystoscopy) Cystoscopy (examining the inside of the bladder with a camera) Intravenous pyelogram - IVP

Pelvic CT scan Urinalysis Urine cytology

If tests confirm you have bladder cancer, additional tests will be done to see if the cancer has spread. This is called staging. Staging helps guide future treatment and follow-up and gives you some idea of what to expect in the future. The TNM (tumor, nodes, metastatis) staging system is used to stage bladder cancer:

Ta: The cancer is in the lining of the bladder only and has not spread T1: The cancer goes through the bladder lining, but does not reach the bladder muscle T2: The cancer spreads to the bladder muscle T3: The cancer spreads past the bladder into the fatty tissue surrounding it T4: The cancer has spread to nearby structures such as the prostate gland, uterus, vagina, rectum, abdominal wall, or pelvic wall

Tumors are also grouped based on how they appear under a microscope. This is called grading the tumor. A high-grade tumor is fast growing and more likely to spread. Bladder cancer can spread into nearby areas, including the:

Lymph nodes in the pelvis Bones Liver Lungs

Treatment Treatment depends on the stage of the cancer, the severity of your symptoms, and your overall health. Stage 0 and I treatments:

Surgery to remove the tumor without removing the rest of the bladder Chemotherapy or immunotherapy placed directly into the bladder

Stage II and III treatments:

Surgery to remove the entire bladder (radical cystectomy) and nearby lymph nodes Surgery to remove only part of the bladder, followed by radiation and chemotherapy Chemotherapy to shrink the tumor before surgery A combination of chemotherapy and radiation (in patients who choose not to have surgery or who cannot have surgery)

Most patients with stage IV tumors cannot be cured and surgery is not appropriate. In these patients, chemotherapy is often considered.

CHEMOTHERAPY Chemotherapy may be given to patients with stage II and III disease either before or after surgery to help prevent the tumor from returning. For early disease (stages 0 and I), chemotherapy is usually given directly into the bladder. A Foley catheter can be used to deliver the medication into the bladder. Common side effects include bladder wall irritation and pain when urinating. For more advanced stages (II-IV), chemotherapy is usually given by vein (intravenously). IMMUNOTHERAPY Bladder cancers are often treated with immunotherapy. In this treatment, a medication triggers your immune system to attack and kill the cancer cells. Immunotherapy for bladder cancer is usually performed using the Bacille Calmette-Guerin vaccine (commonly known as BCG). A medicine called Interferon is sometimes used. It is given through a Foley catheter directly into the bladder. If BCG does not work, patients may receive interferon. As with all treatments, side effects are possible. Ask your doctor what side effects you might expect, and what to do if they occur. SURGERY Surgery for bladder cancer includes:

Transurethral resection of the bladder (TURB): Cancerous bladder tissue is removed through the urethra. Partial or complete removal of the bladder: Many people with stage II or III bladder cancer may need to have their bladder removed (radical cystectomy). Sometimes only part of the bladder is removed. Radiation and chemotherapy is usually given after this surgery.

Surgery may also be done to help your body drain urine after the bladder is removed. This may include:

Ileal conduit: A small urine reservoir is surgically created from a short piece of your small intestine. The ureters that drain urine from the kidneys are attached to one end of this piece. The other end is brought out through an opening in the skin (a stoma). The stoma allows the patient to drain the collected urine out of the reservoir. Continent urinary reservoir: A pouch to collect urine is created inside your body using a piece of your intestine. You will need to insert a tube into an opening in your skin (stoma) into this pouch to drain the urine. Orthotopic neobladder: This surgery is becoming more common in patients who had their bladder removed. A part of your bowel is folded over to make a pouch that collects urine.

It is attached to the place in the body where the urine normally empties from the bladder. This procedure allows you to maintain some normal urinary control. Expectations (prognosis) After treatment for bladder cancer, you will be closely monitored by a doctor. This may include:

Bone scans and CT scans to check for the spread or return of cancer Monitoring symptoms that might suggest the disease is getting worse, such as fatigue, weight loss, increased pain, decreased bowel and bladder function, and weakness Complete blood count (CBC) to monitor for anemia Bladder exams every 3 to 6 months after treatment Urinalysis if you did not have your bladder removed

How well a patient with bladder cancer does depends on the initial stage and response to treatment of the bladder cancer. The outlook for stage 0 or I cancers is fairly good. Although the risk of the cancer returning is high, most bladder cancers that return can be surgically removed and cured. The cure rates for people with stage III tumors are less than 50%. Patients with stage IV bladder cancer are rarely cured. Complications Bladder cancers may spread into the nearby organs. They may also travel through the pelvic lymph nodes and spread to the liver, lungs, and bones. Additional complications of bladder cancer include:

Anemia Swelling of the ureters (hydronephrosis) Urethral stricture Urinary incontinence

Calling your health care provider Call your health care provider if you have blood in your urine or other symptoms of bladder cancer, including:

Frequent urination Painful urination Urgent need to urinate

Prevention

If you smoke, quit. Smoking can increase your risk of bladder cancer. Avoid exposure to chemicals linked to bladder cancer.

OVARIAN CANCER
Cancer occurs when cells undergo a transformation and begin to grow and multiply without normal controls. As the cells grow and multiply, they form masses called tumors. Cancer is dangerous because it overwhelms healthy cells by taking their space and the oxygen and nutrients they need to survive and function. Ovarian cancer occurs when a tumor forms in one or both of a woman's ovaries. The ovaries are a pair of small organs that produce and release ova, or human eggs. The ovaries also produce important hormones such as estrogen and progesterone. They are located in the lower abdomen (pelvis), on either side of the womb (uterus). Ova released by the ovaries travel through the fallopian tubes to the uterus, where they may or may not be fertilized by the male sperm. Cancerous tumors are malignant. This means they spread to other tissues and organs. Not all tumors, however, are malignant. In a process called metastasis, malignant tumors may encroach on and invade neighboring organs or lymph nodes, or they may enter the bloodstream and spread to remote organs such as the liver or lungs. Metastatic tumors are the most aggressive and serious of all tumors. The type of cell that originated the abnormal growth determines the class of the ovarian tumors.

Epithelial tumors: These tumors arise from a layer of cells that surrounds the outside of the ovary called the germinal epithelium. About 70-80% of all ovarian cancers are epithelial. These are most common in women who have been through menopause (aged 45-70 years). Stromal tumors: Stromal tumors develop from connective-tissue cells that help form the structure of the ovary and produce hormones. Usually, only one ovary is involved. These account for 5-10% of ovarian cancers. These tumors typically occur in women aged 4060 years. Often, surgical removal of the tumor is the only treatment needed. If the tumor has spread, though, the woman needs chemotherapy. Germ cell tumors: Tumors that arise from germ cells (cells that produce the egg) account for about 15% of all ovarian cancers. These tumors develop most often in young women (including teenaged girls). Although 90% of women with this type of cancer are successfully treated, many become permanently infertile. Metastatic tumors: Only 5% of ovarian cancers have spread from other sites. The most common sites from which they spread are the colon (52%), breast (17%), stomach (10%), and pancreas (5%).

Within these main classes are many different subtypes of tumors.

Noncancerous (benign) ovarian masses include abscesses or infections, fibroids, cysts, polycystic ovaries, endometriosis-related masses, ectopic pregnancies, and others.

Of markedly enlarged ovarian masses (>4 cm) found in women who are still menstruating (have not been through menopause), about 20% are cancerous. Of markedly enlarged masses found in women who have been through menopause, about 45-50% are cancerous.

The incidence of ovarian cancer varies greatly. Globally, Scandinavia, Israel, and North America have the highest rates. Developing countries and Japan have the lowest rates.

At least 15,000 women die each year from ovarian cancer. The 5-year survival rate is greater than 75% if diagnosis of the cancer occurs before it has spread to other organs. However, the 5-year survival rate drops to 20% when the tumor has spread to the upper abdomen. In the United States, about 1 in 56 women develops cancer of the ovary. More than 26,000 new cases are diagnosed each year.

Ovarian Cancer Causes In 95% of ovarian cancer cases, no identifiable cause is present; however, family history does play a role.

The lifetime risk for US women of developing ovarian cancer is 1.4%. If one first-degree relative -a mother, sister, or daughter -has the disease, the risk increases to 3-5%. The risk can climb to 50% if 2 first-degree relatives have the disease. If a woman has ovarian cancer and her daughter develops ovarian cancer, the daughter will probably develop the cancer at a relatively young age (younger than 60 years).

Ovarian cancer has been linked with 3 hereditary syndromes.

Breast-ovarian cancer syndrome Hereditary nonpolyposis colorectal cancer syndrome Site-specific ovarian cancer syndrome

Breast-ovarian cancer syndrome: A mutation in a gene called BRCA1 has been linked to increased risk of both breast and ovarian cancer.

About 30-40% of women who have this mutation develop ovarian cancer. Another mutation, involving the BRCA2 gene, also increases the risk of ovarian cancer but to a lesser degree. These mutations are hereditary. Clues that may indicate the presence of these mutations include family members who have ovarian cancer or breast cancer (especially those who are diagnosed with these cancers whenyounger than 50 years), a relative with both breast and ovarian cancer, or a male relative with breast cancer. Development of more precise estimates of cancer risk and better genetic testing for carriers of these genes is taking place.

Hereditary non polyposis colorectal cancer (HNPCC) syndrome (Lynch syndrome II): This genetic syndrome has been dubbed "family cancer syndrome" and is associated with colon cancer developing in people younger than 50 years.

Other organs that can be involved include the uterus, ovary, breast, stomach, and pancreas. A mutated gene causes this syndrome. Women with this syndrome have a 10% chance of developing ovarian cancer.

