Hi, I am writing from New Delhi, India.

Papa has been diagnosed with stage 2 oral tongue cancer. CT scan indicates POSSIBLE involvement of the lymph nodes and a MRI and PET scan are being done.

My question: is it normal for the surgeon to remove all or part of the lymph nodes as a precaution?

Does anyone have any statistical info on recurrence?

FInally what is your opinion on how lymph nodes should be handled if no involvement is present? One ENT we saw said to remove ALL the lymph nodes regardless as a precaution, while another said he does a "selective clearance" followed by detailed pathology.

As part of the removal of the forepart of my tongue and replacement with a 'free flap' (new tongue front built from various tissues harvested from my wrist), the surgeon removed the lymph glands under my chin -- He connected the blood vessels from my free flap to the vessels in where the glands were.

He made the comment to me that after the need for the lymph system in youth, he considers them to now just be "repositories for cancer cells".

I would guess that it is up to the practice of the surgeon and the location of the glands with respect to the primary cancer site as to how much additional removal work would be done.

BTW, the PET/CT/MRI scans prior to my surgery indicated that the cancer was limited to my tongue and the biopsies, including the lymph tissue) bore that out.

Here's what I know about this. The thing is even when CTs show no lymph involvement, 30% of the time they are wrong. 30% oif the time there is "occult" metastasis that does not show up on scans but shows up when the nodes are removed and tested. So yes, removing some lymph nodes even when the scans show no cancer is fairly normal, especially if treatment following that will depend on whether any cancer is found in the nodes.

OTOH, if it is already clear there IS cancer in the nodes and treatment is going to be the full thing (chemo and radiation), then it seems sometimes doctors are less likely to remove nodes until after treatment and even then only if there is some sign the treatment may not have gotten rid of the cancer in the nodes.

Hope this helps--it was definitely a relevant issue when I was undergoing the beginnings of treatment so that's why I ;learned this.

Nelie

There are lots of articles and research on the site and on the internet about handling of potential cervical lymph node metastasis.

If there is any clinical indication of lymph node involvement, I think the prevailing view is to do a neck dissection of some sort. These vary from a radical neck dissection, which customarily involves removal of lymph nodes at levels I through V, the Internal Jugular Vein, the Spinal Accessory Nerve and the Sternocleidomastoid muscle. These are done less frequently today, as effort is made to preserve as many of the non-lymphatic structures as possible. Names for other neck dissections short of radical include Modified Radical, Functional, and Selective. The primary difference between the various types is the number of non-lymphatic structures involved and the number of lymph node levels removed.

It is a misnomer to say that all of the lymph nodes are removed. They remove quite a few, but rarely, if ever, is every single lymph node in the neck removed.

In my case, I had a Modified Radical Neck dissection on both sides, where they removed a number of lymph nodes from all 5 levels, as well as the submandibular glands on each side. I had 1 clinically positive node that was enlarged to just under 3 cm, and another that showed some microscopic involvement. My neck dissection came first, followed 4 weeks later by the radiation and chemotherapy. Our CCC has had good results with that protocol, though others have had equally good results by doing chemo/rad first, then the neck dissection.

The type of neck dissection depends upon the clinical findings and where you want to fall on the risk/side effect matrix. The more levels of lymph nodes removed, the greater chance that all of the involved nodes are gone, but also a greater chance of long term side effects.

The neck dissection surgery is the easiest part of the whole process, by far. I had three drains installed after surgery, and was home, without drains, 4 days later. Other than looking like Frankenstein for awhile, it is really not a big issue. I have some stiffness and nerve issues today, but am willing to accept those.

Good luck!

Marma:

I was stage 1 with the tumor being located in my left cheek and also another stage 1 tumor located on the roof of my mouth behind my top left molar. No lymph nodes were involved, no neck dissection. My second cancer (only 4 months after getting a clean PET scan) was the same spot in my cheek, it was also stage 1 with no lymph nodes.

Try not to worry at this point about a recurrance. Anyone who has cancer is always at a higher risk for a recurrance. One thing to know is that your father is being treated and taken care of. If the cancer returns, then it would be caught very early so it would be taken care of quickly. There are several survivors on here who have gone thru having cancer twice.

I was a Stage IV with at least 2 positive nodes, one appx 2 cms and 1 appx 3 cms and Moffitt told me they wouldn't recommend a RND or a PND as the healing would postpone the treatment (radiation) that would most likely kill the cancer anyway. They said they could always go in post Tx if necessary but they didn't believe they would have to. So far so good.

I just want to point out that David's case (which is similar to many peoples in terms of stage at diagnosis) is one where they knew already the cancer had advanced to the lymph nodes and thus that radiation would be done. So in that case, it makes sense to me they wouldn't see a need for doing a neck dissection before the radiation and chemo and would only recommend one afterwards if there was an indication that the rad and chemo hadn't cleaned everything up.

OTOH, in my case, and for many people who are Stage II, there is no indication, either from feeling the nodes or from a CT that the cancer has spread to the nodes BUT ****there is practically a one in three chance**** that it HAS but cannot be detected by any kind of non-invasive clinical observation (such as a CT or feeling the nodes) but WILL be found if a neck dissection is done. If you are one of those 30%, then what THAT means is your cancer is actually more advanced than it appears without a neck dissection and if you DON'T have a neck dissection you may end up being undertreated because of that.

So actually, ironically, from what I've seen here that often mean that people who appear to be stage II are more likely to get neck dissections before the decision about rad/chemo is made than people who have later stage cancers where rad/chemo is going to happen no matter what.

Nelie

My neck dissection upped me from a Stage 3 tumor, with one palpable, involved lymph node, to Stage 4 with three positive nodes, which changed not only my radiation to a longer course, 35 instead of 32, but also added Erbitux to my chemo mix.

So I have no regrets about it.

Granted I didn't have a ND but I have read hundreds of posts of people that did and I guess my question is if you are going to get the radiation anyway and if there's any chance it might have already spread to the nodes then wouldn't it be better to have the nodal areas radiated and potentially avoid one or both ND's? I just don't understand the rush to do the surgery if it can be avoided.