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Editorial Reviews. Review. Isn't the part of the excitement of living your own mystery--seeing if Beg(ga)(he)r - Kindle edition by J. R. Armstrong. Download it.
Table of contents
However, MRI is not without its drawbacks. Because all the images within a given MRI sequence are obtained simultaneously rather than sequentially, patient movement during an MRI is less well tolerated than with CT. In addition, although the soft-tissue contrast is superb with MRI, fine-bone detail is inferior to that obtained with CT. Under certain conditions, exfoliative cytology cell scrapings serves as an adjunct to clinical diagnosis, as it enables more extensive screening and provides microscopic material if there is a delay in or contraindication to biopsy.
J.R. Armstrong
However, cytologic smears are used infrequently, and patients are not treated on the basis of cytologic findings alone. Smears are most helpful in differentiating inflammatory conditions, especially candidiasis, from dysplastic or neoplastic surface lesions.
In addition, cytology may be helpful in detecting field change in oral cancer, especially if this method is used in conjunction with vital staining. Cytology may also be helpful when ulcerations following radiation are suspicious and biopsy is delayed. Fine needle aspiration biopsy of subsurface masses is also an accepted diagnostic test, one that has increased in popularity over the past few years.
This technique is extremely useful in evaluating clinically suspicious changes involving salivary glands and lymph nodes. It expedites diagnosis and. When used by a skilled clinician, fine needle aspiration can often be the best way to establish a definitive diagnosis of unexplained masses of the neck or salivary glands.
It is also valuable in following up cancer patients with suspicious enlargements. The stage of the disease depends on several factors, including the size of the primary lesion, local extension, lymph node involvement, and evidence of distant metastasis. This system has 3 basic clinical features: the size in centimeters of the primary tumor; the presence, number, size, and spread unilateral or bilateral to the local lymph nodes; and the presence or absence of distant metastasis.
N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N2a Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension. N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.
Beg(ga)(he)r
M1 Distant metastasis The individual clinical parameters in the TNM classification system are grouped to determine the appropriate disease stage Table 5 ; stages are ranked numerically from 0 which has the best prognosis to IV the worst prognosis. In general, oral staging classifications do not use histopathologic findings except to determine the definitive diagnosis. Schematic drawings of the tumor tumor maps are frequently prepared to document the site and size of the tumor at the initial time of diagnosis. This initial documentation is later complemented by histopathologic findings and imaging preformed during the treatment phase.
Although the risk of distant metastasis is generally low in patients with oral cancer, there is a 17 correlation between the incidence of distant metastasis and tumor T and neck N stage. When they do occur, the most frequently involved organs are the lungs, bone, and liver. Patients with advanced T or N stages may be at risk for developing metastases outside the head and neck region; a limited workup chest x-ray, CBC and liver function tests, bone scan to exclude such a metastasis may be indicated.
After completion of the initial workup, the final T, N, M metastasis , and overall stage assignment should be formally determined and documented prior to treatment. Oral squamous cell carcinoma spreads primarily by local extension and somewhat less often by the lymphatics.
The lymphatic system is the most important and frequent route of metastasis. Usually the ipsilateral cervical lymph nodes are the primary site for metastatic deposits, but occasionally contralateral or bilateral metastatic deposits are detected. The risk for lymphatic spread is greater for posterior lesions of the oral cavity, possibly because of delayed diagnosis or increased lymphatic drainage at those sites, or both. Cervical lymph nodes with metastatic deposits are firm-to-hard, nontender enlargements. Once the tumor cells perforate the nodal capsule and invade the surrounding tissue, these lymph nodes become fixed and non mobile.
Metastatic spread of tumor deposits from oral carcinoma usually occurs in an orderly pattern, beginning with the uppermost lymph nodes and spreading down the cervical chain. Because of this pattern of spread, the jugulo-digastric nodes are most prone to early metastasis. Carcinomas involving the lower lip and floor of the mouth are an exception, as they tend to spread to the submental nodes. Hematogenous spread of tumor cells is infrequent in the oral cavity but may occur because of direct vascular invasion or seeding from surgical manipulation. Among the most common sites for distant metastasis are the lungs, liver, and bones.
These patients cannot be cured and are treated with palliative intent, usually involving chemotherapy, radiotherapy, or both. These patients are treated with curative intent, usually involving surgery, radiation therapy, 2 or both. Tumor recurrences most often occur during the first 2 years after therapy; later recurrences are rare. Thus, with sufficient follow-up time, second malignancies or other medical diseases become greater problems than recurrence of the primary disease. The use of drug therapy to decrease the rate of second malignancies is being actively investigated.
Patients with locoregionally advanced disease T 3 , T 4 , N 1 , N 2 3 , and N are also treated with curative intent. Given the advanced stage of their disease, surgery and radiation are utilized unless patients are considered inoperable or have unresectable disease. Despite this aggressive bimodality therapy, the majority of these cancers will recur within the first 2 years of follow-up, most commonly either locally or regionally. Some of these patients may have metastases outside the head and neck area, events that might be predicted by their initial T and N stages.
Investigational therapy in this group of patients, therefore, must focus primarily on delivering more effective locoregional care.
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However, should locoregional control be improved, chemopreventive strategies will need to be pursued in this group of patients as well since, in principle, oral cancer patients are at risk for developing second primary malignancies in the oral cavity, pharynx, and respiratory and digestive tracts. When a second malignancy occurs at the same time as the initial lesion, it is called a synchronous carcinoma. Metachronous neoplasms, on the other hand, are additional primary surface epithelial malignancies that develop in a later time period than the original tumor.
The remaining multiple cancers in this population represent metachronous disease and usually develop within 3 years 19 of the initial tumor. The overall risk for developing a second head and neck malignancy is 10 to 30 times higher in populations that use tobacco and alcohol than in the general population. At the present time, the most effective approach to reducing morbidity and mortality from oral cancer is early detection. However, progress in this area requires changes in public and professional knowledge, attitudes, behaviors, and practices see Chapter IX for a full discussion.
The use of immunohistochemical techniques to establish a definitive diagnosis has expanded during the past decade and continues to be refined.
Beg(ga)(he)r by J.R. Armstrong
These diagnostic tests help to establish a definitive diagnosis when, by routine histopathology techniques, a lesion appears morphologically benign or its classification is in doubt. Research on the biochemical, genetic, and cellular levels should yield information that will identify high-risk groups for many types of cancer including oral cancer. Imaging techniques continue to improve at a rapid rate. Newer imaging techniques hold promise for 24 clinical staging of T 2, T 3 and T 4 1 lesions, but T lesions are typically too small to be visualized.
Improvements that increase definition will promote earlier detection of nasopharyngeal, submucosal, and bone lesions. One such technique appropriate for lymph nodes is positron emission tomography, which may help to define tumor activity in clinically negative areas. No matter which diagnostic technique is used, there is the possibility of a false-negative diagnosis.
Armstrong Biography. She has a B. Owe It To The Wind and Truly, Everything the sequel were written in 11 cities on two continents, including a Caribbean Island as the author traveled with her husband who worked in professional baseball. The two live near Lansing, Michigan and have four children, a dog and four cats. Where to find J.
Armstrong online. Where to buy in print. Dead Breaths by J. Words: 3, Language: English. But when the final secrets are revealed, including a romance with a twist, hopefully this engaging tour de force is just the beginning of an exciting new phase for this curious and creative character. Review of Books; review by Carol Davala.