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Autoimmune Hemolytic Anemia

Lauraisabel
Posts: 43
Joined: Jun 2017

Hi there, I found out that I'm severely anemic. I'm having a bonemarrow biopsy,with a rituxin infusion. Has anyone had this i and how did it go?

I also. Have MZL....have been on w/w this whole time...but feel really tired all the time. I am so thankfu for all of you because I learn a lot by reading your experience. You are all heroes!

Thank you for any feedback.

Laura.

 

Sandy Ray's picture
Sandy Ray
Posts: 97
Joined: May 2017

I had a bone marrow biopsy at the very beginning when I also got a needle biopsy and lymph nodes removed for biopsy. The pain after the bone marrow biopsy was minimal just a little like a sore spot at times. I was asleep when they did it because all was done at the same time under anesthesia. So not sure that helps. I read a lot about it and seems like some people say it is terrible and some act like it is no big deal. I was very anxious about it and ended up being nothing.

I also got rituxin on my first day of treatment. My only reaction was a rash that they gave me Benadryl for and it went away in about 5-10 minutes. It did take all day about 6-7 hours to get the treatment. They start off slow and increase slowly if you are having no reactions. If you have a reaction they stop infusion flush the line (give Benadryl in my case )get everything under control. Then we start all over again. Start off slow and start working the flow rate of infusion up again. No pain, no nausea, really just sitting in a chair watching movie on my iPad .

After the first infusion I did not have anymore reactions I have had a total of 5 so far. They go quicker once they realize you are not having reactions they increase the rate so it does not take all day.

Some people do have more reactions and some have none at all. 

Wishing you the best. Hope my experience gives you a little confidence  and takes  away some anxiety.

Sandy Ray

Lauraisabel
Posts: 43
Joined: Jun 2017

I started my first round of rituxin.....so far it went well. The prednisone has helped with the cough and hemolytic anemia. Also my cat scan showed a nodule on my chest...so dr wants a pet scan...another thing to worry about.

I will see dr to go over blood work tomorrow. Just very worried that something is changing and I don't want them to find anything.....had my spleen removed in 2001...that was a major operation!

i really appreciate all your input because you all have gone thru so much....also I saw that people don't want to be on rituxin for more then 2 yrs. On my bill it days rituxin and at the bottom it says chemo....I was told that it was not chemo....I will ask dr. Have not had bmb yet because blood is not coagulating....taking vitamin k.

If anyone had any feedback I would love it.

lindary's picture
lindary
Posts: 664
Joined: Mar 2015

Rituxan is not chemo. Chemocare defines it as a monoclonal antibody   http://chemocare.com/chemotherapy/drug-info/Rituxan.aspx

My Onc told me that a 2 year program of taking Rituxan every 8 weeks has shown to greatly increase the chances of the lymphoma staying in remission longer. One of the important things is to drink plenty of water the day of and for about 2 days after. I haven't read anywhere of someone who was on maintenace longer than that but I haven't really researched it that far. 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3328
Joined: May 2012

Laura,

Linda (Lindary) is, as always, correct, as I too understand Rituxan.  Traditional chemotherapy drugs are known as 'cytotoxic' agents: they kill cancer cells in the process of cell division.  There are so many differing types (over 200 chemos FDA-recognized in the US) because scientists have found many differing points in the cell-division process to disrupt either the DNA or RNA strands from being able to replicate, and by using a multitude of differing chemicals in this cytotoxic process.

Rituxan is (as stated) a drug that operates differently: It produces monoclonal antibodies to allow the body itself to kill cancer, but does not kill directly.  There are a variety of theser drugs in use, mostly developed within the last 20 years or less. Their offical names all end in '--mas', revferring to the fact that each are 'Monoclonal AntibodieS.'

Mas drugs and various immunotherapy agents are the primary advances in kiling cancer in the last decade.  While they assist the body's own defenses, they are not technically called "chemo," but this is not a distinction most non-professionals are concerned about.   "Rituxan" is probably routinely billed as "chemo" by oncology centers, but that is not really an issue or a mistake on their part.    Rituxan is also routinely used agains Rheumatoid (inflammatory) arthritis, in patients for whom the usual first-line drugs have failed.