Site-specific ovarian cancer syndrome: This is the least common of the 3 syndromes and experts don't know much about it, yet. This syndrome may be due to mutations of the BRCA1 gene. Other factors that increase ovarian cancer risk include the following:

Age greater than 50 years No pregnancies Use of fertility drugs: Some studies have shown that the use of fertility drugs increases the risk of ovarian cancer, but study results have not been consistent. Ashkenazi Jewish heritage European (white) heritage: White women are much more likely to have ovarian cancer than African American women.

Asbestos exposure Repeated exposure of the genitals to talc Irradiation of the pelvic area Some viruses, especially the virus that causes mumps

Some findings suggest that estrogen may promote ovarian cancer in women who have been through menopause. For years, the cancer risks involved with using hormone replacement therapy divided the medical community. Research findings in 2002 and early 2003 showed that hormone replacement therapy does not provide many of the benefits it was believed to have, and it increases the risk of heart disease. Experts no longer recommend long-term hormone replacement therapy for most women. Some factors decrease ovarian cancer risk.

Any factor that inhibits ovulation (release of an egg from the ovary) seems to protect against development of ovarian cancer. This may be because ovulation disrupts the epithelial layer of the ovary. As cells divide to repair the damage, uncontrolled division and malignant changes may occur. Term pregnancy (lasting the full 9 months) significantly reduces the risk of ovarian cancer. As the number of pregnancies increases, the risk of ovarian cancer decreases. Use of oral contraceptives (birth control pills) reduces the risk of ovarian cancer. Breastfeeding lowers risk of ovarian cancer, and the risk decreases with increasing duration of breastfeeding. Removal of the ovaries before cancer appears reduces the risk to zero. This may be a consideration in women with inherited cancer risks. Experts should base this decisionon genetic testing and counseling. Having the woman's "tubes tied" (tubal ligation) to prevent pregnancy. Having a hysterectomy lowers the risk of ovarian cancer.

Ovarian Cancer Symptoms Ovarian cancer is difficult to diagnose because symptoms often do not occur until late in the disease. Symptoms do not occur until the tumor has grown large enough to apply pressure to other organs in the abdomen, or until the cancer has spread to remote organs. The symptoms are nonspecific, meaning they could be due to many different conditions. Cancer is not usually the first thing considered in a woman having symptoms.

The only early symptom of the disease is menstrual irregularity. Symptoms that come later include the following:

Pelvic pain or pressure Pain with intercourse Abdominal swelling and bloating Urinary frequency Constipation Ascites - Collection of fluid in the abdomen, contributing to abdominal distension and shortness of breath Loss of appetite Feeling full after eating little Gas and/or diarrhea Nausea and vomiting Abnormalities in menstruation, pubertal development, and abnormal hair growth (with tumors that secrete hormones)

Exams and Tests Many exams and tests are used to determine if a woman has ovarian cancer. Physical exam: Every woman should have an annual pelvic exam in which the health care provider feels (palpates) the ovaries and obtains a Pap smear (Papanicolaou test).

Although the Pap smear is designed to check for cervical cancer, there have been some rare cases in which abnormal ovarian cells were identified with this test. Ovaries are normally small, especially in women who have been through menopause, and are deep within the pelvis. Normal-sized ovaries are difficult to feel. Because of this, the pelvic exam is not very effective in detecting early ovarian cancer. Masses large enough to be felt may represent advanced disease. More often, they are harmless growths or other noncancerous conditions.

Imaging Ultrasound: If a mass is present, the health care provider may recommend an ultrasound examination to find out what kind of mass it is.

Ultrasound imaging can detect small masses and can distinguish whether a mass is solid or fluid filled (cystic). A solid mass or complex mass (having both cystic and solid components) may be cancerous. Incorporating Doppler technology to identify certain patterns associated with tumors seems to improve the usefulness of ultrasound screenings. If the ultrasound shows a solid or complex mass, the next step is to obtain a sample of the mass to see whether it is a cancerous tumor.

Many studies have reviewed the value of ultrasound screenings for ovarian cancer of women who have no symptoms. Although ultrasound identified many masses, very few of these masses (about 1 in 1000) were cancerous. Furthermore, many women underwent unnecessary surgeries only to discover benign masses. CT (computed tomography) scanning: If ultrasound reveals a solid or complex mass, a CT scan of the pelvis may be done.

A CT scan is a type of x-ray that shows much greater detail in 3 dimensions. A CT scan provides more information about the size and extent of the tumor. It can also show whether the tumor has spread to other organs in the pelvis.

Lab tests The health care provider also conducts lab tests to gather information about the woman's medical condition and to detect substances released into the blood by ovarian cancers (tumor markers). The health care provider may request a pregnancy test if there is any chance the woman could be pregnant. Pregnancy can be detected by checking the blood level of beta-HCG, a hormone that increases dramatically during pregnancy.

Ovarian masses during pregnancy may be associated with ectopic pregnancies (pregnancy outside the womb) or may be normal structures that produce other hormones important in gestation.

The woman's blood will probably also be checked for tumor markers. Health care providers suspicious that ovarian cancer is present usually conduct the CA-125 test.

The level of the most widely studied tumor marker, CA-125, is elevated in more than 80% of women with advanced ovarian cancer and in about 50% of women with early ovarian cancer.

The level of this marker value can be affected by a number of factors, including age, menstrual status, and conditions such as endometriosis, pregnancy, liver disease, and congestive heart failure. Cancers of the breast, pancreas, colon, and lung also secrete the CA-125 marker. Because this marker can be influenced by so many factors that have nothing to do with ovarian cancer, this marker is not generally used for routine screening of women who have no symptoms.

Health care providers do not recommend genetic screening for women with no first-degree relative, or only one relative, with ovarian cancer.

Women with 2 or more relatives with breast or ovarian cancer should be referred to a specialist to discuss genetic testing. Members of families with hereditary nonpolyposis colon cancer (HNPCC or Lynch syndrome II) should also be referred to a specialist.

Biopsy and staging Ovarian cancer is diagnosed by taking a sample of the tumor (biopsy). The tumor material is examined by a pathologist, a physician who specializes in diagnosing diseases by looking at the cells under a microscope. There are several ways to collect a biopsy of an ovarian mass.

Laparoscopy is the usual first step in confirming the presence of a mass and obtaining a tissue sample for biopsy. Laparoscopic surgery uses small incisions and specially designed instruments to enter the abdomen or pelvis. (This type of operation is widely used to remove the gallbladder.) If the mass is small, it may be possible to remove the entire mass during laparoscopy. Usually, the surgeon removes the entire ovary. If the mass is larger that 2.75 inches (complex mass) or 3.5 inches (solid mass) on ultrasound, removal will probably be through conventional surgery. This procedure, called exploratory laparotomy, involves making a larger incision in the skin and abdominal muscles to gain access to the pelvic region.

If the biopsy finding is positive for cancer, further staging procedures will be performed.

Staging is a system of classifying tumors by size, location, and extent of spread, local and remote. Staging is an important part of treatment planning, because tumors respond best to different treatments at different stages. Staging is also a good indicator of prognosis.

Staging usually requires imaging studies, lab tests, and exploratory laparotomy.

Exploratory laparotomy is a careful and thorough attempt to find the exact extent of cancer spread.

During the surgery, removal of the ovarian mass usually includes the entire affected ovary. To identify possible invasion by the cancer, samples are taken of other structures in the pelvis and abdomen including the diaphragm (the muscle that separates the organs of the chest from the organs of the abdomen), the peritoneum (the membrane that lines the abdomen), the omentum (a fatty membrane that covers the organs of the abdomen), lymph nodes, bladder, and bowel. The goal is to remove as much cancerous tissue as possible (debulking). This may involve removing one or both ovaries (oophorectomy), the uterus (hysterectomy), fallopian tubes (salpingectomy), and other organs. Typically, the surgeon does not know ahead of time exactly which organs and structures will require removal. If a woman plans to undergo exploratory laparoscopy or laparotomy, she should discuss the possible full extent of the operation with her surgeon before consenting to the procedure. Gynecologic oncologists are specialist trained to operate on ovarian cancer. If a high suspicion of a gynecologic cancer exists, a gynecologic oncology consult may provide input into the surgery.

Ovarian cancers are classified in stages I through IV. Stages I, II, and III are further described by the letters A, B, or C depending on the location of the tumor, the presence of metastasis, and other factors. Stage IV cancer is not subdivided.

Stage I: The cancer is confined to one (IA) or both (IB) ovaries. The tumor may be on the surface of the ovaries, or ascites may be present (IC). Stage II: Cancer is found outside the ovary (pelvic extension) and has spread to the uterus or fallopian tubes (IIA) or other areas in the pelvis (IIB). The tumor may involve the capsule of the ovary, or fluid in the abdomen may contain malignant cells (IIC). Stage III: Cancer has spread to pelvic organs and possibly to lymph nodes. Microscopic "seeds" of cancer are on abdominal peritoneal surfaces (IIIA), or small implants of tumor on abdominal peritoneal surfaces (IIIB). Abdominal implants may be larger or lymph nodes may be involved (IIIC). Stage IV: Cancer has spread to the abdominal organs (liver, spleen), or malignant cells are in the fluid surrounding the lungs.

Ovarian Cancer Treatment Treatment of ovarian cancer should be under the direction of an experienced gynecologic oncologist (a specialist in women's cancers). Surgery is the usual first treatment for ovarian cancer. Whenever possible, the surgery takes place at the time of exploratory laparotomy. The operation is paused while the pathologist rapidly reviews the biopsy tissues. The pathologist's report determines the structures affected by cancer and if they should be removed. This spares the woman from undergoing another surgery.

