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Treatment for NLPHL in abdomen only

Mary from NJ's picture
Mary from NJ
Posts: 57
Joined: Apr 2016

I am searching for folks who have been or are being currently treated for nodular lymphocyte predominant Hodgkins lymphoma.  Because this exists only in my abdomen (mesentery lining around small intestines), doctors do not recommend radiation therapy (because of the risk of secondary cancers).  One doctor recommends R-CHOP, but 2 other lymphoma teams recommend treatment with only Rituxin for now.  The hope is to shrink the enlarged lymph nodes.  I also have a localized schleroderma called Morphea (an autoimmune disease).  Doctors are concerned that the chemotherapy drugs (CHO) will had an adverse effect on the immune system because of the Morphea. 

Has anyone with NLPHL been treated with only the Rituxin and had success? 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Welcome to these Boards, Mary.

About five of us here in the last few years were patients with your strain of HL (Hodgkins's Lymphoma) known as NLPHL. It is the rarest of the five types of HL. Your case must be very early, since the doctors are considering the Rituxan-only approach. I have not heard of that before, but it points out one thing that is unique about NLPHL:  It is the ONLY form of HL that Rituxan is useful against.  That is, virtually all lymphomas that receive Rituxan are Non-Hodgkin's forms ("NHL"). This is because Rituxan kills a cancer cell known as CD-20, and NLPHL is the only form of HL that stains for CD-20.   NLPHL in fact is somewhat of a hybrid form of lymphoma, and for some years in the past oncologists classified NLPHL as NHL, but the worldwide standard today is to consider it an anomoly of HL.

A second curiosity you mentioned is that your oncologist was considering R-CHOP. While I have heard of that a few times in the past, almost everywhere today R-ABVD is first choice agains NLPHL.  CHOP is considered a NHL combination, and ABVD an HL combination, but there are exceptions, and this again shows how close NLPHL is to being a NHL form.  Finally, your doctors "did not recommend radiation."   Radiation is seldom given to advanced stage disease; when lymphoma patients get radiation it is very nearly always either for Stage I or II.  Or, the patient with advanced disease will occasionally have a huge mass that needs debulking, and it will be radiated. But otherwise, radiation is little used against any form of HL, so it is not surprising that they recommend not using it, at least at present.  I am unfamiliar with Morphea, but it is an example of your doctors wisely trying to do a work-around between diseases.

My own NLPHL was very advanced Stage III, from the collar to the pelvic region, and across both sides.

NLPHL is a very indolent, or non-aggressive lymphoma.  Depending on your age and other factors, some doctors think it best to minimize the harshness of chemo for as long as possible.  Since Rituxan is usually effective against CD-20, it seems very reasonable to hold back NLPHL with that drug; it may do so for a long, or even a very long, time.  My understainding is that Rituxan by itself is not CURATIVE against NLPHL, whereas R-ABVD is regarded as clinically curative, meaning that it will eliminate all traces of the disease for years, usually for forever (relapse following ABVD for NLPHL is 15%, meaning that 85% of NLPHL patients who get ABVD never see the cancer again in their lifetimes).

CHOP and ABVD are both harsh.  Rituxan is not a classical chemo, but rather a form of antibody. It too can be unpleasant, but most doctors and patients agree that it is pretty mild compared to CHOP. It will not cause the patient to loose their hair, or most of the other tough side-effects that traditional chemos cause.

I owuld ask the doctors what they think about a few cycles of R-ABVD, toward curative elimination now.  They might have compelling reasons to NOT do that. All of us writers here are not medical professionals; we write of what we have experienced, read, and studied.  I tell people that "I have no medical training; I have just had all medical problems !"  

My summation of all of the above is that Rituxan-only, given the very early stages of your NLPHL, its indolent nature, and your immune system issues, might make Rituxan-only at this time a very sound choice.

I hope you ask more questions and enjoy the fine people here,

max

Mary from NJ's picture
Mary from NJ
Posts: 57
Joined: Apr 2016

Hi Max,

Thank you so much for taking the time to provide so much information. Although I have a wonderful family, I can already see that this network is going to be my best support. I have done a great deal of reading, but none of the doctors suggested R-ABVD treatment.  I am going to do more research on this.  I was told that chemotherapy drugs would be avoided for as long as possible because of the morphea. Thank you again for replying and for the great information! Mary

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

This site has descriptions of any and all chemo drugs.  Whatever you are perscribed, it describes.  Note that the menu can be for individual drugs, or for the Acronyms, that are so common in chemotherapy.

http://chemocare.com/chemotherapy/drug-info/Rituxan.aspx

http://chemocare.com/chemotherapy/acronyms/abvd.aspx

max

Mary from NJ's picture
Mary from NJ
Posts: 57
Joined: Apr 2016

Hi Max ....Thank you for sending the links to chemocare.com.  I have read through the information and have added more questions to my list for the oncologist when I return next week. When you received the ABVD treatment, did you also have Rituxan?  Based on what you have read in the discussion boards, does it seem that most people have received the R-ABVD for NLPHL?  Thanks!

Mary

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

I am sorry that I did not see your question for some time, Mary.

I would say that about 50% of the NLPHL patients here got Rituxan with their abvd, and about half did not. I DID receive Rituxan.

In my reading and experience, I would extimate that around 80% or more of the patients and Journal articles describe NLPHL being treated with abvd; chop is discussed much less often. Only one or two NLPHL patients here over the years have said that they got CHOP, that I can recall. This is all from my memory, and not a scientific determination.

To repeat: None of us here is a doctor, and your oncologist is the one person best able to determine what treatments are best for you, not me or anyone at this Board. But I would ash why he chose what he did.

I have attempted to learn why some NLPHL get Rituxan and some don't but do not have a totally clear answer. Sadly, at least part of the answer is insurance-related:  the diagnosis of NLPHL in some policies apparantly does not readily pay for Rituxan, but I do not believe that that is the only factor.

Rituxan kills the CD-20 cancer cell.  Of the five major forms of Hodgkin's, NLPHL is the ONLY one that has the CD-20 cell, and NLPHL is so rare that in general, when insurance companies and doctors think of a Hodgkin's patient, they are not thinking Rituxan.  NLPHL constitutes arond 5% of all new HL cases, and around 1% or less of all new lymphoma cases in the US annually.  There are few strong or clear treatment suggestions for NLPHL, because it has been much less studied than the more common strains.  In fact NLPHL has a times been classified as a rare Non-Hodgkin's form, but for many years has been put back in the HL camp in most nations. That is, today NLPHL is regarded as a hybrid HL strain by almost everyone.   The fact that NLPHL was regarded as a form of NHL may account for why some medical centers even treat the disease with the most common NHL combination, "CHOP."   All of these things play some role in NLPHL patients getting Rituxan, or not.

Ask you oncologist directly if Rituxan would be good for you. He will tell you.  I have suspected that some of us show lots of CD-20 cells, while othes do not, but I have no evidence of that, and may be incorrect.  That information would come from your biopsy report.

