Cancer Helper

A staging system is used to describe how advanced a cancer is. In the case of Castleman disease, which is not a cancer, there is no formal staging. But it is important to classify the disease as either localized/unicentric (affects only 1 lymph node) or multicentric/systemic (affects 2 or more lymph nodes in different parts of the body and may also affect other internal organs). The doctors will order tests to determine this, usually a chest x-ray and CT scan or MRI of the chest and abdomen. A gallium scan might also be helpful.

No one has discovered the cause of this disease, but many doctors suspect a virus is involved. Doctors have found a virus called human herpes virus type 8 (HHV-8) in many people with multicentric Castleman disease. This is the same virus that has been detected in many people with Kaposi sarcoma. Indeed, some people with Castleman disease also have Kaposi sarcoma. Infection with HHV-8 may cause abnormal production of substances such as interleukin-6 (IL-6) that cause lymphocytes to reproduce excessively. High levels of IL-6 production tend to be associated most often with multicentric disease.

Doctors also suspect that problems with the way a patient’s immune system is working may contribute to development of Castleman disease. Many people with Castleman disease have abnormally high blood levels of certain substances produced by immune system cells.

An enlarged lymph node, usually inside the chest or abdomen, is the only abnormality for most people with the localized form of Castleman disease. They may have trouble breathing, a cough, or a feeling of fullness in the chest. Those with Castleman disease in their abdomen may have trouble eating, pain, or just a feeling of fullness. Some patients may have low grade fever, weight loss, or night sweats. In general, most people with localized Castleman disease feel well otherwise.

People with multicentric Castleman disease have more than one enlarged lymph node. The involved nodes may be in the chest or abdomen, but multicentric Castleman disease often affects lymph nodes in the groin, the underarm area, and on the sides of the neck. Multicentric Castleman disease can also affect lymphoid tissue of internal organs, causing the liver, spleen, or other organs to enlarge.

In addition, people with either type of Castleman disease may have other symptoms. The most common include:

• fever
• weakness
• night sweats
• weight loss
• loss of appetite
• nausea and vomiting
• nerve damage that leads to numbness and weakness

These symptoms occur much more often in multicentric than in localized Castleman disease.

Amyloidosis, a disease where abnormal proteins are deposited in tissues, can occur in Castleman disease. This can lead to kidney damage, heart damage, nerve damage, and intestinal problems, mainly diarrhea. Amyloidosis can go away if the Castleman disease is successfully treated.

Imaging Studies

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine takes pictures of multiple slices of the part of your body that is being studied. This test can help tell if your Castleman disease is in only one lymph node or many. Often after the first set of pictures is taken you will receive an intravenous (IV) injection of a contrast agent, or dye, that helps better outline structures in your body. A second set of pictures is then taken.

CT scans can also be used to guide a biopsy needle precisely into enlarged lymph nodes that might be affected by an infection, lymphoma, metastatic cancer, or Castleman disease. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table while a radiologist advances a biopsy needle toward the location of the lymph node. CT scans are repeated until the doctors are confident that the needle is within the lymph node. A fine needle biopsy sample (tiny fragments of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ?-inch long and less than 1/8-inch in diameter) is removed and examined under a microscope. Although a needle biopsy cannot accurately diagnose Castleman disease by itself, it is sometimes useful in diagnosing or excluding other diseases that can cause large lymph nodes.

CT scans take longer than regular x-rays because you need to lie still on a table for 15 to 30 minutes while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. Also, you might feel a bit confined by the equipment you lie within while the pictures are being taken.

You will need an IV line through which the contrast dye is injected. The injection may cause some flushing. Some people are allergic and get hives, or rarely more serious reactions like trouble breathing and low blood pressure can occur. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays. You may also be asked to drink 1 to 2 pints of a contrast solution. This helps outline the intestine.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans but is used less often.