For stage I tumors, only the involved ovary and fallopian tube may be removed for women who wish to become pregnant in the future. For women who do not wish to become pregnant, both ovaries, both fallopian tubes, and the uterus are removed. This is a hysterectomy with bilateral (2-sided) salpingo-oophorectomy. Usually this procedure removes the lymph nodes surrounding these organs and the omentum. If the tumor cell type is especially worrisome (grade 3 tumors and all stage IC tumors), chemotherapy is usually given as well. Stage II cancer treatment involves removal of the uterus, ovaries, and fallopian tubes, resection (partial removal)of any tumor in the pelvic area, and resection of any other structures affected with cancer. Chemotherapy is strongly recommended. The best treatment at this time involves a platinum-based agent (carboplatin) and paclitaxel (Taxol). These agents are administered in 6 cycles of 3 weeks each. Stage III treatment is identical to stage II treatment, except more aggressive chemotherapy and possibly experimental treatments are given. Some women may be candidates for direct abdominal treatment.This type of treatment is referred to as peritoneal therapy. This type of therapy is more difficult to take but may improve survival. Stage IV treatment involves extensive debulking and multi-agent chemotherapy.

After chemotherapy is completed, the woman may undergo "second-look surgery." Her surgeon will examine her remaining pelvic and abdominal structures for evidence of residual cancer. Samples of fluid and tissues may be taken to check for residual cancer cells.

LIP/ORAL CANCER
is a subtype of head and neck cancer, is any cancerous tissue growth located in the oral cavity.[1] It may arise as a primary lesion originating in any of the oral tissues, by metastasis from a distant site of origin, or by extension from a neighboring anatomic structure, such as the nasal cavity or the Oral cancers may originate in any of the tissues of the mouth, and may be of varied histologic types: teratoma, adenocarcinoma derived from a major or minor salivary gland, lymphoma from tonsillar or other lymphoid tissue, or melanoma from the pigment-producing cells of the oral mucosa. There are several types of oral cancers, but around 90% are squamous cell

carcinomas,[2] originating in the tissues that line the mouth and lips. Oral or mouth cancer most commonly involves the tongue. It may also occur on the floor of the mouth, cheek lining, gingiva (gums), lips, or palate (roof of the mouth). Most oral cancers look very similar under the microscope and are called squamous cell carcinoma. Signs and symptoms Skin lesion, lump, or ulcer that do not resolve in 14 days located:

On the tongue, lip, or other mouth areas Usually small Most often pale colored, be dark or discolored Early sign may be a white patch (leukoplakia) or a red patch (erythroplakia) on the soft tissues of the mouth Usually painless initially May develop a burning sensation or pain when the tumor is advanced Behind the wisdom tooth Even behind the ear

Additional symptoms that may be associated with this disease:

Tongue problems Swallowing difficulty Mouth sores Pain and paraesthesia are late symptoms.

Lip and oral cavity cancer is a disease in which malignant (cancer) cells form in the lips or mouth. The oral cavity includes the following:

The front two thirds of the tongue. The gingiva (gums). The buccal mucosa (the lining of the inside of the cheeks). The floor (bottom) of the mouth under the tongue. The hard palate (the roof of the mouth). The retromolar trigone (the small area behind the wisdom teeth).

Anatomy of the oral cavity. The oral cavity includes the lips, hard palate (the bony front portion of the roof of the mouth), soft palate (the muscular back portion of the roof of the mouth), retromolar trigone (the area behind the wisdom teeth), front two-thirds of the tongue, gingiva (gums), buccal mucosa (the inner lining of the lips and cheeks), and floor of the mouth under the tongue. Most lip and oral cavity cancers start in squamous cells, the thin, flat cells that line the lips and oral cavity. These are called squamous cell carcinomas. Cancer cells may spread into deeper tissue as the cancer grows. Squamous cell carcinoma usually develops in areas of leukoplakia (white patches of cells that do not rub off). Lip and oral cavity cancer is a type of head and neck cancer. Tobacco and alcohol use can affect the risk of developing lip and oral cavity cancer. Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for lip and oral cavity cancer include the following:

Using tobacco products.

Heavy alcohol use. Being exposed to natural sunlight or artificial sunlight (such as from tanning beds) over long periods of time. Being male. Being infected with human papillomavirus (HPV).

Possible signs of lip and oral cavity cancer include a sore or lump on the lips or in the mouth. These and other symptoms may be caused by lip and oral cavity cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

A sore on the lip or in the mouth that does not heal. A lump or thickening on the lips or gums or in the mouth. A white or red patch on the gums, tongue, tonsils, or lining of the mouth. Bleeding, pain, or numbness in the lip or mouth. Change in voice. Loose teeth or dentures that no longer fit well. Trouble chewing or swallowing or moving the tongue or jaw. Swelling of jaw. Sore throat or feeling that something is caught in the throat.

Lip and oral cavity cancer may not have any symptoms and is sometimes found during a regular dental exam. Tests that examine the mouth and throat are used to detect (find), diagnose, and stage lip and oral cavity cancer. The following tests and procedures may be used:

Physical exam of the lips and oral cavity: An exam to check the lips and oral cavity for abnormal areas. The doctor or dentist will feel the entire inside of the mouth with a gloved finger and examine the oral cavity with a small long-handled mirror and lights. This will include checking the insides of the cheeks and lips; the gums; the roof and floor of the mouth; and the top, bottom, and sides of the tongue. The neck will be felt for swollen lymph nodes. A history of the patients health habits and past illnesses and medical and dental treatments will also be taken. Endoscopy: A procedure to look at organs and tissues inside the body to check for abnormal areas. An endoscope is inserted through an incision (cut) in the skin or opening in the body, such as the mouth. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of disease. X-rays of the head, neck, and chest: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist. If leukoplakia is found, cells taken from the patches are also checked under the microscope for signs of cancer.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI). CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. Exfoliative cytology: A procedure to collect cells from the lip or oral cavity. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the lips, tongue, mouth, or throat. The cells are viewed under a microscope to find out if they are abnormal. Barium swallow: A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and x-rays are taken. This procedure is also called an upper GI series. PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

Certain factors affect prognosis (chance of recovery) and treatment options. Prognosis (chance of recovery) depends on the following:

The stage of the cancer. Where the tumor is in the lip or oral cavity. Whether the cancer has spread to blood vessels.

For patients who smoke, the chance of recovery is better if they stop smoking before beginning radiation therapy. Treatment options depend on the following:

The stage of the cancer. The size of the tumor and where it is in the lip or oral cavity. Whether the patient's appearance and ability to talk and eat can stay the same. The patient's age and general health.

There are three ways that cancer spreads in the body. The three ways that cancer spreads in the body are:

Through tissue. Cancer invades the surrounding normal tissue. Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.

Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer. The following stages are used for lip and oral cavity cancer: Stage 0 (Carcinoma in Situ) In stage 0, abnormal cells are found in the lining of the lips and oral cavity. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ. Enlarge

Pea, peanut, walnut, and lime show tumor sizes. Stage I In stage I, cancer has formed and the tumor is 2 centimeters or smaller. Cancer has not spread to the lymph nodes. Stage II In stage II, the tumor is larger than 2 centimeters but not larger than 4 centimeters, and cancer has not spread to the lymph nodes. Stage III In stage III, the tumor:

may be any size and has spread to one lymph node that is 3 centimeters or smaller, on the same side of the neck as the tumor; or is larger than 4 centimeters.

Stage IV Stage IV is divided into stages IVA, IVB, and IVC.

In stage IVA, the tumor: o has spread through tissue in the lip or oral cavity into nearby tissue and/or bone (jaw, tongue, floor of mouth, maxillary sinus, or skin on the chin or nose); cancer may have spread to one lymph node that is 3 centimeters or smaller, on the same side of the neck as the tumor; or o is any size or has spread through tissue in the lip or oral cavity into nearby tissue and/or bone (jaw, tongue, floor of mouth, maxillary sinus, or skin on the chin or nose), and cancer has spread: to one lymph node on the same side of the neck as the tumor and the lymph node is larger than 3 centimeters but not larger than 6 centimeters; or to more than one lymph node on the same side of the neck as the tumor and the lymph nodes are not larger than 6 centimeters; or to lymph nodes on the opposite side of the neck as the tumor or on both sides of the neck, and the lymph nodes are not larger than 6 centimeters. In stage IVB, the tumor: o may be any size and has spread to one or more lymph nodes that are larger than 6 centimeters; or o has spread further into the muscles or bones in the oral cavity, or to the base of the skull and/or the carotid artery. Cancer may have spread to one or more lymph nodes anywhere in the neck. In stage IVC, the tumor has spread beyond the lip or oral cavity to distant parts of the body, such as the lungs. The tumor may be any size and may have spread to the lymph nodes.

Treatment There are different types of treatment for patients with lip and oral cavity cancer. Different types of treatment are available for patients with lip and oral cavity cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment. Patients with lip and oral cavity cancer should have their treatment planned by a team of doctors who are expert in treating head and neck cancer. Treatment will be overseen by a medical oncologist, a doctor who specializes in treating people with cancer. Because the lips and oral cavity are important for breathing, eating, and talking,

patients may need special help adjusting to the side effects of the cancer and its treatment. The medical oncologist may refer the patient to other health professionals with special training in the treatment of patients with head and neck cancer. These include the following:

Head and neck surgeon. Radiation oncologist. Dentist. Speech therapist. Dietitian. Psychologist. Rehabilitation specialist. Plastic surgeon.

Two types of standard treatment are used: Surgery Surgery (removing the cancer in an operation) is a common treatment for all stages of lip and oral cavity cancer. Surgery may include the following:

Wide local excision: Removal of the cancer and some of the healthy tissue around it. If cancer has spread into bone, surgery may include removal of the involved bone tissue. Neck dissection: Removal of lymph nodes and other tissues in the neck. This is done when cancer may have spread from the lip and oral cavity. Plastic surgery: An operation that restores or improves the appearance of parts of the body. Dental implants, a skin graft, or other plastic surgery may be needed to repair parts of the mouth, throat, or neck after removal of large tumors.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. Radiation therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated. For patients who smoke, radiation therapy works better when smoking is stopped before beginning treatment. It is also important for patients to have a dental exam before radiation therapy begins, so that existing problems can be treated.