Prednisone, a steroid given with many of the most popular chemo drugs, is also often called a "chemo," but it is not cytotoxic either (but neither is it a monoclonal agent)....I don't want to get too complex in all this, and I hope Linda and my responses are of assistance,

max

Lauraisabel
Posts: 43
Joined: Jun 2017

Thank you!

Lauraisabel
Posts: 43
Joined: Jun 2017

Hi Max..did you get iron infusions.....how did that go?

Laura

Lauraisabel
Posts: 43
Joined: Jun 2017

thank you...I'm dealing with a spot on the lung that the pet scan said showed some activity...they will do a bonemarrow biopsy next week....also they thought I was not coagulating...and now I'm coagulating too much!

laura 

po18guy
Posts: 1011
Joined: Nov 2011

Many cancers arise in parts of the body which are inflamed. As an anti-inflammatory, Prednisone reduces inflammation - the inflammation which fosters the growth of cancer cells.

Lauraisabel
Posts: 43
Joined: Jun 2017

Hi there.. wanted your advice..just had a bmb..no signs of anything different..dx with mzl..but my red counts are always low..so they saw that I have a lot of lymphocytes in my marrow...they want me to start Cytoxan together with rituxin and they are telling me it’s mild...would love to wait and see what my counts are ...don’t want to start something if I️ don’t have to...what do you know about this chemo...thank you!!!!

laura 

Lauraisabel
Posts: 43
Joined: Jun 2017

Thank you so much for the info....just found out that I have lupus anticoagulant....and pet scan shows some activity in the lower lobe....they want to do a bonemarrow biopsy next week...to see exac what's going on...I'm so nervous that they are going to tell me I need chemo.....if so I will get a second opinion....It seems that every time I go in they find one more thing...also the facts that I have lupus anticoagulant...makes me worry about clots!!!,

Does anyone have any though!!!!

thank you!!!!!!

Laura.

Sandy Ray's picture
Sandy Ray
Posts: 97
Joined: May 2017

I just wanted to encourage you. I know it is all scary right now. However chemo is not like the chemo we usually hear stories about. Is it fun? No  I promise though after having been through it and having come out on the other side there are lots of things worse than Chemo. It for sure is not like taking a vacation but I have had worse times with the flu. The biggest difference is Chemo last longer and the fatigue last longer. The actual severity Chemo was not that bad. Please understand there are lots of Types of Chemo. Mine was RCHOP for Lymphoma. Other Types may be easier and some harder. They have gotten much better at treating the side effects.

My worst side effect was constipation. The second worse was the crash from Prednisone which is not even Chemo but a steroid given as part of RCHOP .

Please let us know if we can help with any questions.

Sandy Ray

Lauraisabel
Posts: 43
Joined: Jun 2017

I'm taking the 70 mg of prednisone....thank you for you feedback..I'm just very scared...but talking to you does help.....I will get a 2nd opinion when the time comes....it's just that I heard devastating things about chemo....

i know that everyone is different.....just hoping that it's not cancer...and just an infected lymphnode.....

laura 

Lauraisabel
Posts: 43
Joined: Jun 2017

how are you doing after chemo? Did you get a 2nd opinion when they told you what you had to do?

Laura

Sandy Ray's picture
Sandy Ray
Posts: 97
Joined: May 2017

Well I am fatigued but getting there. My last treatment was July 3. I got 3 opinioms and 4 if you count the fact my Oncologist called another Dr at a leading university hospital. However to put that in a little perspective. I was diagnosed with 2 Types of Lymphoma at the same time. One was the rarest type of Hodgkins there is and the other was a very rare type as well of Non-Hodgkins. One was indolent and the other was very aggressive. So with standard types of common Lymphoma the treatments are pretty well set. Mine on the other hand was very rare and even to add to the twist was 2 rare types at the same time . They still all agreed on the RCHOP so felt that was my best choice. I spent about $1,500.00 to fly to a leading university hospital just to get another opionon.

i just point blank asked my local Oncologist if you were going to go to a leading medical institution for this type of Lymphoma where would it be. He gave me 2 I researched what he gave me chose one and went. He never had a problem with me getting more opinions. Hey even called someone else and was willing to tell me so. Ultimately the treatment was going to be the same so I stayed with the local guy. There was a place about an hour away that had nicer facilities and maybe some more onsite testing facility. If I had a lot of complications thst may have been a better option. However, he worked very hard for me whenever I needed anything. Always called me back after hours if I had a fever or anything that I needed to check on. I only called 2 both times a fever above the threshold of 100.5 which is important when getting Chemo.  I chose to have treatments about 25 minutes from home. When going through Chemo the fatigue sometimes makes thinking about an hour long drive just is added energy. Could not imagine if I had gone an hour away and had got stuck in traffic.

