Question: Dr. Chiragbhai, thank you for explaining in last part about why transplant continues to be first line treatment of myeloma, how it reduces need for prolonged chemotherapy, improves quality of life, and is feasible in patients with old age and comorbidities including patients with renal failure-partial or complete.
What is the next hematological malignancy that we are going to discuss?
Answer: Lymphoma – Hodgkin and Non Hodgkin’s.
Lymphomas are some of the commonest, interesting, and rewarding to treat malignancies. Affects people of all ages, from very young to very old, and range from very slow growing requiring no treatment to very fast growing like leukemias. Few of them have a well known etiology, such as secondary to a bacteria or virus.
Que: That seems like a very broad topic.
Ans: Yes, but we will make it simple. Let us start with Hodgkin’s disease – easier to understand.
Hodgkin’s disease is one of the earliest successes of medical oncology. This is the cancer with highest cure rates. In fact, cure rates in most cases are over 80%, hence current research has focused a lot on issues of long term survivors and how to reduce long term side effects. This is a pleasant problem, since there are so many patients who are now being cured.
Que: That is nice to know. But how does Hodgkin’s disease present and diagnosed?
Ans: Etiology for this disease is still not known. Commonest presentation is lymphadenopathy, followed by various symptoms like fever, weight loss, night sweats, pruritus-itching, abdominal symptoms and others, mostly non specific symptoms, and laboratory tests like high ESR, anemia, eosinophilia etc. Evaluation of such symptoms leads to identification of lymphadenopathy on examination or on sonography.
Most important first step when suspecting a lymphoma is, to obtain preferably a whole lymph node by biopsy (excisional biopsy), not FNAC (fine needle aspiration cytology). If deep seated lymph node, a trucut biopsy should be obtained under radiology guidance. FNAC is the most important reason for false diagnosis in such cases, either reported as reactive (benign) or reported as likely tuberculosis. Such patients are then left without right treatment and progress to higher stages, with inferior survival.
Also, it is better to obtain IHC (immunohistochemistry) in most cases to ensure correct typing of lymphoma.
PET–CT scan should be done in nearly all cases, if possible, for staging. This test has a very important advantage over standard CT scan, providing activity level of tumor. After 2-3 cycles of chemotherapy, repeating a PET has changed how we manage these patients, allowing in many cases to reduce number of chemotherapy cycles, and for most precise prognostication.
Bone marrow biopsy is also required in most cases for complete staging. It can be omitted in patients with stage 1 or 2 disease, and no unfavorable features.
Young patients should be given the option of fertilitypreservation before starting therapy. Once again, it is important to remember that this cancer has the highest cure rates, and hence long term side effects should be considered at start of therapy. Fertility preservation options generally take only a few days, are widely available. Delaying initiation of therapy for few days is acceptable in most cases, especially early stage disease with minimal or no symptoms, or those with non bulky disease.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. email@example.com
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com