New types of treatment are being tested in clinical trials. This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site. Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Hyperfractionated radiation therapy Hyperfractionated radiation therapy is radiation treatment in which the total dose of radiation is divided into small doses and the treatments are given more than once a day. Hyperthermia therapy Hyperthermia therapy is a treatment in which body tissue is heated above normal temperature to damage and kill cancer cells or to make cancer cells more sensitive to the effects of radiation and certain anticancer drugs. Patients may want to think about taking part in a clinical trial. For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment. Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment. Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward. Patients can enter clinical trials before, during, or after starting their cancer treatment. Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test

new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment. Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials. Follow-up tests may be needed. Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging. Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups. Stage I Lip and Oral Cavity Cancer Treatment of stage I lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity. Lip If cancer is in the lip, treatment may include the following:

Surgery (wide local excision). Internal radiation therapy with or without external radiation therapy.

Front of the tongue If cancer is in the front of the tongue, treatment may include the following:

Surgery (wide local excision). Internal radiation therapy with or without external radiation therapy. Radiation therapy to lymph nodes in the neck.

Buccal mucosa If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

Surgery (wide local excision) for tumors smaller than 1 centimeter, with or without internal and/or external radiation therapy. Surgery (wide local excision with skin graft) or radiation therapy for larger tumors.

Floor of the mouth If cancer is in the floor (bottom) of the mouth, treatment may include the following:

Surgery (wide local excision) for tumors smaller than centimeter. Surgery (wide local excision) or radiation therapy for larger tumors.

Lower gingiva If cancer is in the lower gingiva (gums), treatment may include the following:

Surgery (wide local excision, which may include removing part of the jawbone, and skin graft). Radiation therapy with or without surgery.

Retromolar trigone If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

Surgery (wide local excision, which may include removing part of the jawbone.) Radiation therapy with or without surgery.

Upper gingiva or hard palate If cancer is in the upper gingiva (gums) or the hard palate (the roof of the mouth), treatment is usually surgery (wide local excision) with or without radiation therapy. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I lip and oral cavity cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site. Stage II Lip and Oral Cavity Cancer Treatment of stage II lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity. Lip If cancer is in the lip, treatment may include the following:

Surgery (wide local excision). External radiation therapy and/or internal radiation therapy.

Front of the tongue

If cancer is in the front of the tongue, treatment may include the following:

Radiation therapy and/or surgery (wide local excision). Internal radiation therapy with surgery (neck dissection).

Buccal mucosa If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

Radiation therapy for tumors that are 3 centimeters or smaller. Surgery (wide local excision) and/or radiation therapy for larger tumors.

Floor of the mouth If cancer is in the floor (bottom) of the mouth, treatment may include the following:

Surgery (wide local excision). Radiation therapy. Surgery (wide local excision) followed by external radiation therapy, with or without internal radiation therapy, for large tumors.

Lower gingiva If cancer is in the lower gingiva (gums), treatment may include the following:

Surgery (wide local excision, which may include removing part of the jawbone, and a skin graft). Radiation therapy alone or after surgery.

Retromolar trigone If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

Surgery (wide local excision, which includes removing part of the jawbone). Radiation therapy with or without surgery.

Upper gingiva or hard palate If cancer is in the upper gingiva (gums) or the hard palate (the roof of the mouth), treatment may include the following:

Surgery (wide local excision) with or without radiation therapy. Radiation therapy alone.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II lip and oral cavity cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site. Stage III Lip and Oral Cavity Cancer Treatment of stage III lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity. Lip If cancer is in the lip, treatment may include the following:

Surgery and external radiation therapy with or without internal radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Front of the tongue If cancer is in the front of the tongue, treatment may include the following:

External radiation therapy with or without internal radiation therapy. Surgery (wide local excision) followed by radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Buccal mucosa If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

Surgery (wide local excision) with or without radiation therapy. Radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Floor of the mouth If cancer is in the floor (bottom) of the mouth, treatment may include the following:

Surgery (wide local excision, which may include removing part of the jawbone, with or without neck dissection). External radiation therapy with or without internal radiation therapy.

A clinical trial of chemotherapy before or after surgery. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Lower gingiva If cancer is in the lower gingiva (gums), treatment may include the following:

Surgery (wide local excision) with or without radiation therapy. Radiation may be given before or after surgery. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Retromolar trigone If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

Surgery to remove the tumor, lymph nodes, and part of the jawbone, with or without radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Upper gingiva If cancer is in the upper gingiva (gums), treatment may include the following:

Radiation therapy. Surgery (wide local excision) and radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Hard palate If cancer is in the hard palate (the roof of the mouth), treatment may include the following:

Radiation therapy. Surgery (wide local excision) with or without radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Lymph nodes For cancer that may have spread to lymph nodes, treatment may include the following:

Radiation therapy and/or surgery (neck dissection). A clinical trial of chemotherapy and radiation therapy. A clinical trial of hyperfractionated radiation therapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III lip and oral cavity cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site. Stage IV Lip and Oral Cavity Cancer Treatment of stage IV lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity. Lip If cancer is in the lip, treatment may include the following:

Surgery and external radiation therapy with or without internal radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

Front of the tongue If cancer is in the front of the tongue, treatment may include the following:

Surgery to remove the tongue and sometimes the larynx (voice box) with or without radiation therapy. Radiation therapy as palliative therapy to relieve symptoms and improve quality of life. A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

Buccal mucosa If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

Surgery (wide local excision) and/or radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

Floor of the mouth

If cancer is in the floor (bottom) of the mouth, treatment may include the following:

Surgery before or after radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

Lower gingiva If cancer is in the lower gingiva (gums), treatment may include the following:

Surgery and/or radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

Retromolar trigone If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

Surgery to remove the tumor, lymph nodes, and part of the jawbone, followed by radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

Upper gingiva or hard palate If cancer is in the upper gingiva (gums) or hard palate (the roof of the mouth), treatment may include the following:

Surgery with radiation therapy. A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

Lymph nodes For cancer that may have spread to lymph nodes, treatment may include the following:

Radiation therapy and/or surgery (neck dissection). A clinical trial of chemotherapy and radiation therapy. A clinical trial of chemotherapy before or after surgery. A clinical trial of hyperfractionated radiation therapy.

KIDNEY/RENAL CELL CARCINOMA

Renal cancer; Kidney cancer; Hypernephroma; Adenocarcinoma of renal cells; Cancer - kidney Renal cell carcinoma is a type of kidney cancer that starts in the lining of very small tubes (tubules) in the kidney. Causes, incidence, and risk factors Renal cell carcinoma is the most common type of kidney cancer in adults. It occurs most often in men ages 50 - 70. The exact cause is unknown. The following may increase your risk of kidney cancer:

Dialysis treatment Family history of the disease High blood pressure Horseshoe kidney Polycystic kidney disease Smoking Von Hippel-Lindau disease (a hereditary disease that affects blood vessels in the brain, eyes, and other body parts)

Symptoms

Abdominal pain and swelling Back pain Blood in the urine Swelling of the veins around a testicle (varicocele) Flank pain Weight loss

Other symptoms that can occur with this disease:

Excessive hair growth in females Pale skin Vision problems

Signs and tests The health care provider will perform a physical exam. This may reveal:

Mass or swelling of the abdomen A varicocele in the male scrotum

Tests include:

Abdominal CT scan Blood chemistry Complete blood count (CBC) Intravenous pyelogram (IVP) Liver function tests Renal arteriography Ultrasound of the abdomen and kidney Urine tests

The following tests may be done to see if the cancer has spread:

Abdominal CT scan Abdominal MRI Bone scan Chest x-ray Chest CT scan PET scan

Treatment Surgery to remove of all or part of the kidney (nephrectomy) is recommended. This may include removing the bladder, surrounding tissues, or lymph nodes. A cure is unlikely unless all of the cancer is removed with surgery. Hormone treatments may may the tumor smaller in some cases. Chemotherapy is generally not effective for treating kidney cancer. However, the drug interleukin-2 (IL-2) may help some patients. It is a very powerful drug that can have severe side effects. Newer medicines to treat kidney cancer include:

Sorafenib (Nexavar) Sunitinib (Sutent) Temsirolimus (Torisel) Bevacizumab (Avastin)

Radiation therapy usually does not work for kidney cancer. Support Groups You can ease the stress of illness by joining a support group whose members share common experiences and problems.

See also:

Cancer - support group Kidney disease - support group

Expectations (prognosis) Sometimes both kidneys are involved. The cancer spreads easily, most often to the lungs and other organs. In about one-third of patients, the cancer has already spread (metastasized) at the time of diagnosis. How well a patient does depends on how much the cancer has spread and how well treatment works. The survival rate is highest if the tumor is in the early stages and has not spread outside the kidney. If it has spread to the lymph nodes or to other organs, the survival rate is much lower. Complications

High blood pressure (hypertension) Too much calcium in the blood High red blood cell count Liver problems Spread of the cancer

Calling your health care provider Call your health care provider any time you see blood in the urine. Also call if you have any other symptoms of this disorder. Prevention Stop smoking. Follow your health care provider's recommendations in the treatment of kidney disorders, especially those that may require dialysis.

GALLBLADDER
Cancer is a disease in which malignant (cancer) cells form in the tissues of the gallbladder. Gallbladder cancer is a rare disease in which malignant (cancer) cells are found in the tissues of the gallbladder. The gallbladder is a pear-shaped organ that lies just under the liver in the upper abdomen. The gallbladder stores bile, a fluid made by the liver to digest fat. When food is being broken down in the stomach and intestines, bile is released from the gallbladder through a tube called the common bile duct, which connects the gallbladder and liver to the first part of the small intestine.