Given the option of getting Rituxan or not, I would request it myself, but I always wanted to maximize my treatments, rather than minimize them.  In "a goody bag of abvd," adding Rituxan is usually not too bad, except that it is administered pretty slowly, and lengthens the infusion day. My infusion day lasted eight hours: I started at 8:00 AM, and left at around 4:00 PM. Take a book with you!  Rituxan can cause muscle cramps and flulike feelings, as well as respritory symptoms (runny nose, cough) but two of the other abvd drugs do that anyway.  By itself, Rituxan does not cause hair loss or nausea, but you will have no hair after a few abvd treatments; I even lost all of my eyebrows and eyelashes, and even my nose hairs.  If I had been a dog during chemo, I would have been the breed known as the Mexican Hairless !

I am interested to hear what your oncologist says about this, since it is a fairly common question among NLPHL patients.

max

Jeff148's picture
Jeff148
Posts: 183
Joined: Apr 2014

If you click on my picture it will take you to additional info and my blog address.

Jeff

Jules21's picture
Jules21
Posts: 1
Joined: Mar 2017

Stage I maybe II NLPHL in abdomen, found during appenditicitis 3 wks ago, 3cm node removed so already has excision biopsy during an aggressive surgery, diagnosed last week following two different locations running pathology, no Rituxan yet (chemo and radiation not recommended at this time for me either), recommends repeat PET in 4mo (need a few months post-op so I don't get false positive PET due to current surgery trauma/inflammation).  What do you think of this wait and see treatment plan?  I am also getting a colonoscopy (another area lit up transverse during PET prior to surgery).

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

"Active Survellance" is very common with Prostate Cancer (I learned the hard way) and a few others.

I would never agree to it for any form of cancer -- ever. Just me.

max

Jeff148's picture
Jeff148
Posts: 183
Joined: Apr 2014

I know that NLPHL has a slow growth rate, but I wanted treatment right away. I would get a second opinion if you are having doubts.

Hockeymomof2
Posts: 4
Joined: Apr 2017

Hello,

I have just come across this site as I seach the internet for infomation on NLPHL.  I have had a CT and Core Needle biopsy where the pathology report came back as highly probable for NLPHL but inconclusive as the there was nt enough tissue sample.  I am having a surgical biopsy hopefully mid April to get something difinative.  Just from the little bit of reading I have done it appears that this is a rare HL type that reponds relatively well to treatment.  I should say I am a 47 year old female, with few symptioms.  A radiologist found a 4.5 cm mass on my mesentry during an ultrasound for something else.  A follow up CT confimed what the US showed.  Unfortunatly becasue of the location of the mass (base of the central mesentry anterior to the aorta) they tried to get a core needle biopsy hoping to avoid surgery, unfortunatly it did not net enough tissue so next step is surgical biopsy for confirmation.  

I will read back on older posts to see what others experience has been.  Thanks for sharing your stories!

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
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Joined: May 2012

Welcome Hockeymom,

Yes, a definitive biopsy result is what you need. Treatment cannot begin on a "maybe"  -- it could do more harm than good.

If you have only the one, or a few nodes, that's good, although late-stage indolent Lymphomas are usually no harder to cure than early-stage disease.  If it is confirmed as NLPHL, expect to begin R-ABVD, which is almost universally the choice for  first-line NPLHL treatment, although Stanford and perhaps a few other places commonly use R-CHOP.  If it is indeed very early, they might want to use a little radiation and a couple of cycles.  If it is later stage, radiation is usually avoided and the number of infusions is increased.

I hope yo ushare what the biopsy discovers,

max

 

Hockeymomof2
Posts: 4
Joined: Apr 2017

Thanks Max, I will certainly share once I have the final biopsy results.  They tell me there are multiple masses but I am hopeful that its early and therefore spread is limited.  Interestingly I had a ultra sound in July of 2016 and there was no mass and in Feb 2017 there was several with the larget being 4.5 cms - I am hopeful that that is a good sign that is has only been there for a short time.  

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
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Joined: May 2012

Actually that is a little odd for NLPHL, which tends to grow very slowly.   To have got that big since July may suggest that it is a different strain, NOT NLPHL.  NLPHL is commonly misidentified.  It is fundamental and critical that an excise (surgically removed) biopsy precisely determines what you have.  What treats one strain of NL or NHL is ineffective on others.

I understand that Jeff148 above has a blog regarding his NLPHL experience that you may want to start reading.  It is linked on his "About Me" section here at CSN.  Go to Jeff's About Me, and on the far right, in Blue, is his blog link.

And know this: widespread, even advanced stage 4 NLPHL is ordinarily put into CR without too much fuss (within 6 months chemo or thereabout).  I had it from my neck to pelvic region, and from axillary (armpit) to axillary.  It was wrapped around my escophagus, crowding my heart cavity, and elsewhere. My excise node in the (L) axillary was golfball-sized.   It is easily beaten, nearly always.

Please do write and continue updating,

max

Galllessgal
Posts: 1
Joined: Jun 2018

Hello!

First off, I can't tell you how amazing it has been to find a board focused not only on those diagnosed with NLPHL, but those who have had lymph node enlargement in their mesentery. From much of the reading I've done and from what my oncologist has told me, it's really not as common for this disease to present in the mesentery, so it has been reassuring to know that I'm not the only one with this uncommon presentation.

A little background: I've been dealing with illness and inconclusive symptoms for a few years now, the main two being extreme bouts of fatigue, and bouts of diarrhea that have become more frequent over the past three years. I also have had a slew of colds and seemed to be able to get sick quite easily, or at least easier than in the past. I only really started to feel incredibly sick in January of this year, with severe abdominal pain, nausea, lightheadedness, more fatigue, and more intense bouts of diarrhea paired with bouts of constipation. I do have a history of GI issues including gallstones and resulting pancreatitis (gallbladder removed in 2012), stomach ulcers, and GERD, so my GP and GI put me on a massive dose of PPI's and told me to hold out for a few weeks while they started to work.

Lo and behold I didn't feel any better after a few months, so I went back to my GP in tears saying that I just don't feel right and I really feel like something more must be going on. She ordered a CT and in April I was diagnosed with a mesenteric mass; a PET CT one week later showed inflammation or disease in the 3.3cm mass and was told that it looked like I had a carcinoid tumor (especially based upon my symptoms). The PET also showed up to a dozen other enlarged masses, but they were not exhibiting disease or inflammation in the scan.

After consulting with a specialist in neuroendochrine tumors and having a specialized gallium dotatate PET scan in early May, I came back negative for that type of tumor and was back to square one. Mind you that at this point, none of the oncologists or other specialists that I had consulted with had thought this could be Lymphoma. I'd already felt nuts because these symptoms are so common from many other, less scary disorders; after being told I didn't have a carcinoid tumor I started to wonder if this was all in my head.

