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Metastatic Lymph Nodes

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If an adult in your life has metastatic lymph node cancer, you may want to learn more about it. This page has information about metastatic lymph nodes, the types and what to expect.

First, you should understand what cancer is. Cancer is a disease of unhealthy cells. Our bodies are made of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they don’t allow our normal cells to work properly. There are many different types of cancer that can grow anywhere in the body.

Some people with head and neck cancer go to a doctor because they feel a “swollen gland” or lump in the neck. Lymph nodes can be swollen for many reasons, including inflammation, infection or cancer. In general, swollen glands that get larger and then smaller, or those that go away, are not cancer. Also, enlarged lymph nodes that are there for just one to two weeks are not typically cancer.

This article is about those who have been diagnosed with metastatic lymph node(s) in the neck. The only way to make that diagnosis with certainty is after looking at some cells from the lymph node under a microscope.

Metastasis means when cancer cells spread outside the main tumor. Cancer spreads from the main site in two ways: through the lymph nodes and through the bloodstream.

Lymph nodes are tiny round or oval organs found all over the body, and they are connected through a system of lymphatic channels. They help the body fight infection through white blood cells. They act as filters of anything that should not be in the body, including cancer cells. Metastatic lymph nodes are those that have cancer cells in them (spread from a primary tumor somewhere else).

Lymphatic spread of cancer in the head and neck region results in swollen lymph nodes in the face or neck (these are called regional lymph nodes because they are in the region of the head and neck).

Your loved one may have noticed a lump or swelling in the neck and brought it to the attention of a doctor. Not every lump or bump is cancer, but it is a good idea to ask a doctor when you are not sure. The earlier cancer is found, the better the outcome.

Understanding the anatomy

To understand metastatic lymph node cancer, you need a basic understanding of the anatomy (parts) of your head and neck.

Fluid around cells—along with toxins, bacteria, viruses, nutrients and proteins—enters lymphatic vessels near arterioles and veins. This fluid, once inside the lymphatic vessel, is called lymph. Lymph contains byproducts from cells in organs and tissues all over the body. Lymph travels from these tissues throughout the body through lymphatic channels. Lymph then enters into the bloodstream through veins as well as in the spleen. The organs of the lymphatic system are lymph nodes, the spleen and the thymus. The (palatine) tonsils, adenoids and lingual tonsils are part of the lymphatic system.

Lymph and lymph nodes are found all over the body, in and around all organs. That is why the blood cancer called lymphoma can be found just about anywhere in the body. When a head and neck cancer spreads into the lymph system, however, there is a fairly predictable pattern of where the cancer spreads.

Head and neck cancers spread to lymph nodes in the neck. The lymph nodes of the neck are broken down into different regions called levels. This helps doctors talk about and research spread of cancer into the neck:

73_lymph_nodes_neck07_neck_levels

Causes of metastatic lymph node cancer

You may want to know what caused the metastatic lymph node cancer. The short answer is that we don’t know. You can be sure that you did nothing to cause it. Also, it is not contagious (you can’t catch it).

Signs and symptoms of metastatic lymph node cancer

Cancer in the neck presents in two ways: there is a lump in the neck, or medical tests show a mass in the neck that needs to be examined.

If your loved one has metastatic lymph node cancer, he or she may have had a fever, chills, night sweats, tiredness and weight loss. There may also be swollen lymph nodes in other places in the body.

But don’t jump to conclusions. Your loved one could have one or more of these symptoms but NOT metastatic lymph node cancer. There are several non-cancerous causes of the same symptoms. That’s why he or she needs to see a specialist.

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to the patient talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face or mouth?
  • Do you have any changes in your vision or hearing?
  • Do you have a change in your sense of smell?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of cancer?
  • Have you been exposed to a cat?
  • Have you travelled anywhere or been around anyone with an infectious disease such as tuberculosis?