The wall of the gallbladder has 3 main layers of tissue.

Mucosal (innermost) layer. Muscularis (middle, muscle) layer. Serosal (outer) layer.

Between these layers is supporting connective tissue. Primary gallbladder cancer starts in the innermost layer and spreads through the outer layers as it grows. Being female can increase the risk of developing gallbladder cancer. Anything that increases your chance of getting a disease is called a risk factor. Risk factors for gallbladder cancer include the following:

Being female. Being Native American.

Possible signs of gallbladder cancer include jaundice, pain, and fever. These and other symptoms may be caused by gallbladder cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

Jaundice (yellowing of the skin and whites of the eyes). Pain above the stomach. Fever. Nausea and vomiting. Bloating. Lumps in the abdomen.

Gallbladder cancer is difficult to detect (find) and diagnose early. Gallbladder cancer is difficult to detect and diagnose for the following reasons:

There aren't any noticeable signs or symptoms in the early stages of gallbladder cancer. The symptoms of gallbladder cancer, when present, are like the symptoms of many other illnesses. The gallbladder is hidden behind the liver.

Gallbladder cancer is sometimes found when the gallbladder is removed for other reasons. Patients with gallstones rarely develop gallbladder cancer. Tests that examine the gallbladder and nearby organs are used to detect (find), diagnose, and stage gallbladder cancer.

Procedures that create pictures of the gallbladder and the area around it help diagnose gallbladder cancer and show how far the cancer has spread. The process used to find out if cancer cells have spread within and around the gallbladder is called staging. In order to plan treatment, it is important to know if the gallbladder cancer can be removed by surgery. Tests and procedures to detect, diagnose, and stage gallbladder cancer are usually done at the same time. The following tests and procedures may be used:

Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken. Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. An abdominal ultrasound is done to diagnose gallbladder cancer. Liver function tests: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. A higher than normal amount of a substance can be a sign of liver disease that may be caused by gallbladder cancer. Carcinoembryonic antigen (CEA) assay: A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of gallbladder cancer or other conditions. CA 19-9 assay: A test that measures the level of CA 19-9 in the blood. CA 19-9 is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of gallbladder cancer or other conditions. CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it. Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI). A dye may be injected into the gallbladder area so the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine will show up better in the image. This

procedure is called MRCP (magnetic resonance cholangiopancreatography). To create detailed pictures of blood vessels near the gallbladder, the dye is injected into a vein. This procedure is called MRA (magnetic resonance angiography). ERCP (endoscopic retrograde cholangiopancreatography): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes gallbladder cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope (a thin, lighted tube) is passed through the mouth, esophagus, and stomach into the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the bile ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumor, a fine tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. Tissue samples may also be taken. Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The biopsy may be done after surgery to remove the tumor. If the tumor clearly cannot be removed by surgery, the biopsy may be done using a fine needle to remove cells from the tumor. Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples for biopsy. The laparoscopy helps to determine if the cancer is within the gallbladder only or has spread to nearby tissues and if it can be removed by surgery. PTC (percutaneous transhepatic cholangiography): A procedure used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is sometimes left in the liver to drain bile into the small intestine or a collection bag outside the body.

Certain factors affect the prognosis (chance of recovery) and treatment options. The prognosis (chance of recovery) and treatment options depend on the following:

The stage of the cancer (whether the cancer has spread from the gallbladder to other places in the body). Whether the cancer can be completely removed by surgery. The type of gallbladder cancer (how the cancer cell looks under a microscope). Whether the cancer has just been diagnosed or has recurred (come back).

Treatment may also depend on the age and general health of the patient and whether the cancer is causing symptoms.

Gallbladder cancer can be cured only if it is found before it has spread, when it can be removed by surgery. If the cancer has spread, palliative treatment can improve the patient's quality of life by controlling the symptoms and complications of this disease. Taking part in one of the clinical trials being done to improve treatment should be considered. Information about ongoing clinical trials is available from the NCI Web site. Stages of Gallbladder Cancer Tests and procedures to stage gallbladder cancer are usually done at the same time as diagnosis. See the General Information section for a description of tests and procedures used to detect, diagnose, and stage gallbladder cancer. The following stages are used for gallbladder cancer: Stage 0 (Carcinoma in Situ) In stage 0, abnormal cells are found in the innermost (mucosal) layer of the gallbladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ. Stage I In stage I, cancer has formed. Stage I is divided into stage IA and stage IB.

Stage IA: Cancer has spread beyond the innermost (mucosal) layer to the connective tissue or to the muscle (muscularis) layer. Stage IB: Cancer has spread beyond the muscle layer to the connective tissue around the muscle.

Stage II Stage II is divided into stage IIA and stage IIB.

Stage IIA: Cancer has spread beyond the visceral peritoneum (tissue that covers the gallbladder) and/or to the liver and/or one nearby organ (such as the stomach, small intestine, colon, pancreas, or bile ducts outside the liver). Stage IIB: Cancer has spread: o beyond the innermost layer to the connective tissue and to nearby lymph nodes; or o to the muscle layer and nearby lymph nodes; or o beyond the muscle layer to the connective tissue around the muscle and to nearby lymph nodes; or

through the visceral peritoneum (tissue that covers the gallbladder) and/or to the liver and/or to one nearby organ (such as the stomach, small intestine, colon, pancreas, or bile ducts outside the liver), and to nearby lymph nodes.

Stage III In stage III, cancer has spread to a main blood vessel in the liver or to nearby organs and may have spread to nearby lymph nodes. Stage IV In stage IV, cancer has spread to nearby lymph nodes and/or to organs far away from the gallbladder. For gallbladder cancer, stages are also grouped according to how the cancer may be treated. There are two treatment groups: Localized (Stage I) Cancer is found in the wall of the gallbladder and can be completely removed by surgery. Unresectable (Stage II, Stage III, and Stage IV) Cancer has spread through the wall of the gallbladder to surrounding tissues or organs or throughout the abdominal cavity. Except in patients whose cancer has spread only to lymph nodes, the cancer is unresectable (cannot be completely removed by surgery). Recurrent Gallbladder Cancer Recurrent gallbladder cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the gallbladder or in other parts of the body. Treatment Option Overview There are different types of treatment for patients with gallbladder cancer. Different types of treatments are available for patients with gallbladder cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Three types of standard treatment are used: Surgery Gallbladder cancer may be treated with a cholecystectomy, surgery to remove the gallbladder and some of the tissues around it. Nearby lymph nodes may be removed. A laparoscope is sometimes used to guide gallbladder surgery. The laparoscope is attached to a video camera and inserted through an incision (port) in the abdomen. Surgical instruments are inserted through other ports to perform the surgery. Because there is a risk that gallbladder cancer cells may spread to these ports, tissue surrounding the port sites may also be removed. If the cancer has spread and cannot be removed, the following types of palliative surgery may relieve symptoms:

Surgical biliary bypass: If the tumor is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass may be done. During this operation, the gallbladder or bile duct will be cut and sewn to the small intestine to create a new pathway around the blocked area. Endoscopic stent placement: If the tumor is blocking the bile duct, surgery may be done to put in a stent (a thin, flexible tube) to drain bile that has built up in the area. The stent may be placed through a catheter that drains to the outside of the body or the stent may go around the blocked area and drain the bile into the small intestine. Percutaneous transhepatic biliary drainage: A procedure done to drain bile when there is a blockage and endoscopic stent placement is not possible. An x-ray of the liver and bile ducts is done to locate the blockage. Images made by ultrasound are used to guide placement of a stent, which is left in the liver to drain bile into the small intestine or a collection bag outside the body. This procedure may be done to relieve jaundice before surgery.

Radiation therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated. Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer

cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. New types of treatment are being tested in clinical trials. These include the following: Radiosensitizers Radiosensitizers are drugs that make tumor cells more sensitive to radiation therapy. Combining radiation therapy with radiosensitizers may kill more tumor cells. This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site. Treatment Options for Gallbladder Cancer Localized Gallbladder Cancer Treatment of localized gallbladder cancer may include the following:

Surgery to remove the gallbladder and some of the tissue around it. The liver and nearby lymph nodes may also be removed. Radiation therapy with or without chemotherapy may follow surgery. Radiation therapy with or without chemotherapy. A clinical trial of radiation therapy with radiosensitizers.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site. Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with localized gallbladder cancer. Unresectable Gallbladder Cancer Treatment of unresectable gallbladder cancer may include the following:

Radiation therapy as palliative treatment, with or without surgery or the placement of stents, to relieve symptoms caused by blocked bile ducts. Surgery as palliative treatment to relieve symptoms caused by blocked bile ducts. Chemotherapy as palliative treatment to relieve symptoms caused by the cancer. A clinical trial of internal radiation therapy or radiosensitizers. A clinical trial of chemotherapy.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site. Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with unresectable gallbladder cancer. Recurrent Gallbladder Cancer Treatment of recurrent gallbladder cancer is usually done in a clinical trial. Information about ongoing clinical trials is available from the NCI Web site. Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with recurrent gallbladder cancer.

CANCER - THROAT OR LARYNX

Cancer of the throat is cancer of the vocal cords, voice box (larynx), or other areas of the throat. Causes People who smoke or use tobacco are at risk of developing throat cancer. Excessive alcohol use also increases risk. Smoking and drinking alcohol combined lead to an increased risk for throat cancers. Most cancers of the throat develop in adults older than 50. Men are 10 times more likely than women to develop throat cancers. Symptoms

Abnormal (high-pitched) breathing sounds Cough Coughing up blood Difficulty swallowing Hoarseness that does not get better in 1 - 2 weeks Neck pain Sore throat that does not get better in 1 - 2 weeks, even with antibiotics Swelling or lumps in the neck Unintentional weight loss

Exams and Tests The doctor will perform a physical exam. This may show a lump on the outside of the neck. The doctor may look in your throat or nose using a flexible tube with a small camera at the end.

