Frequently Asked Questions

Lymphoma

A lymphoma is a cancer of cells in the lymphatic system.

Lymphomas are divided into two types - Hodgkin's lymphoma and non-Hodgkin's lymphoma.

There are different types of non-Hodgkin's lymphoma. It is important to know exactly what type you have. This is because the treatments and outlook (prognosis) can vary for different types of lymphoma.

The lymphatic system consists of lymph nodes (lymph glands), a network of thin lymphatic channels (similar to thin blood vessels), and organs such as the spleen and thymus.

Functions of Lymphatics :

  1. Lymph nodes are joined together by a network of lymphatic channels. Lymph mainly consists of a fluid that forms between the cells of the body.
  2. The watery lymph fluid (which contains nutrients and waste of the cells) travels in the channels, through various lymph nodes and eventually drains into the bloodstream.
  3. The lymphatic system is also a major part of the immune system. Lymph and lymph nodes contain white blood cells called lymphocytes and antibodies which defend the body against infection. 

It’s only possible to tell the difference between Hodgkin lymphoma and non-Hodgkin lymphoma when the cells are looked at under a microscope.

 

In most cases of Hodgkin lymphoma, a particular cell called the Reed-Sternberg cell is found when cells from the lymph node are examined during diagnosis.

The cause is not known. The cancer seems to start from one abnormal cell. In the case of non-Hodgkin's lymphoma, the cancer develops from a lymphocyte cell which becomes abnormal. The exact reason why the cell becomes cancerous is unclear. If the abnormal cell survives, it may multiply and produce many abnormal cells.

Anyone can be affected. Most cases occur in people over the age of 60. It is the seventh most common type of cancer . Men are more commonly affected than women.

 A specialist will normally arrange a biopsy of one of the swollen nodes. A biopsy is when a small sample of tissue is removed from a part of the body.

 

If the biopsy confirms that you have a non-Hodgkin's lymphoma, then further tests are usually advised. For example, you may have a CT or MRI scan, blood tests, a bone marrow biopsy or other tests. This assessment is called staging. The aim of staging is to find out how much the lymphoma has grown locally, and whether it has spread to other lymph nodes or to other parts of the body.

The microscope allows abnormal cells to be seen. By looking at certain features of the cells, and by doing various other tests on the cells, the exact type of lymphoma can be diagnosed.

  1. High-grade (fast-growing)
    The cancerous cells tend to grow and multiply quite quickly and are more aggressive.
  2. Low-grade (slow-growing)
    The cancerous cells tend to grow and multiply quite slowly and are not so aggressive.

Treatments which may be considered include the following:

  1. Chemotherapy
    Chemotherapy is a treatment which uses anti-cancer medications to kill cancer cells, or to stop them from multiplying.
  2. Monoclonal antibodies
    This treatment is sometimes used in addition to chemotherapy. (For example, a product called rituximab is the commonly used monoclonal antibody.) Monoclonal antibodies are small proteins and are different to normal chemotherapy. They work by attaching to the abnormal lymphocytes, which helps to destroy them without harming other cells.
  3. Radiotherapy
    Radiotherapy is a treatment which uses high-energy beams of radiation which are focused on cancerous tissue.
  4. Surgery
    Surgery is not used very often. Occasionally, an operation may be done to remove an organ (such as the spleen) or part of an organ that is badly damaged by a lymphoma. Sometimes a large mass of tumour may be removed to de-bulk the tumour prior to chemotherapy.
  5. Intent of the treatment :
    Treatment may aim to cure the lymphoma. Some non-Hodgkin's lymphomas can be cured. In particular, most high-grade non-Hodgkin's lymphomas can be cured with treatment. Remission means there is no evidence of lymphoma following treatment. If you are in remission, you may be cured.
    Treatment may aim to control the lymphoma. If a cure is not realistic, it is often possible to limit the growth or spread of the lymphoma with treatment.
      Treatment may aim to ease symptoms. If a cure is not possible, treatments may be used to reduce the size of lymphoma tumours.
  6.  