My surgeon convinced me that the only way to really know what this mass was is through surgical removal, so on 5/17 I had laprascopic surgery to remove the mass - a week later on 5/22 my surgeon called saying that it looked like I had a rare version of lymphoma. Two days later I saw a hemotologist oncologist aat UCLA who finally diagnosed me with NLPHL. While the blow of a cancer diagnosis was huge, for the first time in months (or years, really), I finally felt like I wasn't crazy, that the fatigue wasn't just me being lazy or not taking care of myself. It's been freeing in a way.

I will be starting a BR regimen (Bendamustine and Retuximab) in the next week or two - four three week cycles followed by a PET scan to look for disease, then up to two more cycles if needed. Bendamustine doesn't have a clear record of causing or not causing damage to the ovaries, but to be safe we are highly considering egg retrieval prior to starting chemo since it does contain alkylating agents. My oncologist, who I trust implicitly, said that in recent studies BR has an over 90% success rate (100% in some studies) at treating NLPHL, and is much better tolerated than R-Chop or R-AVBD by most patients, with far fewer side effects. What really hit home was when he told me that I'd likely feel better after the first dose of this protocol than I have been feeling over the past few years.

I'm wondering, did no one else's doctors discuss BR protocol with them as opposed to R-CHOP and R-AVBD? It was such a straighforward decision for my doctor, but the factors of age (I'm 33), the fact that I want to have children, and disease stage may have been an influence in his decision.

As far as radiation, it was a moot point in the discussion of my care since my largest mass was in my mesentery and it has now been removed. It also sounds like targeted radiation is pretty impossible for mesenteric masses because of their location. Has anyone heard differently?

Has anyone else had any overt symptoms related to their NLPHL? Sounds like many people just find a mass and go from there. Anyone else with fatigue?

Hoping everyone is doing well with treatment and I so appreciate any insight compared to your own journeys!

Sonja

Zentao
Posts: 5
Joined: May 2018

Hi Sonja,

NLPHL relapser here. Currently undergoing R_CHOP and have been confirmed last week I am in complete remission (!!).

Had NLPHL 2 times. Second time was a IIA, located in the lower abdomen. No specific symptoms other than some mild discomfort which for some reason triggered me to get really anxious about it. The actual nodes were small and 3 doctors believe their finding was incidental but i believe otherwise.

Regarding radiation, this is very specific to each case. But in mine although it was considered as an option (my first treatment was radiation only in the neck and responded very well) it was dropped because of location as you mentioned, coupled with the fact that I was relapsing after 15 years and therefore my hematologist leaned on a more systemic approach.

Happy to answer any specific questions you might have - just let me know.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Welcome to you Sonja. 

I applaud that you are apparantly such a quick study, and learning about our shared disease.  As you can see from this thread, there are a few members here with NLPHL, which constitutes less than 1% of all newly-diagnosed lymphomas annually.  It is 5% of new HLs, but HL in turn is much, much less common than NHL.  To my knowledge I am the only NLPHL guy still actively writing, but may be incorrect in that.  I would say that about one new NLPHL person a year begins active participation.  While < 1% may seem like a very small number, NLPHL nonetheless remains a lot more common than some of the extremely rare lymphomas, like the T-cell and CSN (central nervous system) varieties.

I do not have time to reread what I wrote above on this thread (or other threads), so bear with any redundancy.

NLPHL is very indolent, and ordinarily easily put into full remission, although lifetime relapse potential is around 15%.  I can recall a few here who had refractory disease, or disease that would not go to NED (no evidence of disease, or complete remission).

ABVD is the most common treatment for NLPHL in ternationally, although a few Cancer Centers sometimes use CHOP, a mostly NHL regimin.   I do not recall ever hearing of anyone before using B&R, although B&R is growing in popularity, and new sets tend to get experimented with on other disease strains over time.  NLPHL is actually the ONLY HL that EVER receives Rituxan anyway, because no other HL presents the CD-20 cell, which is what Rituxan kills exclusively.  This shows of course that NLPHL is an anomolous form, and more like NHL than any other form of HL.  In various countries over time NLPHL has even been classed as a NHL, but this is rare today.

Presentation in the gut is rare; axillary is most common, followed by lower neck.  Presentation is usually early-stage, but we have had some present here as advanced Stage IV. I presented as an advanced Stage III, with grossly large nodes in the heart cavity, wrapped around the esophagus, around the superior vena cava, in both axillaries, all over the spleen, and on both lungs. Yet six months of R-ABVD cleared everything, with full remission now since 2010.  I did later develop wholly unrelated prostate cancer however.

Radiation treatment of any Lymphoma past stage I is very rare, since it is a systemic disease. And adding radiation to many chemos confers a slight increase in the chance of later developing a leukemia.  Leukemia and Lymphoma are sister WBC diseases.

It will be interesting to see how effective B&R is, but I suspect it will work well. Best of luck and please become a regular throughout this journey,

max

 

Bill_NC's picture
Bill_NC
Posts: 128
Joined: Jan 2013

Hi all, Hi Max & Jeff148. Although I am not an active contributor. I still visits the site most often and read the latest. The reason I am writing today as I received the bad news from My last CT scan. it's been exactly 5 years since my last chemo infusion for LNPHL. and this last scan shows couple node enlarged in the left external iliac adenopathy (abdomen left side) worrisome for recurrent disease. One of these nodes is measuring 1.3 x 02.1 cm in size. A second node is measuring 1.5 x 1.9 cm in size. and I am waiting to do the PET scan and ONC explained to me it's very hard to get to the nodes with surgery as it's hidden deep in small intestines. I am really worry what the next approach will be. if it light up in PET scan, how it will be diagnosed and treat it. will he go with radiation since it's unknown. It's all deja vo again. 

Zentao
Posts: 5
Joined: May 2018

Hi Bill,

NLPHL relapser speaking here. Had my first bout in the year 2002 - and now gone through my second bout (diagnosed early 2018). Have done now 4 rounds of R-CHOP and have been told I am in complete remission (2 more rounds to go). 

Happy to answer any specific questions you might have. In my case many of my 2nd round nodes (had 5) were in a similar location to yours. For the actual diagnosis, we tried 2 Core Needle Biopsies but these proved inconclusive (I knew going this was a possibility in particular if dealing with NLPHL). Ended up having a laparoscopy.

Not sure what kind of chemo regimen you've had in the past - but R-CHOP has proven to be manageable/tolerable to me, although of course it's not a walk in the park. All in all, the biggest side effect has been fatigue. 

I've opened up a separate thread as well, you'll find a bit more of information on my case there.

Bill_NC's picture
Bill_NC
Posts: 128
Joined: Jan 2013

you had no relapse for 15 years what your first treatment was ?  mine was ABVD alone. I checked under your name and did not see any blog. not sure where to go to read the blogs. 

Zentao
Posts: 5
Joined: May 2018

Hi Bill,

My first time was a stage IA located in head & neck. I noticed a fairly big lump which turned out to be NLPHL. 

The treatment I had at the time was radiotherapy only, something called "mantle field" (which was a form of extended radiotherapy). I believe extended fields are now considered obsolete, at least for this type of cancer as an approach. In both situations given that prognosis was good a lot of the discussion around treatment has to do with minimizing long term effects. 