Other may include:

Biopsy of suspected tumor Chest x-ray CT scan of chest CT scan of head and neck MRI of the head or neck

Treatment The goal of treatment is to completely remove the cancer and prevent it from spreading to other parts of the body. When the tumor is small, either surgery or radiation therapy alone can be used to remove the tumor. When the tumor is larger or has spread to lymph nodes in the neck, a combination of radiation and chemotherapy is often used to preserve the voice box. Some patients need surgery to remove the tumor, including all or part of the vocal cords (laryngectomy). If you have a laryngectomy, speech therapy can help you learn other ways to talk. Many patients also need swallowing therapy after treatment to help them adjust to the changes in the structure of the throat. Possible Complications

Airway obstruction Difficulty swallowing Disfigurement of the neck or face Hardening of the skin of the neck Loss of voice and speaking ability Spread of the cancer to other body areas (metastasis)

When to Contact a Medical Professional Call your health care provider if:

You have symptoms of throat cancer, especially hoarseness or a change in voice with no obvious cause that lasts longer than 3 weeks You find a lump in your neck that does not go away in 3 weeks

Prevention Avoid smoking and other tobacco exposure. Limit or avoid alcohol use.

Alternative Names Vocal cord cancer; Throat cancer; Laryngeal cancer; Cancer of the glottis Pharyngeal Cancer Information What is Pharyngeal Cancer? The pharynx, often called the throat, is a hollow tube about 5 inches long that starts behind the nose and goes down to the neck to become part of the esophagus (tube that goes to the stomach). Air and food pass through the pharynx on the way to the windpipe (trachea) or the esophagus. Cancer of the pharynx is often categorized as follows:

The nasopharynx is behind the nose and is the upper part of the throat. The nares, the holes in the nose through which people breathe, lead into the nasopharynx. Two openings on the side of the nasopharynx lead into the ear. Cancer of the nasopharynx most commonly starts in the cells that line the oropharynx. The oropharynx is the middle part of the throat. The oropharynx includes the soft palate (the back of the mouth), the base of the tongue, and the tonsils. Cancer of the oropharynx most commonly starts in the cells that line the oropharynx. The hypopharynx is the bottom part of the throat. Cancer of the hypopharynx most commonly starts in the cells that line the hypopharynx, called squamous cells.

A doctor should be seen if a person has a sore throat that does not go away, trouble swallowing, a lump in the back of the mouth or throat, a change in the voice, or pain in the ear. If there are pharyngeal cancer symptoms, a doctor will examine the throat using a mirror and lights. The doctor will also feel the throat for lumps. If tissue that is not normal is found, the doctor will need to cut out a small piece and look at it under the microscope to see if there are any pharyngeal cancer cells. This is called a biopsy. The chance of recovery (prognosis) depends on where the cancer is in the throat, whether the cancer is just in the throat or has spread to other tissues (the stage), and the patient's general state of health. After the pharyngeal cancer treatment, a doctor should be seen regularly because there is a chance of having a second cancer in the head or neck region Symptoms Symptoms that are common to several head and neck cancer sites include a lump or sore that does not heal, a sore throat that does not go away, difficulty swallowing, and a change or hoarseness in the voice. Other pharyngeal cancer symptoms may include the following:

Oropharynx and hypopharynx cancer symptomsEar pain. Nasopharynx cancer symptomsTrouble breathing or speaking, frequent headaches, pain or ringing in the ears, or trouble hearing.

These symptoms may be caused by pharyngeal cancer or by other, less serious conditions. It is important to check with a doctor or dentist about any of these symptoms. Staging Once cancer of the pharynx is found, more tests will be done to find out if cancer cells have spread to other parts of the body. This is called staging. A doctor needs to know the stage of the disease to plan treatment. For Nasopharynx Stage I The cancer is in only one part of the nasopharynx and has not spread to lymph nodes in the area (lymph nodes are small bean-shaped structures that are found throughout the body; they produce and store infection-fighting cells). Stage II The cancer is in more than one part of the nasopharynx and has not spread to lymph nodes in the area. Stage III Either of the following may be true:

The cancer has spread into the nose or to the part of the throat behind the mouth (the oropharynx). The cancer is in the nasopharynx or has spread to the nose or the oropharynx. The cancer has spread to only one lymph node on the same side of the neck as the cancer. The lymph node that contains cancer measures no more than 3 centimeters (just over one inch).

Stage IV Any of the following may be true:

The nasopharynx cancer has spread to the bones or nerves in the head. The lymph nodes in the area may or may not contain cancer. The cancer is in the nasopharynx or has spread to the nose, the nasopharynx, or the bone or nerves in the head. The cancer has spread to more than one lymph node on the same side of the neck as the cancer, to lymph nodes on one or both sides of the neck, or to any lymph node which measures more than 6 centimeters (over 2 inches). The cancer has spread to other parts of the body.

For Oropharynx Stage I The oropharynx cancer is no more than 2 centimeters (about 1 inch) and has not spread to lymph nodes in the area (lymph nodes are small bean-shaped structures that are found throughout the body; they produce and store infection-fighting cells). Stage II The oropharynx cancer is more than 2 centimeters, but less than 4 centimeters (less than 2 inches), and has not spread to lymph nodes in the area. Stage III Either of the following may be true:

The cancer is more than 4 centimeters. The cancer is any size but has spread to only one lymph node on the same side of the neck as the cancer. The lymph node that contains cancer measures no more than 3 centimeters (just over one inch).

Stage IV Any of the following may be true:

The cancer has spread to tissues around the oropharynx. The lymph nodes in the area may or may not contain cancer. The cancer is any size and has spread to more than one lymph node on the same side of the neck as the oropharynx cancer, to lymph nodes on one or both sides of the neck, or to any lymph node which measures more than 6 centimeters (over 2 inches). The oropharynx cancer has spread to other parts of the body.

For Hypopharynx Stage I The cancer is in only one part of the hypopharynx and has not spread to lymph nodes in the area (lymph nodes are small bean-shaped structures that are found throughout the body; they produce and store infection-fighting cells). Stage II The cancer is in more than one part of the hypopharynx or has spread to tissue next to the hypopharynx, but has not grown into the voice box (larynx). The cancer has not spread to lymph nodes in the area.

Stage III Either of the following may be true:

The cancer is in more than one part of the hypopharynx or has spread to tissue next to the hypopharynx. The cancer has grown into the larynx. The cancer is in the hypopharynx or has spread to the tissue around the hypopharynx. The cancer has spread to only one lymph node on the same side of the neck as the cancer. The lymph node that contains hypopharynx cancer measures no more than 3 centimeters (just over one inch).

Stage IV Any of the following may be true:

The hypopharynx cancer has spread to the connecting tissue or soft tissues of the neck. The lymph nodes in the area may or may not contain cancer. The cancer is in the hypopharynx or has spread to the tissues around the hypopharynx. The cancer has spread to more than one lymph node on the same side of the neck as the cancer, to lymph nodes on one or both sides of the neck, or to any lymph node that measures more than 6 centimeters (over 2 inches). The hypopharynx cancer has spread to other parts of the body.

Treatment Treatment for pharyngeal cancer depends on the location of the tumor, as well as the stage of the cancer, and the person's age and overall health. Treatment options aim to minimize damage to a person's ability to eat, breathe and talk. For Oropharynx There are treatments for all patients with cancer of the oropharynx. Three kinds of treatment are used:

surgery (taking out the cancer) radiation therapy (using high-dose x-rays or other high-energy rays to kill oropharynx cancer cells) chemotherapy (using drugs to kill oropharynx cancer cells) hyperthermia (warming the body to kill oropharynx cancer cells) is being tested in clinical trials.

Surgery is a common treatment of cancer of the oropharynx. A doctor may remove the cancer and some of the healthy tissue around the cancer. If cancer has spread to lymph nodes, the lymph nodes will be removed (lymph node dissection). A new type of surgery called micrographic surgery is being tested in clinical trials for early cancers of the oropharynx. Micrographic surgery removes the cancer and as little normal tissue as possible. During this surgery, the doctor

removes the cancer and then uses a microscope to look at the cancerous area to make sure there are no oropharynx cancer cells remaining. Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy). External radiation to the thyroid or the pituitary gland may change the way the thyroid gland works. The doctor may wish to test the thyroid gland before and after therapy to make sure it is working properly. Giving drugs with the radiation therapy to make the oropharynx cancer cells more sensitive to radiation (radiosensitization) is being tested in clinical trials. If smoking is stopped before radiation therapy is started, there is a better chance of surviving longer. Chemotherapy uses drugs to kill oropharynx cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in the vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells throughout the body. People with oropharyngeal cancer have a higher risk of getting other cancers in the head and neck area. Clinical trials of oropharynx chemoprevention therapy are testing whether certain drugs can prevent second cancers from developing in the mouth, throat, windpipe, nose, or esophagus (the tube that connects the throat to the stomach). Hyperthermia uses a special machine to heat the body for a certain period of time to kill cancer cells. Because cancer cells are often more sensitive to heat than normal cells, the oropharynx cancer cells die and the cancer shrinks. Because the oropharynx helps in breathing, eating, and talking, patients may need special help adjusting to the side effects of the cancer and its treatment. A doctor will consult with several kinds of doctors who can help determine the best oropharynx cancer treatment. Trained medical staff can also help patients recover from treatment and adjust to new ways of eating and talking. Plastic surgery, or help learning to eat and speak, may be needed if a large part of the oropharynx is taken out. For Nasopharynx There are treatments for all patients with cancer of the nasopharynx. Three kinds of treatment are used:

radiation therapy (using high-dose x-rays or other high-energy rays to kill nasopharynx cancer cells) surgery (taking out the cancer) chemotherapy (using drugs to kill nasopharynx cancer cells) biological therapy (using the body's immune system to fight nasopharynx cancer) is being tested in clinical trials.