So I gave you lots of background info. Anymore questions just ask.

Lauraisabel
Posts: 43
Joined: Jun 2017

Thank you....I guess I will see what they say about bonemarrow biopsy....

I really appreciate your feedback....it's so nice to be able to talk to other people...

laura

lindary's picture
lindary
Posts: 664
Joined: Mar 2015

Years ago a co-worker was diagnosed with multiple myeloma. A couple years after that a Cancer Treatment Centers of America to look into what kind of treatments they had for his cancer. He said it was very similar to what he was also getting. After a lot of positive comments about the place he said that he had to think how far he wanting to ride to get to his Dr/Onc/treatment center if he was "pucking his brains out".  

So when I was diagnosed I stayed with the hospital near our house (15 mins) that has a cancer clinic as part of the complex. I did have to go into Chgo when I got the RICE because it was prep for Stem Cell. The Stem Cell was dropped for several reasons so I am back to our local hospital for everything. I can't complain about it at all. 

 

 

Lauraisabel
Posts: 43
Joined: Jun 2017

I will see what happens with the bone marrow biopsy...and from there I will seek a 2nd opinion...and stay within in my location....I wonder when they say there is activity in a pet scan....does that always mean cancer?

laura

Lauraisabel
Posts: 43
Joined: Jun 2017

If your pet scan shows fdg reading of 3.7 ...is that usually cancer?

laura

yesyes2
Posts: 590
Joined: Jul 2009

It's been my experience that an increase in SUV does not always mean cancer.  I have had elevated rates which upon biopsy were classified as inflamation of  tissues, but non-cancerous.  This has happened to me at least three times, stomach, tail bone, throat.  Both times my NHL were diagnosed my suv's were over 20.  The second time my values were 35 and 38.  I had an up take value on a PET of 2.7,  left breast, and turned out to be a very early, stage zero breast cancer.  So in my experience the values can be all over the place on both cancer and non cancer.  Also it can be any type of cancer not just lymphoma, hence the need for biopsy.

 

Lauraisabel
Posts: 43
Joined: Jun 2017

thank you....they told me I could not have a biopsy because of where the nodule is....so I'm going to have a bonemarrow biopsy ...so I'm waiting to see what happens...

laura

Lauraisabel
Posts: 43
Joined: Jun 2017

Thank you...I'm waiting for results...finished 4th infusion....

lowering prednisone....bonemarrow biopsy went pretty good....

thank you for all your feedback...it really helps me.Laura

Lauraisabel
Posts: 43
Joined: Jun 2017

Had bonemarrow biopsy done...now waiting for results.....still on rituxin for 4 weeks...and baby aspirin...the waiting to see where all of this is going is hard....thanks for your suppor!

laura 

Lauraisabel
Posts: 43
Joined: Jun 2017

Got results of bonemarrow biopsy....it's pretty much the same as 2013...but there is still a nodule that the pet scan showed activity....so would it not show on the bonemarrow? They want me tp repeat pet scan in 3 months...I want a second opinion......what do you think? Thank you for any feedback.....Laura

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3328
Joined: May 2012

Laura,

It is clear that your docs are following your case closely and being very thorough. What you have is obviously extremely indolent (slow-moving, non-aggressive).  I would follow the doc's advice and simply recheck in three months.   In my view a second opinion is unnecessary, given the multitude of tests you've already received. Ask your own doc if he thinks a second opinion is warranted. He will give an honest opinion; it is an ethical requirement on any doctor's part to do so.