MRI scans are very helpful in looking at the brain and spinal cord. MRI scans are a little more uncomfortable than CT scans. First, they take longer ??鈥?often up to an hour. Also, you have to be placed inside tube-like equipment, which is confining and can upset people with a fear of enclosed spaces. The machine also makes a thumping noise that you may find disturbing. Some places provide headphones with music to block this out.

Chest x-ray: This test may be done to find out whether there are enlarged lymph nodes in your chest ??鈥?usually in the center part called the mediastinum.

Gallium scan: For this test, the radiologist injects a radioactive chemical called gallium into a vein. The chemical is attracted to areas of the body affected by certain diseases such as lymphoma or Castleman disease. A special camera can then view the location of the gallium. A gallium scan can detect unsuspected sites of Castleman disease, but it is not always reliable since the radioactive gallium may not be taken up by lymph nodes affected by Castleman disease.

Lymph Node Biopsy

Castleman disease is diagnosed by removing the enlarged lymph node and examining it under the microscope. This procedure is called a biopsy. If the lymph node is near the skin surface, the surgeon can remove the node under local anesthesia (using numbing medication). The surgeon makes a small incision over the enlarged lymph node, removes the node, and then stitches the incision closed. If the procedure removes the entire lymph node, it is called an excisional biopsy. If only part of the node is removed, it is called an incisional biopsy.

Sometimes lymph nodes are biopsied by putting a needle into the node. A very thin needle can remove tiny fragments of tissue, and a slightly larger needle can remove a cylinder-shaped core or tissue. Although needle biopsies are useful for diagnosing some types of cancers, it is not possible to accurately diagnose Castleman disease by needle biopsies alone.

If the lymph node is in the chest or the abdomen, then the surgeon may need to make a large incision to get into either of these places. This is more like major surgery but may be necessary in order to know what is causing the lymph node to enlarge. Sometimes, lymph nodes in the chest can be removed by mediastinoscopy. In this procedure, the surgeon can biopsy the lymph nodes with special instruments through a hollow tube called a mediastinoscope, which is inserted through a small incision just above the breastbone (sternum).

All biopsy specimens are examined under a microscope by a pathologist (a doctor who is specially trained to diagnose disease). The pathologist looks at the size, shape, and arrangement of the cells in the lymph node. Since the disease is so rare, the pathologist may ask another pathologist with additional training in the diagnosis of blood and lymph node diseases (called a hematopathologist) to look at the biopsy. Sometimes it is hard to tell whether the lymph node is affected by Castleman disease or by lymphoma. In these cases, other tests may be done on the lymph node tissue.

Immunohistochemistry: In this test, a part of the biopsy sample is treated with special manmade antibodies. The cells are treated so that certain types of cells change color. The color change can be seen under a microscope. It may be helpful in telling whether there is Castleman disease or lymphoma in the lymph node.

Flow cytometry: The cells being examined by this test are treated with special manmade antibodies and passed in front of a laser beam. Each antibody sticks only to certain types of cells. If the sample contains those cells, the laser light causes them to give off light of a different color. The intensity of each color is measured exactly and analyzed by a computer. This test can help determine whether lymph node swelling is caused by lymphoma, some other cancer, or a noncancerous disease like Castleman disease.

A risk factor is anything that might increase a person’s chance of getting a disease. Risk factors can be classified as either inherited (genetic), lifestyle-related, or environmental.

Most patients with Castleman disease have no known risk factors. The only clear-cut risk factor for Castleman disease is infection with the human immunodeficiency virus (HIV). Castleman disease is much more common in people with this infection, particularly in those who have developed the acquired immunodeficiency syndrome (AIDS).

Having one or more risk factors doesn’t mean that a person will get the disease, however.

An Israeli psychologist has developed a radical new technology which would enable an ordinary mobile phone to diagnose breast cancer and various type of heart disease, the Haaretz daily has reported.

By installing new software and adding a basic infra-red camera, a mobile phone could be transformed into a highly-effective diagnostic tool, offering far more accurate results than the self-checks many women do themselves.