Radiation therapy is the most common treatment for cancer of the nasopharynx. Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy). External radiation to the thyroid or the pituitary gland may change the way the thyroid gland works. A doctor may wish to test the thyroid gland before and after therapy to make sure it is working properly. Surgery is sometimes used for cancer of the nasopharynx that does not respond to radiation. If nasopharynx cancer has spread to lymph nodes, the lymph nodes may be removed (lymph node dissection). Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in the vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells throughout the body. Biological therapy tries to get the body to fight nasopharynx cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. Because the nasopharynx helps in breathing and is close to the face, a patient may need special help adjusting to the side effects of the nasopharynx cancer and its treatment. A doctor will consult with several kinds of doctors who can help determine the best nasopharynx cancer treatment. Trained medical staff can also help patients recover from treatment. Patients may need plastic surgery if a large part of the nasopharynx is taken out. For Hypopharynx There are treatments for all patients with cancer of the hypopharynx. Two kinds of treatment are used:

surgery (taking out the hypopharynx cancer) radiation therapy (using high-dose x-rays or other high-energy rays to kill cancer cells) chemotherapy (using drugs to kill hypopharynx cancer cells) is being tested in clinical trials

Surgery is a common treatment of cancer of the hypopharynx. A doctor may remove the larynx and part of the throat in an operation called a laryngopharyngectomy. If the cancer is in the lymph nodes, the lymph nodes may be removed (lymph node dissection). Radiation therapy uses high-energy x-rays to kill hypopharynx cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the hypopharynx cancer cells are found (internal radiation therapy). Giving drugs with the radiation therapy to make the cancer cells more sensitive to radiation (radiosensitization) is being tested in clinical trials. If smoking is stopped before radiation therapy is started, a patient has a

better chance of surviving longer. External radiation to the thyroid or the pituitary gland may change the way the thyroid gland works. The doctor may wish to test the thyroid gland before and after therapy to make sure it is working properly. Chemotherapy uses drugs to kill hypopharynx cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in the vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells throughout the body. Because the hypopharynx helps people with breathing, eating, and talking, a patient may need special help adjusting to the side effects of the hypopharynx cancer and its treatment. The patient's doctor will consult with several kinds of doctors who can help determine the best hypopharynx cancer treatment. Trained medical staff can also help the patient recover from treatment. The patient may need plastic surgery or help learning to eat and speak if all or part of the hypopharynx is taken out.

UTERINE CANCER
Also called: Endometrial cancer

Endometrial cancer refers to several types of malignancies that arise from the endometrium, or lining, of the uterus. Endometrial cancers are the most common gynecologic cancers in the United States, with over 35,000 women diagnosed each year. The incidence is on a slow rise secondary to the obesity epidemic. The most common subtype, endometrioid adenocarcinoma, typically occurs within a few decades of menopause, is associated with obesity, excessive estrogen exposure, often develops in the setting of endometrial hyperplasia, and presents most often with vaginal bleeding. Endometrial carcinoma is the third most common cause of gynecologic cancer death (behind ovarian and cervical cancer). A total abdominal hysterectomy (surgical removal of the uterus) with bilateral salpingo-oophorectomy is the most common therapeutic approach. Endometrial cancer may sometimes be referred to as uterine cancer. However, different cancers may develop not only from the endometrium itself but also from other tissues of the uterus, including cervical cancer, sarcoma of the myometrium, and trophoblastic disease. Classification Carcinoma Most endometrial cancers are carcinomas (usually adenocarcinomas), meaning that they originate from the single layer of epithelial cells that line the endometrium and form the endometrial glands. There are many microscopic subtypes of endometrial carcinoma, including the common endometrioid type, in which the cancer cells grow in patterns reminiscent of normal endometrium, and the far more aggressive papillary serous carcinoma and clear cell endometrial

carcinomas. Some authorities have proposed that endometrial carcinomas be classified into two pathogenetic groups:[1]

Type I: These cancers occur most commonly in pre- and peri-menopausal women, often with a history of unopposed estrogen exposure and/or endometrial hyperplasia. They are often minimally invasive into the underlying uterine wall, are of the low-grade endometrioid type, and carry a good prognosis. Type II: These cancers occur in older, post-menopausal women, are more common in African-Americans, are not associated with increased exposure to estrogen, and carry a poorer prognosis. They include:

the high-grade endometrioid cancer, the uterine papillary serous carcinoma, the uterine clear cell carcinoma.

FIGO grading of Endometrial Carcinoma G1: Highly differentiated (composed of glands and 5% of lesion is of solid growth pattern). G2: Moderately differentiated ( 6%-50% of lesion composed of solid sheets of cells). G3: Undifferentiated ( > 50% of lesion composed of solid sheets of cells). Sarcoma Main article: Uterine sarcoma In contrast to endometrial carcinomas, the uncommon endometrial stromal sarcomas are cancers that originate in the non-glandular connective tissue of the endometrium. Uterine carcinosarcoma, formerly called Malignant mixed mllerian tumor, is a rare uterine cancer that contains cancerous cells of both glandular and sarcomatous appearance - in this case, the cell of origin is unknown.[2]

Endometrial stromal sarcoma.

Uterine carcinosarcoma.

An endometrial adenocarcinoma invading the uterine muscle. Signs and symptoms

Vaginal bleeding and/or spotting in postmenopausal women. Abnormal uterine bleeding, abnormal menstrual periods. Bleeding between normal periods in premenopausal women in women older than 40: extremely long, heavy, or frequent episodes of bleeding (may indicate premalignant changes). Anemia, caused by chronic loss of blood. (This may occur if the woman has ignored symptoms of prolonged or frequent abnormal menstrual bleeding.) Lower abdominal pain or pelvic cramping. Thin white or clear vaginal discharge in postmenopausal women.

Risk factors

obesity - the larger the woman, the larger the risk high levels of estrogen endometrial hyperplasia hypertension polycystic ovary syndrome[3] nulliparity (never having carried a pregnancy) infertility (inability to become pregnant) early menarche (onset of menstruation) late menopause (cessation of menstruation) endometrial polyps or other benign growths of the uterine lining diabetes Tamoxifen high intake of animal fat[4] pelvic radiation therapy breast cancer ovarian cancer anovulatory cycles age over 35 lack of exercise[5] heavy daily alcohol consumption (possibly a risk factor) [6]

Diagnosis

Clinical evaluation Routine screening of asymptomatic women is not indicated, since the disease is highly curable in its early stages. Results from a pelvic examination are frequently normal, especially in the early stages of disease. Changes in the size, shape or consistency of the uterus and/or its surrounding, supporting structures may exist when the disease is more advanced.

A Pap smear may be either normal or show abnormal cellular changes. A Pap smear is used to screen for cervical cancer not endometrial cancer. Office endometrial biopsy is the traditional diagnostic method. Both endometrial and endocervical material should be sampled. If endometrial biopsy does not yield sufficient diagnostic material, a dilation and curettage (D&C) is necessary for diagnosing the cancer. Hysteroscopy allows the direct visualization of the uterine cavity and can be used to detect the presence of lesions or tumours. It also permits the doctor to obtain cell samples with minimal damage to the endometrial lining (unlike blind D&C). Endometrial biopsy or aspiration may assist the diagnosis. Transvaginal ultrasound to evaluate the endometrial thickness in women with postmenopausal bleeding is increasingly being used to evaluate for endometrial cancer. Ongoing research suggests that serum p53 antibody may hold value in identifying highrisk endometrial cancer.[7]

Diagnostic test study of S-p53 Ab and agreement study for high-risk endometrial cancer Kappa: 0.70 Sensitivity (%): 64 Specificity(%): 96 PPV: 78 NPV: 92 Pathology

Endometrial adenocarcinoma The histopathology of endometrial cancers is highly diverse. The most common finding is a welldifferentiated endometrioid adenocarcinoma, which is composed of numerous, small, crowded glands with varying degrees of nuclear atypia, mitotic activity, and stratification. This often appears on a background of endometrial hyperplasia. Frank adenocarcinoma may be distinguished from atypical hyperplasia by the finding of clear stromal invasion, or "back-to-

back" glands which represent nondestructive replacement of the endometrial stroma by the cancer. With progression of the disease, the myometrium is infiltrated.[2] However, other subtypes of endometrial cancer exist and carry a less favorable diagnosis such as the uterine papillary serous carcinoma and the clear cell carcinoma. Further evaluation Patients with newly-diagnosed endometrial cancer do not routinely undergo imaging studies, such as CT scans, to evaluate for extent of disease, since this is of low yield. Preoperative evaluation should include a complete medical history and physical examination, pelvic examination and rectal examination with stool guaiac test, chest X-ray, complete blood count, and blood chemistry tests, including liver function tests. Colonoscopy is recommended if the stool is guaiac positive or the woman has symptoms, due to the etiologic factors common to both endometrial cancer and colon cancer. The tumor marker CA-125 is sometimes checked, since this can predict advanced stage disease.[8] In addition to this, both D&C and Pipelle biopsy curettage give 65-70% positive predictive value. But most important of these is hysteroscopy which gives 90-95% positive predictive value. Staging Endometrial carcinoma is surgically staged using the FIGO cancer staging system. The 2010 FIGO staging system is as follows: Carcinoma of the Endometrium

IA Tumor confined to the uterus, no or < myometrial invasion IB Tumor confined to the uterus, > myometrial invasion II Cervical stromal invasion, but not beyond uterus IIIA Tumor invades serosa or adnexa IIIB Vaginal and/or parametrial involvement IIIC1 Pelvic lymph node involvement IIIC2 Para-aortic lymph node involvement, with or without pelvic node involvement IVA Tumor invasion bladder mucosa and/or bowel mucosa IVB Distant metastases including abdominal metastases and/or inguinal lymph nodes

Treatment The primary treatment is surgical. Surgical treatment should consist of, at least, cytologic sampling of the peritoneal fluid, abdominal exploration, palpation and biopsy of suspicious lymph nodes, abdominal hysterectomy, and removal of both ovaries (bilateral salpingooophorectomy). Lymphadenectomy, or removal of pelvic and para-aortic lymph nodes, is sometimes performed for tumors that have high risk features, such as pathologic grade 3 serous or clear-cell tumors, invasion of more than 1/2 the myometrium, or extension to the cervix or adnexa. Sometimes, removal of the omentum is also performed.