Hope this helps!

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Hey Bill.

I'm very disappointed to hear of your apparant relapse, something that occurs among around 15% of all NLPHL patients.  I have my own annual oncology check this week. I'm in a lifetime followship program run by my cancer center.  I had a CBC a few months ago after an ER visit due to extreme blood pressure, and it was all normal, but I have been having extreme itching for a few months now also, so checking is well advised.  I have not had any other symptoms.

I have read some articles this year about new drugs used against relapsed NLPHL, some of which show substantial promise. I will look for those.  You must have a biopsy, since NLPHL often (not usually, but often) does not return as NLPHL, but rather as different strains, often Large-B NHLs.  To treat properly, exactly what the node is must be established.  But an irony of this is that Large-B is easier to permanently eradicate than indolent HL anyway.

Radiation therapy (RT) as a treatment is highly unlikely.  I've never read of RT as a salvage therapy for NLPHL, but that of course does not mean that it has never been tried; perhaps some reader here will share.   Until a few years ago, stem cell transplantation (SCT) was the most common second-line approach.

Please share all developments, since ours is a rare disease with few established protocols,

max

Bill_NC's picture
Bill_NC
Posts: 128
Joined: Jan 2013

Hi Max, Any info on the new drugs used against NLPHL relapse?  

Bill_NC's picture
Bill_NC
Posts: 128
Joined: Jan 2013

Not sure if the same what you read about

https://www.esmo.org/Oncology-News/Ibrutinib-First-FDA-Approved-Therapy-for-Marginal-Zone-Lymphoma

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Bill,

What your doctors must first do is establish what strain of lymphoma (if any) you now have. Scans cannot prove cancer, and even if the did, there are over 60 known varieties of lymphoma, and treatments differ radically, depending on strains.

"Marginal zone" cancer is different from NLPHL, so no, that study most likely is irrelevant to us.  You mentioned somewhere that because you had previously received chemo, your next trerapy would "not be chemo."  That statement is more than 99% likely to be incorrect.  Virtually all salvage or second-line (these terms are synonomous, mean the same thing) therapies for all types of lymphoma are chemotherapy combinations of some sort.

I recall back when you were in initial treatment. You very frequently though that things were not working, that problems were emerging: but they never did.  Let us know as soon as you have a certain, definitive diagnosis.

Pulling for you again, buddy,

max

Bill_NC's picture
Bill_NC
Posts: 128
Joined: Jan 2013

As always I feel you have a lot of knowledge about the subject matter than Some ONC out there. 

PBL
Posts: 182
Joined: Jul 2016

Hello Bill,

I am sorry to read about your latest news. Although yours is not the same brand of lymphoma as mine, I would assume, based on my personal experience with absolutely no nodes available for biopsy (Primary Bone Lymphoma...) that the PET will help doctors see if there are any hot spots aside from your two swollen iliac nodes, for instance, in your bone marrow. The orthopaedic surgeon would then go for a chunk of bone to nail diagnosis.

Or course, there may still be a chance that this is just about two unhappy nodes reacting to some passing bug - and then, it will just have been a little scare...

Do keep us posted.

Wishing for the best,

PBL

Bill_NC's picture
Bill_NC
Posts: 128
Joined: Jan 2013

I did the PET scan yesterday and got a call from ONC last night. The swollen 2 nodes in left external iliac adenopathy (abdomen left side) are HOT for activity (registered at 6.9 as 3.3 or less is normal) Also another node under the right armpit but it shows a weak activity (at 3.6 a little bit above the normal).So I am waiting to be scheduled for laparoscopy.

Not sure why my ONC ask me to cancel all my vacations plans for August and beyond, and want to start the treatment right after identifying the cancer type. Made me a little worry and I am really scared if the ONC recommend going for SCT although I don't have as many hot lymphomas as 5 years ago. I can admit my level of anxiety is not high and not even close to what it was 5 years ago, but still worrisome.  

I appreciate your thoughts on this.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Bill, the doctor is making progress in figuring out your nodes, but as you know, nothing is confirmed. A PET result can be highly suggestive, but cannot confirm lymphoma or other cancer.

It is premature for your oncologist to suggest a SCT, not knowing what type of lymphoma you may have, if any. You are somewhat younger than me, and in that sense a SCT would make more sense for you than in my case.  I am not "too old" for one (62), but would simply demand something less radical, at least for a time.

I do believe that we get desensitized to cancer, at least to some degree.  Not everyone, but many people.  A friend at church has a wife who was advanced Stage IV peritoneal cancer. It is an aggressive cancer of the lining in the abdominal cavity, indirectly related to ovarian cells, and often mistaken for ovarian cancer when it occurs (most patients are women, but rarely men get it also, just as occasionally men get breast cancer). This has around a 20% prospect for cure. She has been remission, but had a scare a month ago.  They were calm, even placid.  They have hope, but will not be shocked if a doctor one day says the end is near (there is basically no real second-line therapy for peritoneal cancers). Her husband told me one evening regarding relapse, "Well, you know, the chances are only 20% or less. We are just enjoying things day-by-day."  He then smiled slightly. They know.  Peritoneal cancer, like many other cancers, is much closer to a 'death sentence' than virtually any lymphoma diagnosis, even with multiple relapses.

When I went for my prostate biopsy in 2014, which I was reasonably sure would be positive, getting confirmation from the urologist was a huge yawner.  I told her thanks, and that we were planning to go see a radiation oncologist and urological surgeon for opinions, whom I had already picked out beforehand.  There was no drama at all, no emotion really.  I don't know if it is better or worse to get to that point, but it does happen.  I "'cared," but it just didn't elicit an emotional response from me, or my wife either, remarkably enough.  Her attitude was simply, "Let's get to work on this new thing now."  

In a way, a relapse of NLPHL would be not the worse news on earth, since some doctors will simply run a combination chemo again..  But a more aggressive strain, like Large B long-term might be better in a roundabout way, since when aggressive NHLs are killed off, they are more likely to stay gone. But all of this is speculative at the moment.

Your next step is the biopsy. Until then, nothing is certain or predictable.

max

Bill_NC's picture
Bill_NC
Posts: 128
Joined: Jan 2013

Thanks, MAX. I just got back from the surgeon office as they had an opening today.  (Yesterday I did PET and today I am at the surgeon Smile).  I have been scheduled for surgery in 3 days on Monday 7/16. He said he will use the laparoscope first. If it fails he may do a 6-inch incision to get the node as it's buried in fat. Until then I will pray to GOD all go well. Until then I will try to stay calm and enjoy these days before starting treatments if needed. Will update you on the results from the pathologist. 

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Bill_NC
Posts: 128
Joined: Jan 2013

Hello All, it's been a wild ride last month, I did the surgery and thank GOD the surgent was able to do a laparoscopy instead of an incision (My Prayer was answered). Also he was able to get both nodes in the abdomen, I was able to set and work the next morning. then the waiting game for the pathology results.