Dr Nitzan Yaniv, who developed the technology, said the results of the scan could be immediately transferred to a medical laboratory for analysis, which could determine whether further checks were necessary.

The infra-red camera uses two techniques, both of which have proved effective in diagnosing breast cancer: one analyses temperature differences in different parts of the breast, while the other analyses oxygen flow to areas of the breast.

Israeli phone operator Cellcom is working to integrate the infra-red sensor technology into the cameras currently built into many mobile handsets.

Dr Yaniv said he was first exposed to the benefits of infra-red photography while working with biofeedback - a therapy which trains a patient to control certain bodily functions which are usually unconscious, such as blood pressure or heart rate.

Biofeedback therapy can help patients control conditions such as high blood pressure, migraines or epilepsy, with infra-red cameras used to show data about the patient’s physical state.

With the cameras attached and the software installed, the mobile phone was transformed into the affordable equivalent of a biofeedback machine, Dr Yaniv said.

The device, which is still under development, has yet to be approved by the US Food and Drug Administration (FDA).

The Soroka medical centre in the southern city of Beersheba is now testing the device’s ability to detect heart problems as well as breast cancer.

A new treatment for pancreatic cancer developed by clinical researchers of Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center substantially reduces the size of tumors and lowers the risk of local recurrence of the disease. Fifty percent of patients in the study responded to therapy - one of the highest response rates ever seen with pancreatic cancer. Results of the study were published in the December 2005 issue of the Annals of Surgical Oncology.

Researchers, led by oncologist and principal investigator J. Marc Pipas, M.D., were able to reduce the size of tumors so significantly that a number of patients who previously had been categorized as borderline or inoperable could have their tumors surgically removed.

Surgery, and the complete removal of the tumor, is the only curative hope for people with pancreatic cancer, the fourth leading cause of cancer death in the U.S., according to the National Cancer Institute. NCI estimates that of the 32,180 new cases of pancreatic cancer in 2005, 31,800 will die.

The overall five-year survival rate for pancreatic cancer is only 4 percent, but for patients whose tumors can be completely removed, long-term survival jumps to 18 to 24 percent. Detecting the tumor in an early stage is crucial, but pancreatic cancer has few symptoms and is often diagnosed only after the cancer has grown into surrounding tissue or metastasized, making surgery impossible.

“The only way to cure these tumors is to remove them completely,” explains Pipas. “You try to do something to make sure there is no microscopic disease left. If you can’t remove it, the prognosis is poor.”

Traditional treatment for pancreatic cancer is surgery followed by chemotherapy and radiation. The treatment Pipas developed reverses the treatment steps. He administers chemotherapy and radiation in combination first, in order to reduce the size of the tumor and increase the possibility of surgery. The reverse treatment regimen results in many tumors previously considered borderline or inoperable shrinking to a size where they could be surgically removed.

In the Norris Cotton Cancer Center trial, 24 patients were treated with short-course, high-dose chemotherapy of docetaxel and gemcitabine, followed by a combination of radiation and twice-weekly low-dose gemcitabine. Chemotherapy doses in this trial were higher than previously attempted.

Results showed that 50 percent of tumors shrank by at least a third, including complete disappearance of a tumor in a patient who previously had been judged inoperable. No tumors progressed during treatment.

The ability to shrink a pancreatic tumor is important because in order to eradicate the cancer, the tumor must be small enough to be completely removed without damaging major blood vessels surrounding the pancreas. Seventeen patients in the study underwent surgery, including nine previously considered inoperable or borderline operable. Subsequent follow-up showed that no patient whose tumor was surgically removed had a local recurrence of the disease, and no patient whose disease was considered inoperable had local progression.

Because the treatment Pipas and his team developed is allowing more patients the option of surgery, it is now the standard treatment for pancreatic cancer at the Norris Cotton Cancer Center.

In a new study, Pipas is using gemcitabine and radiation in combination with cetuximab (Erbitux), an antibody treatment. Norris Cotton Cancer Center is the only center testing this treatment for pancreatic cancer.

