LYMPHOMA CANCER

What is Cancer ?

Cancer is the uncontrolled growth of abnormal cells in the body. Cancer develops when the body’s normal control mechanism stops working. Old cells do not die and instead grow out of control, forming new, abnormal cells. These extra cells may form a mass of tissue, called a tumor. Some cancers, such as leukemia, do not form tumors.

What are the most common forms of cancer?

Cancer may occur anywhere in the body. In women, breast cancer is one of the most common. In men, it’s prostate cancer. Lung cancer and colorectal cancer affect both men and women in high numbers.

There are five main categories of cancer:

Carcinomas begin in the skin or tissues that line the internal organs.
Sarcomas develop in the bone, cartilage, fat, muscle or other connective tissues.
Leukemia begins in the blood and bone marrow.
Lymphomas start in the immune system.
Central nervous system cancers develop in the brain and spinal cord.

How is cancer treated?

Treatment options depend on the type of cancer, its stage, if the cancer has spread and your general health of the patient. The goal of treatment is to kill as many cancerous cells while reducing damage to normal cells nearby. Advances in technology make this possible.

The three main treatments are:

Surgery: directly removing the tumor
Chemotherapy: using chemicals to kill cancer cells
Radiation therapy: using X-rays to kill cancer cells
The same cancer type in one individual is very different from that cancer in another individual. Within a single type of cancer, such as breast cancer, researchers are discovering sub-types that each requires a different treatment approach.

Stem Cell Transplant
What can you do to manage the side effects of cancer treatment?

Integrative oncology services describe a broad range of supportive therapies designed to combat side effects and maintain well-being. Treating cancer requires focusing on more than the disease alone; it must also address the pain, fatigue, depression and other side effects that come with it.

Integrative oncology services include:

Nutrition therapy to help prevent malnutrition and reduce side effects
Naturopathic medicine to use natural remedies to boost energy and reduce side effects
Oncology rehabilitation to rebuild strength and overcome some of the physical effects of treatment
Mind-body medicine to improve emotional well-being through counseling, stress management techniques and support groups

What does the future hold for cancer treatment?

The future of cancer treatment lies in providing patients with an even greater level of personalization. Doctors are beginning to offer treatment options based on the genetic changes occurring in a specific tumor.

An innovative new diagnostic tool, the genomic tumor assessment, examines a patient’s tumor genetically to identify the mechanism that caused the cancer. Genomic tumor assessment may result in a more personalized approach to cancer treatment.

Note: Regarding the SCT – Stem Cell Transplant read under the home page ‘Research and Clinical Trial’. After 6th chemotheraphy and after one week PET SCAN will be carried out on May 1-3, 2017 and then future course of action will be decided. Whether go for radiation or still avoid future relapse by going for SCT.

Lymphoma

Lymphoma is a blood cancer that develops in the lymphatic system. The lymphatic system is made up of groups of lymph nodes which keep body fluids free from infection.

The blood cancer may spread from one group of lymph nodes to another in order (Hodgkin lymphoma) or (This type of cancer is rare and difficult to cure)

Spread randomly (non-Hodgkin lymphoma). This is the most common and 80% of people get this kind of cancer and it is curable.

My non-Hodgkin lymphoma is called Type B Large Diffused Cell and is curable.

Chemotherapy is the only option since it spread 23cms x 16cms in the abdomen covering many organs and also blocking supply of food from stomach to small intestine.

Physical Check Up all Good:

It is surprising to note that I had gone for physical check 2 weeks ago and all blood, stool and vitals were perfect. In fact doctor allowed me to go home with no issues. Only when I complained about the firmness in the abdomen, he thought it is Hernia and so I went to MRI/CT scan where we could see large lump.

More tests, consultations and Biopsy:

Since biopsy took almost 7-10 days to confirm Lymphoma cancer, I was sent home with the procedures.

For most types of cancer, a biopsy is the main way doctors diagnose cancer. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. It is a complete manual process.

Biopsy may be performed with the help of an imaging test, such as an ultrasound, CT scan, or MRI. Occasionally, surgery may be needed to get a tissue sample. The type of biopsy you receive depends on where the possible tumor is located.

The types of biopsies include:

Fine needle aspiration biopsy. For this type of biopsy, the doctor uses a very thin, hollow needle attached to a syringe. A small amount of tissue is collected from the suspicious area for examination and more testing. This biopsy may be used for a mass that can be felt through the skin. It can also be used with image-guided biopsy (see below).

Core needle biopsy. Similar to a fine needle biopsy, a core needle biopsy uses a larger needle to remove a larger sample of tissue.

Vacuum-assisted biopsy. This type of biopsy uses suction to collect a tissue sample through a specially designed needle. This means the doctor does not have to insert the needle more than one time. The doctor can collect multiple or larger samples from the same biopsy site with this method.

