From JAMA article on extracapsular spread (ECS) of nodes in SCC patients.

Can ECS be determined without neck biopsy done from removed nodes in neck dissection? There was no indication on the PET/CT, FNA of lymph node, or other biopsies done on me.

Maybe spending too much time trying to scare myself these days but got interested in the topic of extracapsular nodes.

[quote]Five-year adjusted survival for patients without metastatic nodes in the neck dissection (pN0) was 85.5%, for patients with neck node metastases without ECS (pN+/ECS−) it was 62.5%, and for patients with neck node metastases with ECS (pN+/ECS+) it was 29.9%. [/quote]

http://archotol.jamanetwork.com/article.aspx?articleid=1688126#RESULTS

I didn't read the article yet, Don. There is extracapsular extension and extracapsular spread, which difference I'm not fully sure about or just means the same. Maybe one is more wide spread than the other or one is more concerned with the nodes?

I have extracapsular spread, for lack of better words, which could be from the primary or nodes. I was told in laymen's term it's "Roaming" and "Free Form Cancer" basically cancer not lymph nodes or primary, and can go anywhere, and did. My lymph's from the Radical neck dissection levels II-V, had no nodal extension, negative margins, but cancer was found in my neck muscle from surgery...not a good sign, but it was taken out..a good thing. 5 months later I had another recurrence, the two suspected lymph nodes were in level III, V, but after removal were found not to be lymph nodes, most were removed anyway, but was "free form cancer" or "roaming cancer" or extracapsular spread for a better medical term I could find. The FNAB of the suspicion had confirmed it was metastic, but not that it wasn't a node. Positive margins, perineural and lymphovascular invasion was also found from the biopsy, meaning cancer was likely to spread along the nerve, blood, and lymph line, and did in less than a month to the edipermal layer of skin in level V, and had further surgery, radiation, and more chemoradiation. I have another suspicion on my last PET a few weeks ago in Level III, and have to get a FNAB with sonogram on Thursday, which again says a node? I had cancer in the same spot 3x, surgery 3x, radiation 3x and is close to the carotid artery, so wondering also.

Anyway, to answer your question they may be able to tell, not for certain, but by diagnostic scan due the lymph shape, size if its has signs of ECD or other. An MRI is good to see if there is nerve, vein involvement, but as usual, nothing is confirmed without a biopsy, I guess. A biopsy of the node or even primary may tell if it's out of the node or primary, or has other involvement.

Even with ECS or ECE, PNI, LVI, does not mean cancer will return or spread just that it may or will likely based on the percentages. Usually more surgery is done, if possible, more radiation, chemo to help prevent the spread. I think PNI has worse prognostic factor than LVI.

As I mentioned, most post treatments scans are clear, I believe in the hight 90% range. HPV HNC has a lower rate of recurrence, 15%, compared to non HPV, which is much higher.

The p before the TNM classification means pathological, A c means clinical, and a s means surgical classification.

Good luck with your PET. All I an say between now and then is go to the festival on Sept. 7th

Extracapsular spread usually refers to microscopic cancer cells outside of the lymph glands and extracapsular extension is an indication of macroscopic cancer cells typically between lymph nodes or connected cancer cells from lymph node to lymph node if that makes sense. I have heard one mentioned as random or loose cells only visible under a microscope while extension is usually visible from PET/Ct scans or MRI with contrast.

Thanks Ed, basically in line what I thinking. i read somewhere ECS can mean cancer outside the tumor, including the primary. It can be confusing. I guess several of my tumors, non lymph's, a few cm, are just called metastases caused by ECE, ECS, PNI, LVI, floating cancer or by some other route micro or macroscopically, and will never find out. Another one is extracapsular tumor growth lol. The most I see about is ECE with the lymph's, but probably used as a general term, non medically, for anything outside the lymph area.

Add to that an unknown primary and the numbers skew to who knows what. My tumors were extracapsular. I also was HPV+. Initial PET showed uptake in the neck nodes that were removed via selective neck dissection and a very small uptake right tonsil. Subsequent biopsies found nothing in the tonsils (palatine and lingual). 1st post TX PET was clear.

Based on those stats, I have a pretty good chance at a recurrence but I honestly don't dwell on it at all. I must suffer from the opposite of anxiety ~lol~

With HPV+ it can happen that the primary may not be found. One thought is the body fought off the HPV disease at the primary site, but had a chance to metastesize, another is the primary dies off when the primary metastesises to the lymph nodes taking all the nutrients, blood with it. I guess similar to angiogenesis of something like that or the primary is too small to be seen on any scans, and only found when it is in the lymph nodes where it can grow much larger due to cystic fluid, rich in nutruents, blood. 80% of the time, an unknown primary is in the oropharynx, basucally the lingual and plentine tonsils, and reason they do a tonsillectomy, and radiate, usually both sides.

I have seen studies for one year overall survival with HNC HPV+ to be 100%, another at 3years overall survival was also 100%. I seen rates increased in one analysis after three years, but overall, is still low at 15% vs. non HPV.