“Our goal for therapy is more people to complete resection,” explains Pipas. “That’s going to be the first step to curing patients.”

If a cell phone tower is erected near your child’s school or your mother’s nursing home, will low-level radio-frequency emissions cause them to develop cancer?

That question came up recently at an informational meeting Sprint PCS-Nextel held at the Chancellor Community Center, not far from where the carrier is seeking Spotsylvania County’s approval to put up a 195-foot cell tower.

The growth of the wireless industry is requiring more and more cell towers and other sites that beam signals to users.

A decade ago there were 24 million cell phone subscribers in the United States, according to CTIA-The Wireless Association, an industry trade group in Washington. The number of cell phones in use in America today is approaching 200 million.

Joe Farren, director of public affairs for CTIA, noted that a study released by the Health Council of the Netherlands last week found no evidence that cell towers pose any health risk.

Stephanie B. Freeman of Network Building and Consulting LLC in Linthicum, Md., who was representing Sprint-Nextel at the Chancellor meeting, said cell phones are two-way radios and cell sites are radio transmitters that only put out 70 watts, while some big radio station towers beam 50,000 watts.

No studies have produced conclusive evidence that radio-frequency emissions are dangerous at levels allowed by the Federal Communications Commission, Freeman said. Therefore, she said, the law does not allow rejection of a tower based on health risk.

“There’s no evidence of harmful effects from such towers,” said John H. Johnson, a spokesman for Verizon Wireless. “We have schools coming to us asking for towers on their roofs to improve signal and generate revenue. Unfortunately, emotion gets in the way of fact and reason in many public meetings like this one.”

Not everyone was concerned. F.D. Jamerson, secretary of the fundraising committee of nearby Salem Baptist Church, came to the same meeting to complain that Nextel had ignored its request to host a more aesthetically pleasing “stealth” site on its steeple so the church could earn $1,500 to $1,800 a month in rental revenue.

“The wireless industry is definitely a regulated industry,” said Sprint PCS-Nextel spokeswoman Lisa I. Malloy. “The FCC sets limits deemed safe and our sites come in thousands of times lower than what’s deemed safe. TV and radio station emissions are at such a higher level,” she said.

The American Cancer Society hasn’t taken a position, saying the cell industry is too new for a determination to be made but that there’s no evidence of health risk.

Malloy said technology isn’t new.

“We’re talking about radio waves–they’ve been used by radio stations for decades,” she said. “And all the research out there points to the fact that there are no negative effects to health.”

Ken Hyers, a wireless industry analyst at ABI Research in New York, said there have been no studies that prove any threat exists from cell sites.

“Nobody’s been able to say they’re dangerous,” Hyers said.

Video-assisted thoracoscopic surgery, a minimally invasive surgery, may increase options for people in their eighties with some lung cancers by removing part or all of a lung.

The study was conducted on a group of 159 patients between ages 0 and 94 suggests

Robert McKenna Jr, M.D., thoracic surgeon, surgical director of the Center for Chest Diseases and chief of Thoracic Surgery and Trauma at Cedars-Sinai, said that the study showed that it was possible to conduct a standard complete lung cancer surgery in people over 80 with very low risk and good success.

“Our study shows that we can do a standard, complete lung cancer surgery in people over 80 with very low risk and good success so that older patients with lung cancer do not have to suffer the consequences of widespread cancer,” he said

In the video-assisted thoracoscopic surgery, only several small incisions through which instruments and a thoracoscope are inserted are required. A camera lens at the tip of the scope feeds high-resolution images to a video monitor, giving the surgeon a detailed, magnified view.

McKenna further added that the number of patients who experienced any type of complication after undergoing video-assisted thoracoscopic surgery, was very low.

“Compared to the percentage of people who experience any type of complication after a major pulmonary resection, our numbers were low, and especially low for patients in this age range,” he said.