Image-guided biopsy. This biopsy may be used when a tumor cannot be felt by the doctor or when the area is deeper inside the body. During this procedure, a needle is guided to the location with the help of an imaging technique. An image-guided biopsy can be done using a fine needle, core, or vacuum-assisted biopsy. The type of scan used depends on the location, amount of tissue needed, and other factors.

Most popularly imaging scans may be used:

Computed Tomography (CT) scan

Incisional biopsy. In an incisional biopsy, the doctor makes a small incision in the skin to collect a sample of tissue from underneath the skin.

Excisional biopsy. An excisional biopsy is the removal of an entire suspicious area. This type of biopsy is common for a suspicious change on the skin. It is also sometimes used for a small lump under the skin when it can be easily removed. However, fine needle aspiration or a core biopsy are more common for lumps that cannot be seen or felt through the skin.

Shave biopsy. For this type of biopsy, the doctor uses a sharp tool to scrape tissue from the surface of the skin. It is most often used for a mass or nodule on the surface of the skin.

Punch biopsy. During a punch biopsy, the doctor uses a sharp, circular tool that is inserted through the skin. It is used to take a sample of the skin and some tissue below it.

Endoscopic biopsy. An endoscope is a thin, lighted, flexible tube with a camera. Doctors use endoscopes to view the inside of the body, including the bladder, abdomen, joints, or gastrointestinal (GI) tract. Endoscopes are inserted into the body through the mouth or through a tiny surgical incision. The attached camera helps the doctor see abnormal areas. It can also be used to take tiny samples of the tissue using forceps. The forceps are also a part of the endoscope. Find out more about the different endoscopic techniques.

Bone marrow aspiration and biopsy. These 2 procedures are similar and often done at the same time to examine the bone marrow. Bone marrow has both a solid and a liquid part. A bone marrow aspiration removes a sample of the fluid with a needle. A bone marrow biopsy is the removal of a small amount of solid tissue using a needle. These procedures are used to find out if a person has a blood disorder or blood cancer. Blood cancers include leukemia, lymphoma, or multiple myeloma.

In my case all types of biopsies were used to finally determine or rule out particular type of cancer. Shave, Punch or Endoscopic was not required to be carried out.

A common site for a bone marrow aspiration and biopsy is the pelvic bone, located in the lower back by the hip. The skin in that area is usually numbed with medication beforehand. Other types of anesthesia (medication to block the awareness of pain) may be used. Learn more about what to expect during a bone marrow biopsy.

Emergency, Biopsy week at MD Anderson Cancer Center: December 13-16, 2016

Lymphoma Cancer and Me ?

On December 13th I was admitted to Emergency of MD Anderson Cancer Center as I was unable to digest any food and complained of nausea the day before. A tube was inserted through the nose to clear the liquid from the stomach, called Nasogastric tube.

By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction. It will also allow for drainage and/or lavage in drug overdosage or poisoning. In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding. NG tubes can also be used for enteral feeding initially.

Nasogastric tube was very uncomfortable so, later a procedure was done to remove the tube from nostrils and put through the abdomen called G-J Tube. as shown in 3rd picture below. A G-J tube is a single tube that passes through the abdominal surface, into the stomach and down into the second part of the small intestine (the jejunum). The tube stays in the stomach because there is a balloon inflated inside the stomach to help “hold” it in place. I was put on liquid diet with pump feeding protein called osmolite – directly into the small intestine. The feed would be 7 cans per day and would take almost 12 hours to complete 1200 calories of single day diet.

First Chemotherapy at MD Anderson Cancer Center: January 2-6, 2017

We were restless and wanted to start the chemotherapy as soon as possible, we were told that there are over 30 types of cancer relating to abdomen itself so we have to wait for final biopsy result completed by the pathologist can help determine the type of tumor and if it is noncancerous or cancerous.

PICC Line was inserted in the right abdomen to provide chemotherapy through the IV. But what I hated was that the nurses kept pricking my arms 3 times a day for blood withdraws. Later we found the method followed by St Luke’s was better using Power Port.

A PICC line is a thin, soft, long catheter (tube) that is inserted into a vein in your child’s arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws.

After my biopsy and consultation my brother Praveen Sahay left for Boston. However, my younger nephew Prakhar, an Engineer came over and was by my side during the first chemotherapy. Not to mention about Madhavi and Shikhar who always stood like ‘rock’ upto all times. I also thank all my friends who traveled from far and wide and near with love in their heart. Garry, Sara and Anurag came from Dallas and so many local friends including Ganesh and Jaspal visited – it was really nice.