For now, I would just relax and be thankful that all is apparantly non-threatening and lazy.  Three months in 'lymphoma time' is almost always irrelevant,

max

Lauraisabel
Posts: 43
Joined: Jun 2017

Thank you for your feedback...the only reason that I was wanting a second opinion was because on the report it did mention that mds cannot be ruled out....that really scared me...it is a form of leukemia and it looks more serious then what I have now....

laura 

Lauraisabel
Posts: 43
Joined: Jun 2017

Hi there...wanted to know if anyone had any side effects from Rituxin...I heard about possibly getting hepatitis a?...there were a whole bunch of different side effects and that got me nervous....I'm still not feeling the effects of the rituxin....thank you so much!!!

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3328
Joined: May 2012

Hi Laura. I don't have time to re-read this thread, but know that Rituxan was discussed quite a bit here before.

Rituxan will not give anyone Hep A, or any other hepatitis.   I am including a link to all relevant facts a patient would need to knowregarding Rituxan.  Lindary posted this to you some time ago above. 

The most common side-effect of Rituxan is chills, which occur during application and then fade away. Long-term muscle pain occures in a few people, and breathing issues are rare but sometimes happen.  Some people have serious initial reactions, but this is almost always just at their first infusion, and then they do not ordinarily recur.  Side-effects are  ordinarily controllable by adjusting the administration rate.  Among infused drugs for cancer, Rituxan is the mildest thing out there.

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

 

.

Lauraisabel
Posts: 43
Joined: Jun 2017

Thank you....my legs are swollen...but I guess that's normal.

po18guy
Posts: 1011
Joined: Nov 2011

I had two infusions of Arzerra (Ofatumumab), a monoclonal antibody that is more potent than Rituxan. Aside from a mild-moderate allergic reaction at infusion - which was controlled by Benadryl - there were basically zero side effects.

yesyes2
Posts: 590
Joined: Jul 2009

I have been on Rituxan since January 2008, first for NHL and now for RA.  Actually there are some long term side effects from Rituxan such as continuous infections resulting from the reduction in your immune system.  Any long term infection coud possibly be traced to Rituxan.  I can no longer hold any immunizations, ie, flue shots, Pneumonia vaccinations, in my body because of my long term association with this drug.  And most all of my Ig levels are very reduced.  These are known side effects.  Also there is a brain infection which is almost universally fatal, can't recall the name.  There was a woman on the board several years ago whos husband died from this condition.  It is listed in the warnings for the use of Rituxan.  Even knowing all this I still use the drug because of the results it gives withut the usual side effects of chemo.

BTW, I have never had any of the usual side effects of first infusion on this drug.   And I am aware that all drugs carry warnings and can have side effects.

 

 

 

 

 

 

 

 

 

 

 

 

yesyes2
Posts: 590
Joined: Jul 2009

Here is the infection I mentioned.  Viral infection of the brain called progressive multifocal leukoencephalopathy (PML)

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3328
Joined: May 2012

yesyes,

I provided this link previously above. 

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

The following does mention PML linkage, but its occurence must be profoundly rare.   Laura:  It also states that Rituxan can REACTIVATE Hep B in patients who ALREADY HAVE it, but it cannot "infect" people not already carrying it.

http://www.rituxan.com/

max

Lauraisabel
Posts: 43
Joined: Jun 2017

Hi there..wanted some feedback about this..onc wants me to see a rheumatologist because I tested positive for those markers..have any of you tested positive?... also i had blood drawn and my red count was 9.3.   The next day it was at 8...dr wanted me to go to the er...i asked her to repeat the blood work...but on my other arm....blood work was 9.5.... i was so upset...so it seems that if they trouble drawing blood and they poke you a lot....reading won't be accurate....can't believe it!

yesyes2
Posts: 590
Joined: Jul 2009

Hi Lauraisabel,

As I stated in my above post I do have RA.  And yes I did test positive for the RA blood test markers.  I have been taking Rituxan for my RA for over 9 years.  Between my RCHOP for NHL and my Rituxan treatments for RA I have just had my 48th and 49th treatment of Rituxan.  The dosage of Rituxan for RA is higher than for lymphoma treatment.  But it's only fiven 4 times a year.

I did know that if they have a difficult time drawing blood, especially if it is extracted slowly, the numbers will be inaccurate.  It was wise of you to insist the bloodwork be taken again.  I almost had my chemo not given once because a finger prick draw took too long to fill the syringe.  The following day it was retaken and in the acceptable range for someone getting chemo.