He also said that this type of procedure remained a viable option for elderly people.

“If you knew that you could get several additional years to live by having a procedure with low risk and good success in preventing widespread cancer, you might want the option of putting up with the short-term inconvenience of having that operation,” he added.

Coffee and tea may help people who are at risk for liver disease. Researchers found the beverages may reduce the risk of serious liver damage in people who drink too much alcohol, are overweight or have too much iron in their blood.

The study of nearly 10,000 people showed that those who drink two or more cups of coffee or tea a day developed chronic liver disease at half the rate of those who drink less than one cup. Doctors aren’t ready to tell patients to load up on coffee and tea, but say the findings should offer guidance to researchers studying liver disease.

For years, doctors have known exactly what to do with breast cancer patients like Eva Ossorio: Poison them.

Blasting women with toxic chemicals was considered the best way to save their lives. The bigger the cancer or the more it had spread, the more vile liquid doctors pumped into their veins to try to kill it.

But there has been a sea change in the last year.

Guidelines recently adopted in Europe and similar ones unveiled this weekend at a conference in Texas will result in far fewer women getting chemotherapy in the future.

The new advice calls for choosing a treatment based on each woman???s particular type of tumor.

???In the past, we made all decisions based on how big the tumor was and whether the lymph nodes were involved. If you had a lot of cancer, you got treated one way, and if you had a little cancer, you got treated another way,??? said Eric Winer of the Dana-Farber Cancer Center in Boston.

Under the new rules, hormone status ??鈥?whether a tumor???s growth depends on estrogen or progesterone ??鈥?becomes the single most important factor in picking treatment.

That is why Ossorio, 62, a nurse in San Antonio, last week was started on a hormone blocker rather than the chemotherapy she formerly would have received for her relatively large tumor. She was relieved.

???I don???t care if I die tomorrow. I decided I didn???t want chemotherapy,??? she said.

Patients have reason to dread it. Chemotherapy is a sledgehammer, killing all rapidly dividing cells whether they are out-of-control cancerous ones or healthy ones that naturally grow quickly, like those lining the mouth and stomach. That is why chemotherapy causes hair loss, nausea and mouth sores.

But the worst part is, it only helps about 15 percent of those who get it after the usual surgery to remove their tumors.

About 25 percent get worse despite chemotherapy. Sixty percent would have been fine with hormones alone.

???For the vast majority of patients, we probably overtreat,??? said William Gradishar of Northwestern University in Chicago.

???It???s not that chemotherapy is not of value. It???s that the value is smaller in women with hormone-driven disease,??? said Robert Carlson, a Stanford University physician who led the U.S. guideline-writing group. ???We???re trying to determine if the benefit is so small that we should not be recommending chemotherapy.???

Several developments in recent years help doctors pick who really needs it.

First is the realization that breast cancers have different causes, arise from different types of cells, are driven by different genes, and tend to be different in women before or after menopause.

For example, three-fourths of postmenopausal women with breast cancer have tumors fueled by estrogen, called ER-positive disease. Drugs that block this hormone, like tamoxifen and a newer class of medications called aromatase inhibitors, work against those cancers ??鈥?whether they have spread to lymph nodes or not.

On the other hand, women before menopause often have tumors that are ER-negative and orchestrated by bad genes. Hormones don???t help in that case. These women benefit most from chemotherapy.

If hormone drugs are ball-peen hammers compared to chemotherapy, a medication like Herceptin is an even more refined tool. It focuses on the one-fourth of breast cancers that have too much of a protein on cell surfaces called HER-2 and leaves healthy cells alone.

A woman???s HER-2 status is the next factor doctors will consider, after hormone status, in choosing treatments under the new guidelines.

New high-tech laboratory tests help doctors sort it out. They measure the activity of dozens of genes and reveal which ones are most active and what treatments would work best.

The new guidance was developed by the National Comprehensive Cancer Network, a group of cancer treatment centers, in cooperation with the American Cancer Society.