Second Chemotherapy at St. Lukes’s Hospital: January 23-27, 2017

I went for haircut and had an idea to shave the head off for easy maintenance. Well I realized that hair and shave hair stopped growing all together. I have not shaved for past 2 months. My music group had been ready to welcome and we had good singing session for over 6 hours with all musicians.

Third Chemotherapy at St. Lukes’s Hospital: February 13 – 17, 2017

Puja being organized by my St. Michaels’ friends, 1980 batch at Patna temple, where I have been associated for over 15 years. Thanks to all who prayed with love and care and especially Manoj who organized. The function was co-organized by Papa, too. After passing away of Baba, his son is the priest in orange dhoti.

There was alarming increase of fluids in my body with weight increasing by 30 lbs in just 5 days of chemotherapy along with IV. So I had to wear the stockings to hold the weight. Started with lasix was provided to avoid excess collection of fluid and also the rate of IV was dropped from 125ml/hr to 75ml/hr after discussion with the doctors.

Furosemide works by blocking the absorption of sodium, chloride, and water from the filtered fluid in the kidney tubules, causing a profound increase in the output ofurine (diuresis).

Fourth Chemotherapy at St. Lukes’s Hospital: March 6 – 10, 2017

Chemotherapy was given to nervous system under x-ray by Dr Baskaran which is called Fluroscopy Guided Lumbar Puncture with Intrathecal Chemo Injection 5ml, because it has been found that suppose in case of 20% relapse of cancer, it attacks the spine. All I can say it is extremely painful and one needs to be in bed for at least 10 hours after the procedure. There are 3 insertions in the spine tissue:

Blood Transfusion: Unfortunately my situation worsened on March 19th and I was admitted to Emergency at St. Luke’s Hospital. I had severe sore mouth and unable to swallow saliva or water down the throat. Upon admission it was discovered that my WBC, RBC blood count had gone very low and blood transfusion of 1 unit = 200ml was immediately required, which was provided. I came back home after 2 days.

Good oral care is important during cancer treatment. Some anticancer drugs can cause sores in the mouth and throat, a condition called stomatitis or mucositis. Anticancer drugs also can make these tissues dry and irritated or cause them to bleed. Patients who have not been eating well since beginning chemotherapy are more likely to get mouth sores.

Mouth sores, tender gums, and a sore throat or esophagus often result from radiation therapy, chemotherapy, or infection. If you are under treatment for cancer and have a sore mouth or gums, see your doctor to be sure the soreness is a treatment side effect and not an unrelated dental problem. The doctor may be able to give you medicine that will control mouth and throat pain. Your dentist also can give you tips for the care of your mouth.

In addition to being painful, mouth sores can become infected by the many germs that live in the mouth. Every step should be taken to prevent infections, because they can be hard to fight during chemotherapy and can lead to serious problems.

Magic mouthwash is the term given to a solution used to treat mouth sores (oral mucositis) caused by some forms of chemotherapy and radiation therapy.

An antibiotic to kill bacteria around the sore
An antihistamine or local anesthetic to reduce pain and discomfort
An antifungal to reduce fungal growth
A corticosteroid to treat inflammation
An antacid that helps ensure the other ingredients adequately coat the inside of your mouth
Most formulations of magic mouthwash are intended to be used every four to six hours, and to be held in your mouth for one to two minutes before being either spit out or swallowed. It’s recommended that you don’t eat or drink for 30 minutes after using magic mouthwash so that the medicine has time to produce an effect.

It’s unclear how effective magic mouthwash is in treating oral mucositis. That’s because of the lack of standardization in the formulations of mouthwash, and poorly designed studies done to gather data.

Side effects of magic mouthwash may include problems with taste, a burning or tingling sensation in the mouth, drowsiness, constipation, diarrhea, and nausea.

If you have mouth sores, discuss your options with your doctor. In addition to magic mouthwash, medications and other treatments may help relieve your discomfort.

Blackening of Nails of hands
Blackening of front palm
Blackening of back palm
Numbness of all 10 ten fingers
Weakness increases with each chemotherapy
Sore mouth with difficulty in eating, drinking or even talking
I did not have any nausea or vomiting or other complications with vital signs

Things did not go well – and doctor hit the nerve which has led to lot of pain for past one week

Chemotherapy was given to nervous system under x-ray which is called Fluroscopy Guided Lumbar Puncture with Intrathecal Chemo Injection 5ml, because it has been found that suppose in case of 20% relapse of cancer, it attacks the spine. All I can say it is extremely painful and one needs to be in bed for at least 10 hours after the procedure. There are 2 insertions in the spine tissue:

Prednisone is a medicine used in Chemotherapy which may cause Avascular Necrosis (AVN, Osteonecrosis)

Avascular necrosis (AVN) (also known as osteonecrosis, bone necrosis, bone infarction, aseptic necrosis, and ischemic necrosis) is a condition in which the bone “dies” as a result of a loss of circulation to an area of bone tissue. (The word osteonecrosis is Latin for “bone death.”) In extreme cases, it can result in the collapse of a segment of bone. When the surface of a joint is involved, it may lead to rapidly progressive osteoarthritis.