Step 2: Physical Exam

Next, the doctor will look at and feel the patient’s head and neck. The head and neck typically require a specialist to examine them because they are not easy for a general doctor to see and feel. In general, the specialist might do some of the following:

  • Look and feel inside the mouth
  • Feel the neck extensively and carefully to check for any lumps or bumps
  • Look inside the ears
  • Look inside the front of the nose
  • Check the cranial nerves, do some simple hearing tests and test sense of touch all over the face

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests the patient has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing metastatic lymph node cancer

If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that the lesion is cancer, the doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

However, if the doctor is suspicious, he or she may choose one or more of the following actions.

Imaging

Imaging refers to radiologic studies, or scans, that make pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location to see if the tumor has spread to nearby lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment the doctor recommends.

Some surgeons also say getting some imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues about whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information. A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it. The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan uses radiation, which can be dangerous. The pictures might not be clear if the patient moves or has a lot of dental work. Also, a CT doesn’t show damage to nearby body parts as clearly unless the damage is moderate to severe. An MRI takes a lot longer than a CT scan. It requires the patient to lie perfectly still for almost an hour. The patient can’t have an MRI if he or she has metal implants.

For most head and neck cancers, if imaging is required, the doctor will likely start with a CT scan with contrast. Other tests might include an MRI and/or a positron emission tomography (PET) scan.

Biopsy

A biopsy is the main way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during the first visit, and there is a very low chance of anything going wrong.

Some tumors can be biopsied in the office with a little numbing medicine (either a spray or a tiny injection or both). It usually takes only a few seconds to do the biopsy.

In some cases, however, the doctor may want to do the biopsy in the operating room, especially if there is concern about involvement into the neck or throat.

A biopsy can help the doctor plan the surgery if the decision is to take out the whole tumor. A biopsy can also prevent unnecessary surgery.

As good as biopsies sound, there are a few problems. First, biopsies are not 100 percent accurate. A biopsy could show that a growth is NOT cancer when it really is; this is called a false-negative biopsy. A false-positive is also possible when the biopsy seems to show that a growth is cancer but more testing shows it isn’t. Sometimes doctors can’t be sure from a biopsy

Determining the type of metastatic lymph node cancer

Now the doctor will need to figure out what type of cancer it is. He or she may be able to tell from biopsy results. The doctor may also want a second opinion from a specialist to be sure. Cancer can spread to the lymph nodes of the neck from primary tumors in the head and neck or from other sites in your body.

  • Metastatic lymph nodes: Spread to neck lymph nodes from the head and neck region
    • Cancer from the mouth, throat, nose, face or scalp
    • Cancers from the skin, thyroid or salivary glands
    • Cancers from an unknown primary source
  • Distant metastatic cancer: Cancers spread to neck lymph nodes from an area below the collar bones such as the lungs, stomach, kidney, testicles or just about anywhere else.

The doctor will determine the treatment for the cancer based on the category, grade and stage of the tumor.

Determining the grade of the tumor

Determining the grade of the tumor

Pathologists will typically report on the grade of the tumor. This is a pathologist’s interpretation of how much the cancerous cells resemble normal tissue from that site. There are a number of different grading systems that might be used. The most common is as follows:

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly differentiated
  • G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumor or lesion resemble normal cells from the healthy tissue surrounding the tumor. “Well differentiated” means that the cells look similar to normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumor’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this particular cancer type.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be based on all of the available information. Stage is based on the physical exam, imaging studies, laboratory work and biopsies.

Like with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

T stage: the main tumor

Based on a physical examination and review of any imaging, the doctor should be able to assign a T stage that falls within one of the following categories.

Tx The main tumor cannot be assessed.
T0 There is no evidence of the main tumor.
T1a The main tumor is 5 centimeters or less at its largest point (and is superficial).
T1b The main tumor is 5 centimeters or less at its largest point (and is deep).
T2a The main tumor is more than 5 centimeters at its largest point (and is superficial).
T2b The main tumor is more than 5 centimeters at its largest point (and is deep).