Leukaemia

Leukemia is a malignancy (cancer) of blood cells. Leukemia involves the production of abnormal white blood cells ‑ the cells responsible for fighting infection. However, the abnormal cells in leukemia do not function in the same way as normal white blood cells. The leukemia cells continue to grow and divide, eventually crowding out the normal blood cells. The end result is that it becomes difficult for the body to fight infections, control bleeding, and transport oxygen.

For most cancers, researchers are still trying to understand how they are caused. The same is true for leukemia ‑ doctors do not know what causes it. Medical researchers have identified certain risk factors that make leukemia more likely.

  1. Exposure to radiation is known to increase the risk of developing AML, CML, or ALL.
  2. Exposure to benzene, used commonly in the chemical industry, increases the risk of leukemia.
  3. Cigarette smoking is known to increase the risk of developing AML.
  4. Down syndrome, Li-Fraumeni syndrome, and other medical conditions can increase the risk of developing leukemia.
  5. Blood disorders known as myelodysplastic syndromes confer an increased risk of developing AML. Human T-cell leukemia virus type 1 (HTLV-1) is a virus that causes a rare type of leukemia.

There are different types of leukemia, based upon how quickly the disease develops and the type of abnormal cells produced. Leukemia is called an acute leukemia if it develops rapidly. Large numbers of leukemia cells accumulate very quickly in the blood and bone marrow, leading to symptoms such as tiredness, easy bruising, and susceptibility to infections.Acute leukemia requires fast and aggressive treatment.

Chronic leukemias develop slowly over time. These leukemias may not cause specific symptoms at the beginning of their course. If left untreated, the cells may eventually grow to high numbers, as in acute leukemias causing similar symptoms

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  1. Acute lymphocytic leukemia (ALL, also known as acute lymphoblastic leukemia) is the most common type of leukemia in children, but it can also affect adults. In this type of leukemia, immature lymphoid cells grow rapidly in the blood.
  2. Acute myeloid leukemia (AML, also called acute myelogenous leukemia) involves the rapid growth of myeloid cells. It occurs in both adults and children
  3. Chronic lymphocytic leukemia (CLL) is a slow-growing cancer of lymphoid cells that usually affects people over 55 years of age. It almost never occurs in children or adolescents. Chronic myeloid leukemia (CML, also known as chronic myelogenous leukemia) primarily affects adults.

The symptoms and signs of leukemia depend upon the type of leukemia. As stated earlier, slow-growing or chronic leukemia may not cause any symptoms at the outset, while aggressive or rapidly growing leukemia may lead to severe symptoms.

  1. Fevers
  2. Night sweats
  3. Swollen lymph nodes that are usually painless
  4. Feelings of fatigue, tiredness
  5. Easy bleeding or bruising, causing bluish or purplish patches on the skin or tiny red spots on the skin, or recurring nosebleeds
  6. Frequent infections
  7. Bone or joint pain
  8. Weight loss that is otherwise unexplained, or loss of appetite
  9. Enlargement of the spleen or liver, which can lead to abdominal pain or swelling
  10. Red spots on the skin (petechiae)
  11. Mennorhagia Skin nodules
  12. If leukemia cells have infiltrated the brain, symptoms such as headaches,seizures, confusion, loss of muscle control, and vomiting can occur.
  1. Medical History
  2. Bone Marrow Aspiration and Biopsy
  3. Lumbar Puncture

Treatment will typically depend upon the type of leukemia, the patient's age and health status, as well as whether or not the leukemia cells have spread to the cerebrospinal fluid.

Types of supportive and preventive treatments that can be used for patients undergoing treatment for leukemia include the following:

  1. Vaccines against the flu or pneumonia
  2. Blood or platelet transfusions
  3. Anti-nausea medications
  4. Antibiotics or antiviral medications to treat or prevent infections
  5. White blood cell growth factors to stimulate white blood cell production (such as granulocyte-colony stimulating factor [G-CSF], made up of filgrastim [Neupogen] and pegfilgrastim [Neulasta] and granulocyte macrophage-colony stimulating growth factor [GM-CSF], made up ofsargramostim [Leukine])
  6. Red cell growth factors to stimulate red blood cell production (darbepoetin alfa [Aranesp] or epoetin alfa [Procrit])
  7. Intravenous injections of immunoglobulins to help fight infection