Two weeks later I had an appointment with surgent and still no results form the pathologist. The surgent gave them a call and they said it's most likely a lymphoma but they can't determine the type and they sent it to Washington DC for a second look by a lab consultant and I been told it was  (The Johns Hopkins Kimmel Cancer Center) in DC. a 3 days later the results came back negative for cancer it was a hyperplasia (An increase in the number of cells in an organ or tissue. These cells appear normal under a microscope. They are not cancer, but may become cancer.).

The oncologist said will wait for 3 months and do another PET scan to check for the node under the armpit and make sure no other node enlargement. and if the under armpit got larger then will have to extract it and check it. For now, I am trying to enjoy every minute and stay positive until October scan. 

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illead
Posts: 834
Joined: Aug 2012

I am so happy for you, it has been so nice to hear from you again but knew you were going through a lot.  So glad it had a happy ending.

Don't be a stranger Wink

Becky

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Great news, Bill.  I have been busy for some time now with personal issues and just saw your results a moment ago.

As you saw over the last month, I had my doubts about your nodes being lymphoma.  May you get back to some peace of mind and be well forever !

max

joemchicago
Posts: 3
Joined: Oct 2018

Hi everyone,

My name is Joe and finding this forum was the best news I have had since getting my diagnosis last Monday of NLPHP.  I read lots of articles on the web but none talked about NLPHP in the abdomen.

CANCER DIAGNOSIS

I am being seen by a major medical center that is in the National Comprehensive Cancer Network (NCCN).

Strong abdominal pain caused me to go to the ER in mid July, 2018; my CT showed enlarged lymph nodes in the abdomen suggesting cancer.  The strong pain went away and I have not shown any B symptoms; however, I lost about 7 pounds from my last regular physical 18 months ago, I get very tired at least a few evenings per week before bedtime, and I infrequently get light abdominal pain.  In early August, the first core needle biopsy of my upper right mesenteric node (bi-lobed 6cm) was negative for lymphoma, and so the doctor said to redo the CT in 3 months.  But after a delay of about 3 weeks of not getting my questions answered on the pathology report, I finally got connected with a hematologist/oncologist who recommended a PET scan which got done at the end of September.   The PET showed high metabolic activity in three enlarged lymph node areas: lower left mesentery, upper right mesentery (bi-lobed), and para-aortic retroperitoneal.  

The second core needle exam was of the node showing the highest metabolic activity: the left lower mesenteric node (4cm).  The pathology report made a diagnosis of nodular lymphocyte predominant Hodgkin lymphoma (NLPHP), and the comment stated “This is a small biopsy but the morphologic and immuno phenotypic findings are most consistent with the above diagnosis.”

Flow cytometry showed “T-cells with increased CD4:CD8 ratio (8:1), but otherwise an unremarkable phenotype and a polytypic B-cell population.”  Immunohistochemistry showed the following: CD20 (Some positive small B cells clustering within follicles and several large cells.).

A later supplemental pathology report stated:  “The following immunohistochemical stain were performed on block A1:  IGD Highlights many B cells localizing to follicular dendritic cells meshwork.  OCT2 Highlights small B cells and is strongly positive in large atypical cells.   Interpretation: These findings further confirm the previously rendered diagnosis.”

The hematologist/oncologist said I have Stage II NLPHL though I am trying to find out if it is advanced or just unfavorable.  She strongly recommended six 21-day cycles of R-CHOP starting early November with at least 3 more PET scans over the next two years. Because of the abdominal location of the enlarged nodes, she said radiation would be too risky and that I was at a greater risk of transformation to a very aggressive form of Diffuse Large B Cell Non-Hodgkins Lymphoma, and that starting therapy soon would be helpful.   I forgot to ask her about surgery but my wife thought surgery would also be too risky because of the location and in any event surgery wouldn’t help much because the cancer is in the lymphatic system.

OTHER HEALTH INFO

I will be 62 next month and look like a string bean (151 lbs and 6’2”).  I have had restless legs syndrome for several years and was diagnosed with probable irritable bowel syndrome (IBS) over 15 years ago, and with budding BPH (prostrate starting to harden and enlarge) about 18 months ago.  Apparently the prostrate is causing my nighttime urination which wakes me up in the middle of the night 2-5 times a week.  For the IBS I have been taking Citrucell (bulk fiber tablet) and for a Vitamin D deficiency I take a supplement.  Despite the foregoing and my cancer diagnosis, I feel pretty good and think I am otherwise generally in good health (I walk 60-90 minutes a day spread out in a few sessions).

QUESTIONS

Any thoughts on the following questions would be immensely appreciated.  I fully understand that per the terms and conditions of this Discussion Board I am not to construe any responses to my post as medical advice that I can rely on. Despite that I would be grateful for your opinions and responses.  

1) Are there any credible sources of detailed statistics on a) survival rates, and b) major health problems or fatalities resulting from R-CHOP?

2) Any medical centers that have doctors with substantial experience in diagnosing and treating NLPHL?

3) Typical quality of life after R-CHOP?

4) My doctor did say other medical centers may not use R-CHOP and further said they do not use ABVD.   What does the literature possibly say about whether there is a clear optimal treatment for someone with my background?

Thanks!

po18guy
Posts: 989
Joined: Nov 2011

Of all Hodgkin's lymphomas, NLPHL is on the cusp of being declared a non-Hodgkin's. It is substantially different and for that reason, R-CHOP iseems to be the gold standard. ABVD is a classic Hodgkin's regimen, for the classical types of Hodgkin's. As to where the cancer presents, it is pretty much all the same, unless in the central nervous system is involved. It is a cancer of the immune system and thus it can and does flow everywhere in the body. But, so does the treatment.

To me, aggregated survival rates are immaterial. They apply to no one in particular, being a statistical construct for data collection purposes. You, as an individual, either survive or you do not. So, we aim for survival. Classical Hodgkin's has an 85-90% cure rates - somewhat lower with NLPHL. Keep in mind that the default is 100% mortality if untreated - everything must be compared to that default. R-CHOP is far from the worst. 

At 62, I would not get terribly hung up on chasing the cure, as that can actually shorten your life. You may be placed in lifetime remission, and that should be the goal, but not at the expense of substantial quality of life. As to NLPHL specialists, no clue there, so a Google search might be best.

You may have some lingering side effects from treatment, or they may clear up - it is all very individual. Possible heart issues 5 or so years down the road (or not), and maybe some peripheral neuropathy from the Oncovin (Vincristine) in the CHOP.

As to your background, the treatment is aimed at the type of lymphoma. The dosing of that treatment is tailored to your general health. Everything is closely monitored. ABVD is known for both heart and lung toxicity, so best to avoid that if at all possible. There are probably numerous individuals in this forum who have gone through R-CHOP, as that has become the most popular treatment in B Cell Lymphomas, of which NLPHL is one variety.