Moffitt did an exploratory to find my Primary. They had already identified 2 suspicious nodes one of which was biopsied and positive for SCC. They weren't positive but the thought they found what was left of the Primary at BOT. Decided not to do a Neck Dissection but to add chemo and radiate both sides. All of this was before HPV was a first thought or even a second thought. I had to press to get my slides tested by Maura Gillison then at JH post Tx. Those were the HPV Dark Ages but Moffitt's explanation re the Primary was my immune system probably cleared it but not before some cancer cells broke off and found the node as it was supposed to. They couldn't explain why my immune system couldn't handle the nodal attack.

[quote=PaulB] 80% of the time, an unknown primary is in the oropharynx...[/quote]

That's how I was treated, radiating both sides. My team feels my body eradicated the primary site but not before it spread it's joy to my lymph nodes. I would have had rads only if the tumors had not been extracapsulated.

"T"

I was never tested for HPV in 2009, to my knowledge. It was mentioned as possibly the cause by the MO, but I knew very little about it, and never asked further, and I fell through the cracks, and so did my treatment. It wasn't until two years later that I inquired with my ENT, and he saw nothing in the files I was tested. My CCC is also at the forefront with HPV studies, so I don't know what happened, probably not required then, but believe testing is now for any oropharyngeal cancer. There wasn't as much information as there is now about HPV, at least what I saw initially nor that there was a better survival rate with HPV. Anyway, the treatment was/is basically the same for positive and negative HPV. Although, I did have Induction Chemo, to be followed by Chemoradiation, which I found later there was a study for it with HPV about then. I don't know if I was a participant or was used off label. Fact is, I didn't even know what type of chemo I was getting then, and just signed papers lol. I thought I was tougher than anything, cancer, chemo lol.

Extra capsular anything is usually a signal that they should follow up your surgery with rads and chemo...

[quote]Extra capsular anything is usually a signal that they should follow up your surgery with rads and chemo... smile[/quote]The reason I asked about extracapsular is it did not pop up as a term referenced in my tests, diagnosis, or treatment. The main points were the biopsies of the BOT primary and FNA of the lymph stated "poorly differentiated SCC", no mention of extracapsular.

Can they even determine extracapsular from an FNA? I am thinking they can really only determine this if the entire nodes are removed then examined.

Given I got the full "drano" chemo treatment, maybe it does not matter as any loose, micro cancers were killed off which is fine with me. I sure sleep much better knowing my whole system got a full flush then chemo-rads to ensure total annihilation of the nasties.

Foo,

The only way I know that they can tell if the tumors are extracapsulated is by direct exam. When they went in to remove mine, it was obvious they had broken out...

"T"

i read a CT can show ECS, sometimes, and forget the details, and there are always details lol. As Ed explained, ECS is different than ECE, and one is microscopic and other macroscopic, and is surely confusing. I think if its absent in any report is none was seen, but as T mentioned, it wasn't until they went to remove them it was apparent. They can also tell by the size of the node it may. Don, most HPVOPC are poorly differentiated.

Paul,

I'm pretty sure your cancer slides from 2009 are still required to be stored ( I think I remember being told 7 yrs) so they still could be tested for HPV.

Thanks David. I think they have to be frozen, and something about two years, maybe the quality. I'll try to look look into it for my own curiosity, doesn't really matter now, but been so busy with other matters, I never did again.

Yep only mentioned it because I think you are just like me in having to know EVERYTHING. lol

That's true with most everything I have an interest in. I'm reading about pathology right now for breakfast, lunch, I don't know yet lol

The mandatory US storage time is 7 years. However many are stored longer depending on the institution. Hopkins has been building a data bank of OPSCC tissue samples that goes back to Maura's original work in 1998. The National tissue bank has samples that Dr. Gillison and OCF were able to tap into for the article on the HPV pages that is a forward look at where we will be in 2020, by looking back a samples from 1972 forward and projecting a trend line. Small labs only have to keep it for seven years, by then usually any anomalies or lawsuits have come and gone.

Thanks Brian, David! I still have time in the bank..3 years. I'm going to request it, and they should have plenty of samples at my current hospital or previous one.

Giving this oldie a bump due to the recent thread on Prognosis Determination http://oralcancersupport.org/forums/ubbthreads.php?ubb=showflat&Number=185171#Post185171 where the calculator asks about Extracapsular Spread status. It seems odd to ask about this when it is hardly mentioned here and remains unclear to many.

Don, from my readings, it's unclear, but some reports mentioned it being a negative prognostic factor.

I remember in 2011 I was scheduled for a modified radical neck dissection, but surgeon had to do a radical one due to the prior radiation, twisting of nerves, etc. so proceeded during surgery to remover the neck muscle, vein, nerve, besides the nodes from levels ll-V. You know cancer was found in my neck muscle on pathology. A little unrelated, but darn cancer travels. I had no ECE to my lymph nodes.

Here is an article I found for both our reading. Didn't read it yet. I think it's from 2011.

http://www.nature.com/modpathol/journal/v24/n11/full/modpathol2011105a.html