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Subject: Jen wellness update #16 (25Jul00) Futures? Jen watchers, I left Jen sleeping uneasily at the hospital. She elected to have powerful sleeping drugs tonight, to be administered in a progressive way till she drifted off. After the third dose she succumbed. I think there's no doubt she will get through this phase, albeit with some difficulties from her unconscious - fears that if she loses control she will damage herself. Note for the squeamish: there follows detailed discussion of subsequent phases of Jen's treatment.
However, enough of you have been asking me about the next phase that I should give you my lay analysis. It's quite a complex chain of reasoning, with difficult risks to balance at all stages. If I make any really gross errors in what follows, experts please let me know. Jen had a mid term squamous cell carcinoma of the left-side palatal tongue (responsible for taste and articulation). It had also grown into the base of the left tongue (responsible for swallowing). This primary tumor site was removed during surgery. Normally, when surgeons remove a cancerous tumor, they give themselves a large margin of tissue around the primary site. But for a tumor in this position, a wide margin would be very damaging physically, so the surgeon sailed very close to the tumor margins. Obviously this increases the risk that a stray piece of cancer would be left behind. To ameliorate this risk, Jen had a large dose of radiation applied to the surgery site immediately after the excision, and before the reconstruction. The reconstructive flap, if successful, will give Jen almost normal swallowing, and will aid in a limited way with articulation. It seems certain that she will be able to speak intelligibly without any aids, but that her speech will be impaired. The pre-surgery diagnostic instruments were a physical sample of the tumor, along with a three dimensional X-ray-like scan called an MRI, and a chest X-ray. These tests gave enough information to determine the size of the main tumor, and gave clues as to whether the cancer had metastasized (spread by breaking off cells, rather than just growing). Primary cancers in specific areas of the body have known ways that they tend to metastasize. In the case of tongue cancer, the first way of metastasis is along lymphatic channels to the lymph nodes of the neck. Unfortunately, the resolution of an MRI is insufficient to be definitive about whether individual lymph nodes are involved, so the surgeon has to use heuristics like node size and shape to make an assessment. In Jen's case the surgeon was suspicious about the left hand side lymph nodes, so at surgery time he simply removed them *all* (Don't worry, apparently the body is oversupplied with them). Post-surgery (now) a full pathology examination is performed on the removed nodes, whence the lymph node involvement question can be definitively answered. These results are due in five days. If some of the removed lymph nodes were involved, then there is an increased likelihood that metastasis has occurred microscopically in other parts of the body. The treatments for this, at first seemingly intractable, problem are:
Even if there is no lymph node involvement, the standard treatment for this aggressive cancer involves systemic chemotherapy and local radiation. The balancing act that all of the oncologists now have to perform, is juggling the mutually incompatible goals of survival, reoccurrence, side effects, and quality of life. I'm sure that Jen will get intimately involved in the options available at each turn. Let's hope she's still sleeping for now, though. regards, Karl
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