For some perspective, as to quality of life, I have had CHOEP-14, GVD, single agent salvage regimens of Romidepsin, Pralatrexate, Belinostat, Alisertib, and a 5th salvage regimen of TEC ( Bendamustine, Etoposide, Carboplatin) as well as intrathecal Methotrexate, and triple-dose Cyclofosfamide both before and after a stem cell transplant. 18 anti-cancer drugs in total, as well as the equivalent of 1,000 years of backgrpound radiation. Post-transplant, I received Ofatumumab (similar to Rituxan) and an experimental drug called KD025, which is a ROCK2 inhitor, seeking a solution to chronic Graft-Versus-Host-Disease (cGvHD).

Percentage? I was given a 99.5% chance of succumbing to one of the three cancers I have had since 2008. For that reason, I pay no atention to prognosis. Mine began as poor, dropped to extremely poor, and dropped several times after that.

I have a ton of co-morbidities, but life is still worth living. All of the aforementioned took place from age 56-66. What has affected my quality of life the most is the immune suppression drugs to control transplant rejcection issues (GvHD). The bottom line is that our bodies can absorb and tolerate much more than we think. 

po18guy
Posts: 989
Joined: Nov 2011

The Lymphoma Research Foundation is the 800 pound gorilla of the lymphoma world. From the linked page, they have both a downloadable fact sheet as well as a 140+ page booklet that thoroughly explains NLPHL.

https://www.lymphoma.org/aboutlymphoma/hl/

joemchicago
Posts: 3
Joined: Oct 2018
Thank you very much for the thoughtful and insightful comments!  I really appreciate your taking the time to help me with this.
Take care, Joe
Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Welcome to you Joe.

If you go through this discussion thread above, most of your questions are probably answered, and there is a lot of otherwise useful information as well.  I do not have time to re-read it all, but will say a few things. I will be repeating much of what I wrote above, or what others said.

I got NLPHL at 53, advanced Stage III. Everywhere from the neck to around the pelvic area, and across from armpit (axillary) to armpit -- everywhere.  I am now 62, so have been clean for over 8 years now.

My doctor told me that my "odds" for total remission (no evidence of disease), or "NED" was around 60%.  He said that he was using the numbers of a 60 year old man.  Older statistics are just that, older, and life expectancy for almost every form of cancer is always going up, but not much has changed in the world of NLPHL.  It is a mostly neglected strain, due to great rarity, and the fact that it is already easy to control.

The definition of "early" for NLPHL is Stages I and II, and "advanced" is defined as Stages III and IV.  But stage at diagnosis is not highly critical with most lymphomas, unlike organ cancers. Stage IV is commonly as easily cured as Stage II, for instance.

An aspirational biopsy ("needle draw") is not nearly as good as an excised (surgically removed) biopsy.  NLPHL is fairly oftenly MISdiagnosed, and when it is misdiagnosed, it is usually a T-cell disease, which are extremely rare and difficult to control.  I would ask your oncologist how certain they are that the diagnosis is absolutly correct before beginning.  A second review of the sample at another lab is a very reasonable request, and not a lot of money, even if paid out of pocket.

Whether you use R-ABVD or R-CHOP, NLPHL nearly always goes straight into complete remission. You will receive either 4 months or 6 month's worth of chemo, based on the oncologist's judgement.  Because some of the drugs are vesicants, or blister agents, an IV port is highly advised; many cancer centers require an IV port to administer vesicants, but some do not.

I am unaware of prominent hematologists who specialize in NLPHL.  It is just too uncommon, apparantly, and is in essence treated by all oncologists as an indolent HL.   Be sure that you do get the Rituxan, however. NLPHL is the ONLY form of Hodgkin's that expressed the CD-20 cell, which is what Rituxan works against.

I have read of a few doctors approaching NLPHL with just Rituxan, and some others treat relapsed NLPHL with just Rituxan.  But first-line, for permanent cure, R-ABVD or R-CHOP are almost always employed. Bendamustine and Rituxan ("B&R") has been showing promise with NLPHL.  B&R is now used against numerous NHLs with low toxicity.

Bottom line: NLPHL is easy to beat, and easy to control. It is somewhat given to relapse (15%), but relapsed disease is easy to control also.  There is no cause for panic or distress with your given particulars.

Three years ago I got a new diagnosis: Prostate cancer.  Prostate and lymphoma are wholly different, unrelated animals, but you mentioned prostate issues.  Feel free to use the private email funtion here at the Boards to ask prostate questions if you wish.

Write with followup questions as they occur to you,

max

joemchicago
Posts: 3
Joined: Oct 2018
Hi Max, I really appreciate your very helpful comments and all the comments you posted above.  You have a big heart that is making a big difference for many of us.
Take care, Joe
Iluvlucy
Posts: 25
Joined: Feb 2019

I got booted out with the website crash.  I'm early on in my NLPHL journey.  I have met some of you in this discussion board and it has been very helpful to network with others.  I was dx with NLPHL on 1/2/2019.  Had CT of chest/abd/pelvis and PET.  Have been staged at IIIA due to positive nodes in my right armpit and mesenteric nodes.  I've never felt sick, in fact feel fabulous physically.  I haven't missed a day of work in over a decade, no colds, flu, etc.  I found a lump in my R armpit this summer, which is the same area that had a core needle biopsy 4 years ago and came back "normal".  Fast forward 4 years later I have this lump.  Doc wanted to do a mammogram first that came back normal.  I was supposed to have an ultrasound done at the same time but the imaging dept refused to schedule it until the mammo results were in and then they were to call me to schedule, but they never did.  Meantime, my husband and I found our dream home and within 24 hours had an accepted offer and the process of mortgage and move occupied my mind and time.  Once we were settled in I reached out to my doc and got the ball rolling again.  Ultrasound showed large nodes, so had them excised and the path report came back  positive for NLPHL.  I have not agreed to any treatment at this time as I am in the process of getting 2 more opinions at large cancer centers.  I am a nurse in the industry and am having to do far more advocacy for myself than I thought I would need to.  I have to double check everything that professionals and staff say they are going to do as I have found too many miscommunication and assumptions that have delayed my workup and interrupted my path to treatment.  I just had to call the cancer center that my Hem/Onc wanted me to have a second opinion at and the treatment center hadn't contacted me in days.  When I talked with the nurse assigned to my case, she told me that she didn't move forward with my referral as she thought I had already started treatment and she also thought I was dx with classic hodgkins lymphoma.   I'm frustrated at this point.  I don't want to go down the path of traditional chemo as I know these drugs, I've administered these drugs and am terrified.  I don't want to lose my hair and am tired of people saying "it's only temporary".  That minimizes my feelings and makes me angry.  Hair loss is demeaning to me, and I won't be able to work full time, so in essence I will feel sick, have my paycheck affected and lose my dignity for this cancer that if not for the lump, I'd have never known anything was abnormal.  Anyhow, that's my story and my rant.  I'll get through this but am not looking forward to the next 6-8 months of my life.  I have a very strong faith and an incredible posse of family and tons of friends who have worked in hospitals with me, oncology, hospice, and Palliative Care for the past 31 years.  If you've made it through my post to this point, bless you, you have patience.  

