My wife

Thank you for your very kind words. CT machines differ in their state of image refinement. They scan "slices" of the body - think of a spiral cut ham if you will. The thinner each slice is, the more detail is revealed to the radiologist. Some are 64 slice and some are 128 slice, with older units perhaps taking fewer slices. CTs, as you may know, reveal masses. They cannot determine if a mass is malignant or benign. PET scans reveal metabolic activity. Since cancer cells divide rapidly, they use more of our body's energy source: blood sugar. So, areas of hypermetabolic activity (sugar consumption) will be revealed - yet it is up to the radiologist to determine the significance of the various "hot spots" on the scan. The brain and liver always light up, as they are very active organs. The liver, in particular, is used as a baseline color (usually a maroon) with which other shades of red, orange or even white may be compared. PETs also cannot diganose a cancer. They can reveal it, but they also reveal areas of healing or inflammation.

Thus, as Max said, an actual lymph node must come out in its entirety. As to lymph nodes, a needle aspiration of tissue might miss the lymphoma cells within the node - a false negative, which is a bad thing. The pathologist must examine the entire node to see if its internal structure ("architecture")  is present. Think of peeling an orange: you have the skin, stem, segments and seeds inside. Suppose you peel an orange and there is nothing inside except clay. In a lymph node, the tumor cells are the clay. If the node's internal architecture is gone, lymphoma or metastatic solid tumor cancer, is about the only mechanism which can cause that. As well, the pathologist then has a maximum amount of tumor cells to examine and submit to various methods of testing.

So, as to pathologist and radiologist, you want not only techncians, but artists, as it is their judgment which determines the course of action.

EB303 said:

An update on my wife.  Met

An update on my wife.  Met with the Hema/Onc on Friday. The CT/PET (64 slices) confirmed the thw discovered growth to be 3.5cm. They also found another, deeper down in the same area, that was 1.5cm, and detected a possible third (smaller) near but not on her ovary. As mentioned by Max, a larger excise biopsy is next up, but doctor said that the results from the first biopsy are pretty clear this is Hodgkins.  She started to discuss likely treatments, barring no surprises with the biopsy.

Staging-wise, it's somewhere between stage 1 & 2. She said the treatment for this would be ABVD and then radiation after. She said the chemo would likely be one day, every 14-15 days for 3-4 months. I mentioned both the use of Rituxan and "why not CHOP"...she said that ABVD is what's typically used for HL, noting that it side effects are less harsh and that Rituxan doesn't have much affect on this type of lymphoma.  Additional concern, which she brought up - ABVD is known to be more toxic on the lungs. My wife, 46 years old, smoked for over 20 years. She completely quit 7 years ago, however she does have asthma. So they will pay close attention to her lung tests before finalizing treatment (they also check heart too).

We are looking into a second opinion as I type - specifically for someone at MSK. Mt Siani is a phenominal hospital and the hema/onc is very smart, very thorough, and great bedside manner. But we want to make sure we attack this agressively, leaving no stone unturned, and all options at our disposal.

Wondering if anyone's experience with HL had weighed CHOP vs AVBD and if Rituxan was used. Also, is a stem cell transplant something that is ordinarily done as part intial treatment, or would/should doctors wait to see if chemo+rad knocks it out. I feel like MSK would be more prone to the agressive approach.

Staying positive, remaining faithful to the big guy in the sky, and gaining as much knowlegde as possible.

-EB

 

I'm glad you guys are making progress, EB.

I will respond to much of what you mentioned in your Sept 17 post, since I don't have time to reread the thread. If I am redundant, please understand.

ABVD is much, much more common for all strains of HL than CHOP, although a few good cancer centers use both, or sometimes prefer CHOP (Stanford, I believe, is one such CC).  But nationwide, ABVD is much more common.  I suspect that this is true at MSKCC.  Rituxan is almost never used with ABVD. The only time it is is when the HL strain is NLPHL.  NLPHL is very rare and atypical as an HL.   Rituxan only kills the CD-20 cell, and 95% of HLs do not express CD-20, so Rituxan against HL is seldom heard of.  I did have NLPHL and did receive Rituxan as R-ABVD.

"ABVD" as a whole is not more toxic to the lungs than CHOP.  It specifically is the Bleomycin in ABVD that can cause lung problems.   Lung toxicity occurs at around 10% of all users, so 90% are not ordinaily stricken.  This toxicity usually passes after treatments end when it does occur. It is more prone to occuring in older patients, and patients with pre-existing lung disease.  I would not think smoking years before would qualify, unless she has COPD or something similiar, but ask that question again.  The asthma is definitly something that must be discussed, but the pulmonary function testing is underway.    And Bleomycin toxicity is usually more common in higher (more cycles ) use.  But your wife is apparantly only going to get 3 or 4 cycles  (one CYCLE of ABVD is two infusions, or one month's worth of application).  