N stage: spread of cancer to the lymph nodes in the neck

Next, the doctor will use all the available information to figure out the N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

06_Nstages

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 There is a single node on the same side of the main tumor, that is 3 centimeters or less in greatest size.
N2a Cancer has spread to a single lymph node on the same side as the main tumor, and it is more than 3 centimeters but less than or equal to 6 centimeters in greatest dimension.
N2b There are multiple lymph nodes that have cancer on the same side as the main tumor, but none is more than 6 centimeters in size.
N2c There are lymph nodes in the neck on either the opposite side as the main cancer or on both sides of the neck, but none are more than 6 centimeters.
N3 There is spread to one or more neck lymph nodes, and the size is greater than 6 centimeters.

M stage: spread of cancer outside the head and neck

Finally, the doctor will identify an M stage. The M stage is based on an examination of the entire body.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

The cancer stage

After TNM staging, the doctor can assign a cancer stage based on the following chart.

Stage IA T1a N0, NX M0 Low Grade
T1b N0, NX M0 Low Grade
Stage IB T2a N0, NX M0 Low Grade
T2b N0, NX M0 Low Grade
Stage IIA T1a N0, NX M0 High Grade
T1b N0, NX M0 High Grade
Stage IIB T2a N0, NX M0 High Grade
Stage III T2b N0, NX M0 High Grade
Stage IV Any T N1 M0 Any Grade
Any T Any N M1 Any Grade

The clinical stage

Once the tests are completed, and before deciding on a treatment plan, the patient should be given a clinical stage that looks like this:

CLINICAL STAGE
Site Cancer with an Unknown Primary (CUP)
Subsite Unknown
Type Squamous cell carcinoma
cT cTx
cN cN2b
cM cM0
cStage cIV

Deciding on a treatment plan

Like with all cancers in the head and neck, there are three general treatment options:

Let’s look at the types of treatments available.

Surgery

Treatment for metastatic lymph node cancers is likely to include the surgical removal of the affected lymph nodes. Another doctor, called a pathologist, will look at the removed lymph nodes to identify a more exact stage for the cancer. Removing lymph nodes from the neck does not alter the body’s ability to fight infection—so the patient should not be worried about that.

Radiation

Radiation therapy kills cancer cells with high-energy radiation such as X-rays or gamma rays. Radiation may be used as a main treatment for metastatic lymph node cancers. The surgeon will use radiation alone or radiation with chemotherapy, depending on the characteristics of the cancer. Radiation is also often used after surgery to lower the chances that the cancer will come back.

Chemotherapy

Chemotherapy, or “chemo,” uses drugs to kill cancer cells. Chemotherapy is often used when cancer has spread to the lymph nodes and beyond because it attacks cancer throughout the body.

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that a person with cancer will be cured? Will the cancer come back? How will your loved one’s life change? These are the big questions on most people’s minds when they find out that someone they love has metastatic lymph node cancer.

The following characteristics of the cancer may affect the chances of a cure.

Factors That Can Affect the Chances of Being Cured
Stage This is the most important factor that affects the chances of being cured. Cancers in earlier stages usually have better outcomes.
Type and Grade The type and grade of tumor shows how aggressive a tumor is.
Spread to Lymph Nodes If there is spread to lymph nodes in the neck, there is a lower chance of cure.
The Tumor Margins (edges) Some would argue that the ability to completely remove the tumor is the single most important factor in whether a person will be cured.
Spread into Nearby Body Parts Spread into large nerves, skin and bone have been shown to indicate a worse prognosis.

In general, it is very difficult to discuss prognosis without understanding all the details of the cancer; to give a percentage chance of cure is really difficult because cancer research looks at all sorts of different types of cancers and may include patients from long ago.

What to expect after treatment is completed

After making it through treatment, your loved one will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. In general, your loved one should have regularly scheduled doctor’s visits every one to three months for the first year, every two to six months in the second year and every four to eight months in the third to fifth year. After making it past the first five years, your loved one can then see the doctor once a year.

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