 

Paula

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ShadyGuy
Posts: 386
Joined: Jan 2017

adapt and overcome. We all have similar emotions about diagnosis and some amount of whining is expected. But we adapt to it. Really there is no reasonable alternative. I was screaming along in my dream job, flying all over the world, feeling good, always had long hair and was never ill, not even a cold. The hammer fell. Suddenly the French company I worked for let me go because I was unable to constantly travel. I could have sued them but that’s not my style.  I was sick a lot and eventually I had chemo and lost my hair. Now I see that I don’t miss the travel, my wife loves my crewcut and I spend lots of time in the woods. I am happy to just still be looking down at the grass and playing with my grandkids. Its my new normal. I hope you find yours. You are curable, but accept the fact that there are hard times ahead and things will never again be the way they were. You shall overcome and you will be a better person. Its just life.

Iluvlucy
Posts: 25
Joined: Feb 2019

Suck it up and adapt is not much support.  Will look for a bit softer approach elsewhere.  I also didn't see my post as whining but you are entitled to your interpretation.  Have a good day.

 

P

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Max Former Hodg...
Posts: 3256
Joined: May 2012

Please do not leave this Board, iluv....   

I'm sorry that our previous discussions regarding NLPHL seems to be  gone, but most of the stuff above on this thread is directly relevant to you.  PM or post here for any restatement that you may need, or any questions of any form.

It is pretty outrageous that they have you down as Classical (CHl).  But as I have noted, it tends to be treated as-such anyway. It may be that your records show that the TREATMENT protocol is per Classical, not the diagnosis.  Just a possibility.

R-CHOP is what most clinics administer for your disease and stage, that or R-ABVD.  Be certain that they ARE giving yuo the Rituxan, since CHl does NOT express the CD-20 cell, but NHLHL DOES.  Rituxan has strong proven success is lessing relapse vs. CHOP alone for NLPHL.

I would demand a consult with your doctor, a face-to-face, and demand that this all be cleared up.  It is egregious enough to use the "L" word if he hee-haws and avoids the discussion.

It is correct however that Stage III lymphoma of any form requires full application chemo,  and I don't know of any other drug combinations commonly used first-line for indolent lymphomas.

I hope to hear from you soon, 

max

Iluvlucy
Posts: 25
Joined: Feb 2019

Thanks, Max. The only reason I want 2 other opinions is that I have read of many protocols to treat Stage IIIA NPLHL and some non traditional approaches.  I understand the intricacies of the subtype.  I have done incredible research and know that there is more to offer than R-CHOP or R-ABVD.  I want to have the discussion with someone on the cusp of the research.  I know that I probably will end up just where I started but don't want regrets of not exploring them first.  In the meantime, I'm going through all the stages of grieving in a roller coaster fashion and dragging my poor hubby along for the ride.  He says he never knows what he will find from moment to moment.  He such a dear man! 

P

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
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Joined: May 2012

P,

I say the same thing about my wife, and she is not sick !

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

P,

Like Po, I was first diagnosed with cancer in 2009 -- but with the NLPHL.  Massively covered with tumors, as I've described before. Technically Stage III since there was no bone marrow involvement, but with a lot more disease than most Stage IV patients present with.

I was then 53, but my hematologist, who is world-class, used statistics for me for a 60 year-old, a threshold when surival statistics change substantially for most strains of lymphoma.  He told my wife and I that I had a 60% chance of living 5 years, but he said he felt pretty confident.   My take of that (perhaps odd), was "Wow ! Those are good odds !"  I had previously done research on the numbers, and had compiled the exact same probabilities before he spoke with us.  Ten years later, I am still N.E.D.

Some cancers, like many forms of brain, have a 1% to 5% survivorship (recall John McCain, Joe Biden's son, and Teddy Kennedy).   Pancreatic late-stage is not good. Same for lung or colorectal. Same for Peritoneal, ovarian, and many others.   Prostate Stage IV is by definition terminal, but moves very slowly in most treatment cases. (I've had Stage II Prostate, but am apparantly cancer-free today.)  I am not saying that there is anything good about lymphoma, but from a purely rational/logical analysis, it is way better than some other possibilities.  Some personalities will take solace in that, some will not. Neither reaction is wrong.  The human animal is not just logic and statistics -- a good thing.

People always ask me, "How did cancer change you ?"  I give them an unexpected reply:  "It made me more intensly like I had always been."   Although it is a terrible development, most people deal with having cancer the same way they deal with anything else.  Religious people remain religious, secualrists remain secular.  Optimists remain optimistic, pessimists become more so.  Obsessive types continue to obsess; free spirits worry only a little.   

A dear friend died of prostate about six years ago. Because his relatives were all out of state, I drove him to almost all appointments during his last year till he went in to hospice.   He had had PCa 12 years at that time.  We were discussing a mild stroke he had suffered about five years earlier. I asked him what he thought and felt before he passed out from the stroke (he had been at home alone when it occured), and he said he remembered thinking that it was in a fact a stroke, and he recalled thinking in response, "Well, if I don't wake up, it's been a good run....no regrets."

His time during the last year with cancer was the same; his attitude was always, "If this is it, let's get it on."   He always told people to feel no sorrow, that he was good with everything in his life.

His story is peculiar and not the norm.  His attitude is very unlike my own even.  The point is that we all bring our own views and attitudes to this disease.  Use your skills as only you know them.  But do take care of your emotional situation with the tools you possess, and possessed a year ago, before diagnosis.  Because very likely, you will get through this relatively quickly, and have many decades of heath before you.

max

 

ShadyGuy's picture
ShadyGuy
Posts: 386
Joined: Jan 2017

Life can be harsh. Sometimes we just have to face reality. However please don’t leave the board because of me. I will say no more. And if you find an easy, no pain, no suffering , not inconvenient, risk-free cure for lymphoma that lets us keep our hair please share it. I am convinced there will eventually be one. Seriously - best of luck. I wish you well.

po18guy
Posts: 989
Joined: Nov 2011

In 2008, we hoped that I had Hodgkin's. Didn't. Just to show the advancements that are being made, my prognosis, when one even applied, was poor. It immediately dropped to extremely poor. This was in 2009. Since then, there was no patient group for me to belong to. It was only a matter of if I survived or not. In 2015, I had two different aggressive T-Cell non-Hodgkin's lymphomas as well as the AML precursor MDS in my marrow at 26%. In 2017, I was given a 99.5% chance of not making it. Greater understanding of NLPHL has lead the way to greeater success. No time to panic - rather time to live and enjoy life. Every day in the US, 102 people die suddenly in traffic accidents. No warning, no recovery. Those of us with cancer are a universe ahead of them.