Avascular necrosis can occur as a result of an injury that interrupts the blood supply, such as in AVN of the hip after a fracture of the upper femur (thighbone). Other causes include the use of systemic steroids as well as certain inflammatory diseases, such as lupus. The exact mechanism for loss of circulation in these circumstances is not well understood.

The most common body parts affected by AVN are the hip, knee, spine, shoulder and wrist. In cases of AVN of the hip, it is very important to diagnose and treat early in order to prevent disability. Treatment varies considerably, depending on the location and severity, but tthe goal of initial treatment is to prevent collapse of the joint surface. In the advanced stages that result in painful arthritis, a hip replacement may become necessary.

My MRI report has shown some signs of this and hip replacement is the only option in future. The usual life of hip replacement is about 20 years. But I am sure the blood vessels can be recovered using other options like Ayurveda, Yoga etc.

Sixth Chemotherapy at St. Lukes’s Hospital: April 17 – 22, 2017

April 17: I had been feeling low and weak as something was not right. Pratik my friend took me to BCM (Baylor College of Medicine) – Diagnostic Center for blood drawl at around 9:10am. The result would be sent over to oncologist Mr Samir Ali Srour. Their office will fax order to St Luke’s’ Hospital and another order to Pharmacy at St Lukes’ Hospital for preparation of Chemotherapy medicine – this is the process.

After blood count I proceeded to St Lukes’ hospital but the wait was little longer. Anyways got into the room no 2018 on the 20th floor. The news came that the hemoglobin count is too low 6.9 for chemotherapy medicine to be given.

April 18: So blood transfusion was carried out for 2 units – 400ml and then after long wait chemotherapy medicine DOXOrubicin was started at 10am today. The medicine bag will take 24 hours to complete, before next bag will be ready.

Following after effects have been found to be common as patients reach final round of 6th chemotherapy:

Blackening of palm
Blackening of fingers
Blackening of nails
Numbness of all 10 fingers has increased and I find difficult to hold things or type on keyboard
Toe fingers are okay
Although I had shaved off my head after 1st chemotherapy finding the deal to be lucrative $3.99 for haircut and $4.99 for head shave off. I find that some hair has begun to grow.
Severe Sore throat with difficulty in swallowing saliva or water or eating anything – Magic mouth wash and doctor suggested Morphine so that I continue to eat. But taking Morphine leads to Constipation for which medicines have to be taken.
I also observed running nose at times for which doctor suggested anti-allergy tablets.
Chemotherapy-Associated Tongue Hyperpigmentation as shown below: Combination chemotherapy is associated with cutaneous and mucosal side effects. Antineoplastic agents have been associated with mucosal and nail pigmentation. We describe black tongue hyperpigmentation and blue lunula. The diagnosis of drug-associated pigmentary changes is based on correlating the onset of the clinical observations with the temporal initiation of the patient’s chemotherapy agents. Spontaneous fading of antineoplastic therapy-induced tongue or nail dyschromia may subsequently occur following discontinuation of the causative drug.

I did mention earlier that PICC Line was removed and Power Port was put – below is the picture. It has been placed near the right arm and it has to be accessed every time I enter the hospital and blood can be withdrawn or transfusion carried out or chemo can be passed or even IV fluid can be passed on through the pump connected to the Power Port. So no more picking on the skin. Just before discharge the Power Port needs to be de-accessed. It has no maintenance and one can take bath and remains hidden behind the skin and clothes.

Regular check up is necessary especially one day before the actual chemotherapy to make sure blood counts are good. Like this time the counts were not so good and immediately blood transfusion was carried out and hence chemotherapy medication was delayed.

The procedure is inserting injection into the spine and one has to lie on belly for about an hour from preparation to the injection. After the procedure the patient is required to lie flat on bed for at least 10 hours, else leads to nausea and giddiness with headache.

Dr Gustavo Rivero – Attending physician specializing in haematology, at the St Luke’s Hospital. Elaine Chang – Fellow specializing in haematology at the St Luke’s Hospital. Dr Zindani is a regular visiting Physician at St Luke’s hospital specializing in haematology. All excellent doctors.

I gained some weight due to IV fluid from 146 lbs to 160 lbs but will go down in first three days once I reach home after the chemotherapy. I will be discharged tomorrow Saturday April 22, 2017. There have been much less after effects also because the level which optimally should have been 6 for 6th round of chemotherapy was actually reduced to level 2 because of very low hemoglobin leading to blood transfusion. Probably my body cannot take any more double hits R-EPOCH, after all it is also cumulative effect on the body.