Lauraisabel
Posts: 43
Joined: Jun 2017

Thank you!!!

Lauraisabel
Posts: 43
Joined: Jun 2017

My platelets are high and my white lung is high...red count is low..dr. wants me to do a bonemarrow biopsy....again..had last one done 3 months ago and it looked fine. They are thinking I might have this disorder....does anyone else’s have it....it looks very grim and I am very worried...any feedback will be appreciated!

po18guy
Posts: 1011
Joined: Nov 2011

It sounds like doctor wants to eliminate a condition such as MyeloDysplastic Syndrome (MDS) or perhaps MyeloFibrosis. I have had a version of MDS called 20q Deletion for at least the past two years. It occurs in the elderly or in those who have had extensive treatment. Two strikes in my case. 20q Deletion MDS is a slow growing, low risk variety, but some of the more agressive types (differing deletions/mutations in the DNA) can progress into leukemia. "Can" progress, not necessarily "do" progress. There is also a condition known as Polycythemia Vera - however all of your counts would be high in that case. Only a sample of your marrow will clear this up.

Lauraisabel
Posts: 43
Joined: Jun 2017

so they ruled out everything...no leukemia..but so may lymphocytes so you think chemo which they are calling mild..will do the trick and get rid of the lymphocyte?

it looks lik i have no choice..how mild is cytoxa!

thank u

po18guy
Posts: 1011
Joined: Nov 2011

Are they mature lymphocytes?

Lauraisabel
Posts: 43
Joined: Jun 2017

It does not say....it says multiple lymphoid aggregates composed of mixed T and B cells. B cells are increased which is concerning for residual low grade b lymphoma.

what do you think...

yesyes2
Posts: 590
Joined: Jul 2009

Hi,

I have had cytoxan twice.  THe first time was in a breast cancer chemo called CMF and the second time was in my RCHOP chemo for NHL.  As in combination I couldn't tell you how difficult it was, however I do know it caused my eyes to continuely tear.  And it gave me headaches for days after the infusions.  It also can cause you to lose your hair.  The infusion usually took around an hour for the cytoxan drip part but because of the headaches it was given over at least a 2 hour period.  Maybe you need to find out if you will be getting it in an IV or taking the pill form.  Oh, it also can cause nausea so you would need meds for that if taking it in pill form.

Sorry I can't be more helpful.   I can only relate my experiances and for me I could not classify as mild.  But we are all different.

Leslie

Lauraisabel
Posts: 43
Joined: Jun 2017

The

Thank you....I’m supposed to be taking that with rituxin and 100mg of prednisone(the steroids is only for 5 days) Dr said this chemo is mild.....it sure does not sound like it is..it’s not a pill...it’s an iv

yesyes2
Posts: 590
Joined: Jul 2009

Lauraisabel,

Taking Rituxan, cytoxen and the  5 day pulse of steroids is missing just 2 compnants of the standard RCHOP.  Yes it is missing the harsher drugs but in my opinion is in no way mild.  How often are you supposed to receive this treatment?

Lauraisabel
Posts: 43
Joined: Jun 2017

So 5 Times with 3 weeks rest in between..the dr Keeps on saying..mild mild. You probably won’t even loose your hair...

Lauraisabel
Posts: 43
Joined: Jun 2017

i wonder if there is another chemo that is milder..but I’m on blood thinners...it has to target the lymphocytes...

Lauraisabel
Posts: 43
Joined: Jun 2017

So I had a bonemarrow biopsy done a week ago. Dr seemed nonchalant and did say I should get a second opinion with Moffit..which I’m Ok with..but she did say she wants me to have 2 iron infusions one week apart..it seems my body does not absorb it well...

also  have a history of low grade b lymphoma...the report says..there are significant numbers of nodular and well circumscribed lymphoid aggregates comprised of small lymphoid cells with dense chromatin....with T cell predominance. The number of aggregates seen is somewhat atypical. Reticulin stain shows moderate fibrosis within the lymphoid aggregate....so now I’m seeing that B cells are less but more T cells.....does anyone have any idea?....I see a dr in 2days..and wanted your opinion...also has anyone had an iron infusion?

thank you so much for any feedback!!!!

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3328
Joined: May 2012

Hey Laura.  