Abdominal hysterectomy is recommended over vaginal hysterectomy because it affords the opportunity to examine and obtain washings of the abdominal cavity to detect any further evidence of cancer. Women with stage 1 disease who are at increased risk for recurrence and those with stage 2 disease are often offered surgery in combination with radiation therapy.[9] Chemotherapy may be considered in some cases, especially for those with stage 3 and 4 disease. hormonal therapy with progestins and antiestrogens has been used for the treatment of endometrial stromal sarcomas.[10] The antibody Herceptin, which is used to treat breast cancers that overexpress the HER2/neu protein, has been tried with some success in a phase II trial in women with uterine papillary serous carcinomas that overexpress HER2/neu.[11] Complications of treatment

Uterine perforation may occur during a D&C or an endometrial biopsy.

CANCER OF THE LARYNX

The larynx, also called the voice box or Adam's apple, is the part of the body that allows humans to produce sounds and speech. The larynx contains the vocal cords (glottis), which vibrate when air passes through. The epiglottis is a small flap of cartilage found at the top of the larynx. The epiglottis protects the airways by keeping food and saliva from going down the trachea (the "windpipe" tube that leads to the lungs). Cancer of the larynx can occur on the glottis (most laryngeal cancers are there), the supraglottis (the area above the vocal cords that includes the epiglottis), or the subglottis (the area that connects the larynx to the trachea). Cancer of the larynx affects more men then women, although more women are developing it today due to an increase in smoking in the female population.

Causes of Cancer of the Larynx

Although the exact cause of cancer is unknown, some known risk factors for cancer of the larynx include:

smoking: The risk of laryngeal cancer increases up to 30 times for smokers. The heavier the person smokes, the higher the risk. Second-hand smoke is also considered a hazard. alcohol: Heavy drinkers more than double their risk for this type of cancer, and combining smoking with alcohol can increase the risks even more than either drinking or smoking alone. gastroesophageal reflux disease (GERD): In GERD, the stomach acid backs up into the esophagus, causing a burning pain. Although not definitively proven, researchers have

found that irritation from longstanding GERD is related to higher chances of laryngeal cancer. poor nutrition: Many people who abuse alcohol also have poor nutritional habits, but some research also suggests that not getting enough vitamins might be a risk factor. human papillomavirus (HPV): The virus that can cause genital warts can also develop into certain cancers. Mothers may pass the virus on to their children when they're born. It settles in the larynx, developing into growths called laryngeal papillomas later on in life. These growths may develop into cancer. race: Laryngeal cancer is found twice as often among people of African descent than among Caucasians. gender: More men than women are diagnosed with cancer of the larynx. age: This type of cancer is usually detected in people between 50 and 75 years old. weakened immune system: People with weak immune systems (due to diseases such as AIDS or medications that lower immunity to viruses) are more susceptible to laryngeal cancer. toxic exposure: These risk factors include being exposed to wood dust, asbestos, or many types of chemicals that can increase the chances of cancer. voice overuse: People who use their voices a lot, such as singers, may develop polyps (lumps of tissue) that can become cancerous if not removed.

Symptoms and Complications of Cancer of the Larynx

The symptoms of laryngeal cancer depend on where in the larynx the tumour is located. Cancer on the vocal cords can often be detected early because the main symptom is hoarseness. Most people go hoarse from time to time, but if the hoarseness doesn't go away in two weeks, it should be checked. Symptoms that the cancer has spread or is occurring in another part of the larynx include:

a cough that doesn't go away persistent sore throat breathing difficulties, or feeling that something is catching in the throat ear pain (pain from deep in the throat can be felt in the ear) a lump or mass in the neck or throat coughing up of blood

There are a few complications that can result from laryngeal cancer. Airway obstruction: Any tumour or swelling in the airway can cause a blockage, making breathing difficult. If treatment involves total removal of the larynx, a tracheostomy (surgery to create an artificial airway in the trachea) is then performed to improve breathing. Disfigurement: Removing the tumour and surrounding tissue could leave some disfigurement of the throat and neck. Muscles might be removed as well, making neck movement more difficult. If a tracheostomy was performed, the stoma (opening in the throat) is sometimes permanent.

Difficulty eating: After surgery, it may become difficult to swallow certain consistencies of food. Those undergoing radiotherapy may have trouble swallowing or even chewing. Chemotherapy can cause nausea and vomiting. A good, healthy diet is vital when recuperating from cancer, so it's important that adequate nutrition be maintained throughout the treatment. Cancer spread: It's possible that the cancer may spread to other areas of the body. Voice loss: Treatment that involves removing the entire larynx makes normal speech impossible. In this case, alternate methods of speaking need to be learned. These are:

esophageal speech: This is the most basic form of alternate speech, which is done by swallowing air and creating sound by expelling it. tracheoesophageal puncture (TEP): A small one-way valve is placed between the trachea and esophagus. By taking in air through their stoma into the lungs, then covering their stoma (from the tracheostomy), sounds can be made through the mouth. electrolarynx: When you hold this electronic device next to the skin of the throat or the corner of the mouth, it produces a mechanical voice. Muscle movements stimulate the machine to make sounds.

While these new methods of speech are being learned, other ways of communicating will be needed. This might mean keeping a "magic slate" or pad and pencils easily available. It's important to plan ahead to help avoid frustration after surgery.

Diagnosing Cancer of the Larynx

If cancer is suspected, your doctor will first take a medical history, including information about smoking and alcohol use. It's important to mention past use or exposure even if there's none at the present. After a physical exam, the following tests may be performed:

laryngoscopy: A flexible tube (fiberoptic scope) is used to check for tumours or polyps in the larynx, mouth, tongue, and neck. computed tomography(CT): A type of scan that allows the doctors to see any abnormalities (e.g., imaging of the neck). magnetic resonance imaging (MRI): Another type of scan that can detect abnormalities in the neck. chest X-ray: This test checks for any tumours that may have spread into the lungs. positron emission tomography (PET) scan: This test can help define the extent of cancer in the neck, as well as identify any distant areas of spread. biopsy: Removal of a small section of tumour tissue to examine any signs of cancer. The tissue is taken either during an endoscopy or through a fine needle that is inserted into the neck (local freezing or general anaesthesia may be used to make the procedure more comfortable).

Diagnosis also includes determining the stage of the cancer in order to identify how advanced it is.

stage 0: The cancer has not invaded the tissue and can be removed from the vocal cords without removing any tissue. stages 1 and 2: The cancer has invaded the local tissue but is still in the body area where it started. stages 3 and 4: The cancer has invaded beyond the local tissue and has probably spread (metastasis) to local lymph nodes, or even more distant sites elsewhere in the body. recurrent: The cancer has returned after initial treatment.

Treating and Preventing Cancer of the Larynx

Like most cancers, treatment for laryngeal cancer involves surgery, radiotherapy, chemotherapy, or a combination of treatments. The decision about what type of therapy to use is made according to how advanced the cancer is (i.e., the stage) and exactly where it is located. Early-stage cancer of the larynx can often be treated with radiation alone. Radiotherapy is the preferred method whenever possible, because it usually doesn't affect the quality of the voice and side effects are most often temporary. The side effects to radiation can include:

sensitive mouth and gums sores in the mouth dry mouth sore throat voice changes red, dry skin change in or loss of sense of taste or smell

Surgery can involve removing the whole larynx and surrounding tissues or just part of the larynx, depending on how far the cancer has spread. With partial removal (laryngectomy), you will often be able to eat and breathe as you did before the surgery, after healing is complete. You will probably have a temporary tracheostomy while the throat repairs, but the stoma will be allowed to close up and breathing will return to normal. Your voice quality may change but you will be able to speak. If you need to undergo a total laryngectomy where the voice box is completely removed, you will be left with a tracheostomy in order to breathe. This tracheostomy is permanent. Finally, chemotherapy may be needed if the cancer has spread. Chemotherapy is also used to "sensitize" the area for radiation in cases of advanced tumours that are still thought to be treatable. Because chemotherapy circulates throughout the body, more of the body systems are affected by the treatment. Side effects from chemotherapy include:

nausea and vomiting

possible hair loss fatigue diarrhea mouth sores increased risk of infections damage to hearing

The five-year survival rate for laryngeal cancer that's detected early is usually 80% or more. Most recurrences of cancer happen within the first 2 or 3 years of treatment. Follow-up procedures usually involve monthly checkups for the first year and then every few months thereafter. Unfortunately, because the very same risk factors that might have caused the first tumour may also have caused other damage, the chances of a second tumour developing (often in the head, neck, or lung) can be as high as 25%. Many risk factors for cancer of the larynx are known, the most common of these being smoking and heavy alcohol use. Many cases of cancer could be prevented by avoiding these known causes. Other ways to reduce risk include:

using respirators when in industrial areas with cancer-causing chemicals getting treatment for GERD eating a healthy and balanced diet

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