As to dealing with the diagnosis, what do you believe? Those with a strong philosophy, world view, beleief system or religion report a far easier time dealing with it all. There is an article addressing this in the 2018 bonue issue of CURE magazine. EDIT: Find the CURE Magazine story here.

iamoutside
Posts: 1
Joined: Mar 2019

Hi,

I am located in Toronto, Canada and came across this forum over the weekend while researching about NLPHL treatment options. I am a 26 year old male and was diagnosed last week with early stage NLPHL. I do not smoke, have a glass of wine a few times a year, do triathlons, play soccer and eat pretty well. My extended family (uncle, garndparents etc) have some history with lung cancer and heart disease but not my parents. It's not that easy to find primary sources online with people dealing with NLPHL, that's why I was happy to see this forum thread and want to explain my situation in case it can be of any help to someone in the present/future. I also have a few questions at the end regarding treatment options.

My diagnosis process up to now

  • I noticed a lump in my neck (feels like a golf ball inside my neck) while massaging my neck one day in early November 2018
  • I got it checked out at a hospital and had an ultrasound done
  • Ultrasound located the mass on my left neck and the doctor told me its likely a swollen lymph node
  • I told the doctors I had no colds or sicknesses for months leading up to the day I noticed the lump
  • Was referred to a throat specialist at the hospital who also couldn't figure out why I had a swollen lymph node if I hadn't been sick for a long time
  • Was referred to an oncologist at Toronto General Hospital who said I may have a branchial cleft cyst and was ordered a head/neck CT scan
  • CT scan showed a 4cm oval mass suggestive of either lymphadenopathy or a benign peripheral nerve sheath tumor (schwannoma)
  • Ultrasound guided fine needle aspiration biopsy was ordered to narrow down the diagnosis. 
  • The biopsy involved 2 core (solid) samples and 3 liquid samples.
  • Pathology report on the biopsy was suspicious for Hodgkin lymphoma because malignant cells were found and some cells that were observed resembled Reed Sternberg cells
  • I was referred to a lymphoma doctor at Princess Margaret Hospital in Toronto and my oncologist ordered a thorax, abdomen and pelvis CT scan to check if there are any other swollen lymph nodes in my body. 
  • Oncologist also ordered a surgical biopsy because the 1st biopsy didn't retrieve large enough samples to locate/pinpoint the Reed Sternberg cells as there was still a chance I could have non-hodgkin's 
  • Lymphoma doctor ordered a PET scan
  • Thorax, abdomen and pelvis CT scan revealed no evidence of swollen nodes or tumors located anywhere else except for the one in my neck.
  • PET scan reveled cancerous cell activity in the lump in my neck and some activity in the area around the lump as well as some activity on the other side of my neck (i feel no lumps there)
  • Surgical biopsy done and pathology report diagnosis concluded I have Nodular Lymphocyte Predominant Hodgkin Lymphoma. Numerous small CD3+ T-cells and CD20+ B cells were found
  • Was told last week I have early stage NLPHL and I am closer to a stage 2A because of some activity on the other side of my neck. I have no B symptoms (no night sweats, fevers, excessive weight loss etc.) The only physical symptom I have is the painless lump in my neck and this remained the only symptom from the 1st day I noticed the lump till now.
  • Lymphoma doctor is recommending 2 cycles of ABVD, 1 month break followed by radiation therapy. This proposed treatment plan is being presented to the lymphoma board at Princess Margaret today where all the lymphoma doctors gather to discuss the best treatment plan in a collaborative effort. 

Reading all the threads above especially Max's posts revealed to me (along with some digging on google) that Rituximab is a popular drug of choice to treat NLPHL. I brought this up to my lymphoma doctor and found out that this drug is not covered by my province's (Ontario) health care program. Its cost is covered for certain specific lymphoma diagnosis but not for NLPHL. Regardless, I've asked my lymphoma doctor to bring up the possibility of using Rituximab (I would have to pay) for my treatment when my case/proposed treatment plan is discussed at the lymphoma board meeting.

A few questions:

  • Has anyone had any experiences being treated for early stage NLPHL with ABVD and radiation only with no rituximab? I ask this because R-ABVD seems common in posts above
  • In doing some research online surgical removal is sometimes recommended for early stage NLPHL but was told due to the size of my lump and cancerous cell activity being located around the lump and on the other side of my neck that surgical removal is not recommended. Chemo+ radiation is more effective. Has anyone had NLPHL treated with surgery alone?
  • Can ABVD alone treat NLPHL if scans are done after chemo treatment and show no signs of cancerous activity or is radiation always required after chemo?

I am just worried about all the treatment plans out there because I've been reading so many different combinations online. I trust the doctors at Princes Margaret which is well known for their cancer research and treatment but I know there isn't a golden standard for NLPHL because it is a very unique and rare type of Lymphoma with very little studies done. I just don't want to subject my body to anything I don't need to (Iam sure everyone going through cancer thinks the same things) especially if some of these chemo drugs may cause long term permanent side effects like lung problems from using the Belomycin drug in ABVD. 

Thank you for your time to read my post. Hopefully me explaining the process I went through up to now to get a diagnosis will help anyone in the future dealing with Hodgkin's/NLPHL. Any insight into the questions above would be greatly appreciated Smile

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3256
Joined: May 2012

Welcome to you, iam.

You've scanned the posts above in this tread, but it might be useful for you to do so again.

Yes, ABVD without Rituxan was the standard therapy for NLPHL for many years, prior to the development of Rituxan.  It has a record of being very effective. Adding the rituxan helps statistically.   Prior to ABVD, MOPP was the standard Hodgkin's treatment, and MOPP is still in rare use today.

Rituxan is not used with any form of HL even in the US, exept for NLPHL, because Rituxan kills the CD-20 cell, and NLPHL is the only form of HL that presents with CD-20.  Oncologists so seldom see NLPHL that they may be unaware of the benefit of Rituxan against it.  I would guess that 2 cycles of ABVD with follow-on radiation would be totally effective.  But, if you choose to pay to add Rituxan yourself, it certainly can't hurt.

You mention your diet and health overall.  No one knows what causes lymphoma,  and it is not linked (in any convincing manner) with much of anything, so know that you are not to blame for this.  

max

Iluvlucy
Posts: 25
Joined: Feb 2019

I had 3 opinions for my Stage IIIA NLPHL diagnosed a few months ago.  Although I did have 3 somewhat different opinions they ALL included Rituxan.  I had my first chemo a week ago.  Had R-CHOP ( rituxan, cytoxan, adriamycin, vincristine, and prednisone.  My case was reviewed in 3 different tumor boards as well.  2 local tumor boards and one national as well.  What Im reading is that the latest theory is to avoid over treatment as this is a slow growing lymphoma and you are quite young.  Although I wouldn't consider myself old, I am far older than you and they still wanted to avoid over treatment.  I dont know the answer about radiation, but when initially they thought I had StageIA, they were recommending involved site radiation only, meaning just radiating my armpit where the lymphnodes were located.  I, too, do not have a family history or lifestyle that would put me at high risk.  I am participating in a BIO bank at The University of Chicago Cancer  Center so that they can do ongoing research and gather lifestyle and med history info on me so hopefully they can find out more about this cancer and hiw to prevent it.  Good luck to you and my best wishes.   

Paula

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