I received 6 cycles (6 months of treatment) and had had serious lung trauma decades before, and did have serious issues with Bleomycin, but the doctor never even reduced my dosing, said I needed to stay wide-open on the treatment.  I recovered normal breathing some time after treatment ended.  So Bleomycin is a trade-off.  Some writers here describe getting ABVD as AVD, minus the Bleo, or getting Bleo at half-dose.  Bleomycin continues to be popular because it is a higly effective cancer killer against HL cells.

Be aware that ABVD and CHOP are very similiar: Both contain Adriamycin.  And CHOP contains vincristine, but ABVD contains vinblastine, a virtually identical drug, with essentially the same side-effects.  CHOP contains Prednisone, a steroid, but ABVD does not have a steroid.  In practical terms, ABVD usually causes significant weight loss, since it has no appetite stimulant, whereas many patients on CHOP do not lose weight, or even gain weight.  When Rituxan is used, it is of course identical with ABVD or CHOP.

Except for highly aggressive strains that are late-stage, stem cell transplantations are virtually never used in first-line therapy.  SCT takes things to a whole new level of misery and complexity, and is not something I would request, unless compelling clinical reasons exist for it.  And SCT is always available as a second-line therapy (also called "salvage therapy") later if needed.

AVBD is indeed given once every 14 days, and all drugs at once; nothing is staggered, as are many other chemo regimines. Usually, two days after the infusion, she will return for a shot of neulasta in the tummy or similiar drug to boost her WBC count.

ABVD without Rituxan is usually a 3 or 4 hour day in the infusion chair. With Rituxan, expecially at first, this can be an 8 hour day.  I hope this clarifies issues a little. When you get her precise strain iof HL, please share.   But HL is virtually always beatable at any stage with first line treatment.  Nearly all of the life-threatening, highly-aggressive forms of Lymphoma are among the 40 or so strains in NHL.

As a well-informed layperson, it very much sounds like yor wife's case is early stage, relatively simple, and should be very easily put into complete remission.  I doubt globe-trotting at the world's premere cancer centers is necessary, but second opinions are always a good thing,

max

The R-CHOP is, as Max said, beginning to see increasing use against NLPHL, as that  disease is in a sort of gray area between the two categories of lymphoma (HL and NHL). It may be that it was originally misclassified due to lack of advanced testing capability when it was first identified as a separate type. NLPHL, as a rare sub-type, may ultimately be re-classified as a non-Hodgkin's Lymphoma, as more is known about it.

'However, your wife's is very likely one of the well-known types of Hodgkin's, and treatment is well established for those. Still, there are clinical trials of less toxic/more effective drugs and combinations being conducted, and it would certainly be worth investigating one of those., due to her smoking history. I am big on clinical trials, as one was very effective in my case and bought me the time needed for newer drugs and combinations to appear.

The advantage of a clinical trial is that you receive advanced drugs years ahead of their general availability. The downside is that they may not be effective - but this applies to all cancer treatment. If a trial drug/regimen is not effective, she can drop out and receive ABVD in any case. Just something to ponder, as that is how medical science is advanced.

I'm glad you and your wife have clear diagnosis now EB, and can begin the march toward cure.

Classical HL is almost always put in complete remission (C.R.) by fist-line therapy.  Most (not all) stay in complete remission for life. As Po mentioned, Staging is not terribly relevant for most cases of HL. All that usually changes in Stage III or IV is the number of cycles, not the drugs themselves.  I am not forgetting the many here who have had a tougher time in first-line, or those who have had relapses; I am just sharing what is overwhelmingly most common and reasonable to expect.

NLPHL is almost never mistaken for Classical HL, so don't worry about that.  For one, NLPHL has lots of CD20 cells, which would be hard to miss, and NLPHL does not have the traditional, defining cells for cHL at all (Reed Sternberg).  NLPHL is mostly confused with various T-Cells and other very rare NHLs, so NLPHL is irrelevant to you and your wife from this point, 99% + liklihood.

Regarding Bleomycin, it does not harm most people, especially the younger or persons without pre-existing lung problems. But do report any severe, persistent cough to the oncologist if such manifests itself.  Hair loss on ABVD is more of a certainty than a potential, 95% lose all hair.  Most commonly, this occurs a few days after the second infusion (which is about 31 days following the first infusion, of course, since each infusion is two weeks apart).  But hair returns after cessation of treatment. 

After 2 or 3 infusions, anticipate severe weakness also. Many people write a few days after their first infusion and say "Gee..... this is nothing !"  That is later revised by almost everyone.

Bless her progress,

max

EB,

Since 1st infusion is can be reckoned as medical treatment Day 1, and second infusion is Day 15, most ABVD hair loss occures around Day 18. This is an APPROXIMATION for most. I had incorrectly indicated around Day 35 above.

Traditionally, Stage III or IV cHL pateints receive NO RADIATION, unless some mass needs debulking.

MSK is therefore closer to normal recommendation.   I have not read the link yet but will.  Thank you,

max

i been reading through this thread & have to say it sounds like she has great doctors and that is a relief when you are going through something so scary! I will say that ABVD which is what I was on has minor side effects basically stuff you can handle. With the Bleomcyin they might only give her a few doses and take it out. They did that with me. Wishing your wife & your family best wishes and hope you get all your answers soon!