I will address two things. First, I saw where you asked me yesterday if I had received iron infusions.  You must have spotted that on some other thread, because I didn't see it mentioned on this one (or I missed it), but regardless, yes, I have received IV iron.  It was about two or three years after I finished chemo. I went in for an annual check. Prior to that, my labs had always been perfect. This time too, except severely anemic.  My oncologist was worried, and had me checked for a variety of things, all negative. He also put me on four iron IVs, I believe over the course of two weeks.  For some reason, that fixed everything. I was never again (to date) anemic.  I asked the onc what his explanation was, and he said he absolutely did not have one.  But he did say that initially he thought it was relapse.

Receiving iron IVs is almost always event-free. No real risks or side-effects in most cases.  I had no side-effects at all.

Second, your biopsy results sound suspicious. Especially the large number of T-Cells, and the doctors recommendation for a second review.  T-Cell disease is rare and often missed or misdiagnosed even in good pathology labs. You need a real expert review.  But Moffitt is one of the best in the US.  

"Low grade B lymphoma" means an indolent, non-aggressive strain; follicular is the most common of these.

Last year you were getting Cytoxan.  That's another name for cyclophosphamide, a mainstream chemo found in CHOP, EPOCH, and many other combos. I believe it was yesyes who pointed out that this is a mainstream chemo, and in no sense "mild."

I recommend that you demand a careful review of all biopsies and pathology results.  I also recommend that you CNS privately email Po18Guy right away and let him review your biopsy data in detail. He is the best T-cell guy here, ever.

Please keep sharing,

max

Lauraisabel
Posts: 43
Joined: Jun 2017

thank you so much for your feedback....I am going to send PO18Guy a photo of my bmb...I want him to read it....but Dr Bello seemed not worried about my results except that she definitely was for me getting infusions of iron..since none marrow showed deficient...I will keep you posted....I’m so thankful that I have you!!!!

laura 

Lauraisabel
Posts: 43
Joined: Jun 2017

So I had a bonemarrow biopsy done a week ago. Dr seemed nonchalant and did say I should get a second opinion with Moffit..which I’m Ok with..but she did say she wants me to have 2 iron infusions one week apart..it seems my body does not absorb it well...

also  have a history of low grade b lymphoma...the report says..there are significant numbers of nodular and well circumscribed lymphoid aggregates comprised of small lymphoid cells with dense chromatin....with T cell predominance. The number of aggregates seen is somewhat atypical. Reticulin stain shows moderate fibrosis within the lymphoid aggregate....so now I’m seeing that B cells are less but more T cells.....does anyone have any idea?....I see a dr in 2days..and wanted your opinion...also has anyone had an iron infusion? update...had iron infusion last Monday...will have another in 10 days....so what they are saying is not to worry because it’s just because since I have B cell lymphoma....the cytOman was taking care of that...so you will see a “predominance” of T cells.....of course...that has me a little worried...

thank you so much for any feedback

po18guy
Posts: 1011
Joined: Nov 2011

When I was first mis-diagnosed as not having a malignancy, the local pathology lab noted "abnormal B and T cells" in a matrix. What they did not know is that this is a characteristic of Angioimmunoblastic T-Cell Lymphoma (AITL). It is absolutely unique and the B-cells are abnormal but not malignant, while the T-cells are malignant. It is nothing to mess with, but there are four identified variants, at least one of which is known to wax and wane. The problem is that it can decide to stop waning and simply become aggressive. There is no standard therapy for it, other than clinical trial - if one is available.

I would get your biopsy sample(s) to Moffitt ASAP. You might have had a T-Cell Lymphoma all along - which is why treatment is not going as planned. One identifier of AITL is a charcteristic meshwork of fine blood vessels surrounding the tumor cells (the "Angio" in the name stands for angiogenesis - the creation of blood vessels to feed the tumor). Additionally, AITL causes the release of numerous cytokines which can produce AIHA, rash, joint pain, pleural effusions, incessant dry cough, shortness of breath and many other symptoms.

There is also the possibility that you have both MZL and a T-Cell Lymphoma - but still no cause to panic as long as you have a cutting edge hematologist on your case. Moffitt has one such hematologist in Dr. Lubomir Sokol.

 

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