Multiple Myeloma

Multiple myeloma is often referred to simply as myeloma. It is a type of cancer that starts in the plasma cells of the bone marrow. These are protein-making cells which normally make all of the different kinds of proteins that comprise the antibodies of the immune system. In multiple myeloma, the plasma cells undergo what is referred to as a malignant transformation and thereby become cancerous. These myeloma cells stop making different forms of protein in response to the immune system's needs and instead start to produce a single abnormal type of protein referred to as a monoclonal or M protein. Multiple myeloma plasma cell populations accumulate and these collections of cells called plasmacytomas can erode the hard outer shell or cortex of the bone that normally surrounds the marrow. These weakened bones show thinning of the bone such as is seen in nonmalignant osteoporosis or what appear to be punched out or lytic bone lesions. These lesions may cause pain and fractures of the bones so damaged.

What triggers plasma cells to become malignant in multiple myeloma is not known.

The following is a list symptoms and signs of multiple myeloma:

  1. Anaemia
  2. Bleeding
  3. Nerve damage
  4. Enlarged tongue (macroglossia)
  5. Bone tenderness or pain
  6. Weakness or tiredness
  7. Infections
  8. Pathologic bone fractures
  9. Back pain
  10. Spinal Cord Compression
  11. Kidney failure and/or damage
  12. Loss of appetite and weight loss
  13. Constipation
  14. Hypercalcemia
  15. Leg swelling
  1. In many patients, multiple myeloma is first suspected when a routine blood test shows an abnormal amount of protein in the bloodstream or an unusual stickiness of red blood cells causing them to stack up almost like coins in a pattern called rouleaux, an unusual formation for red blood cells.
  2.  
  3. The doctor will do a history and physical exam, looking for signs and symptoms of multiple myeloma. If multiple myeloma is suspected, several studies help confirm the diagnosis.
  4.  
  5. A Bone marrow aspiration and biopsy is most commonly done from the large bones of the pelvis to confirm the diagnosis. Cells obtained from the marrow are studied by a pathologist to determine if there are abnormal types or numbers of cells. A sample of the bone marrow aspirate is also studied for more detailed characteristics such as the presence or absence of abnormal numbers or types of chromosomes by what is called cytogenetic testing. Other molecular testing may be done on the marrow sample as well. The bone marrow biopsy can assess the concentrations of cells in the marrow and the presence of abnormal invasive growth of cellular elements
  6.  
  7. Blood testing and urine testing by several methods can determine levels and types of abnormal protein produced. This is called as M protein. It is measured at diagnosis and during follow up to see the response to treatment.
  8.  
  9. Most clinicians will use X-ray studies to identify skeletal lesions and MRI for spinal, paraspinal, or spinal cord lesions in multiple myeloma. In addition, several routine tests (CBC, sedimentation rate, BUN, C-reactive protein, Serum free light chain ratio, Immunofixation electrophoresis etc.) are also done.
  10.  

The treatment for multiple myeloma may include:

  1. Chemotherapy and other drugs
  2. Stem cell transplant
  3. Bisphosphonates
  4. Radiation
  5. Surgery

It is important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decision that best fits your needs.

Aplastic Anemia

Aplastic anemia or “bone marrow failure” syndromes are characterized by drop in all blood counts , including red blood cells, platelets and white blood cells (WBCs). It is a distinct disease which requires detailed work up to exclude other causes of drop in blood counts. Aplastic anemia can vary in its severity and clinical course, from fulminant illness marked by continous or recurrent hemorrhage and major infection to an indolent process manageable with transfusion therapy alone.

Aplastic anemia is a major sequela of irradiation and exposure to cytotoxic chemotherapy. It has been associated with use of chemicals, drugs, viral infections and other diseases. However, it is not possible to point out exact cause of this devastating disease.

Aplastic anemia is a disease of young. Most patients present between 15 and 25 years of age or older than 60 years of age. This disease is more common in developing countries.

Most patients with aplastic anemia seek medical attention for symptoms that occur as a result of low blood counts, which can be as follows-

  1. Bleeding
  2.  
  3. Anemia
  4.  
  5. Bleeding and anemia
  6.  
  7. Bleeding and infection
  8.  
  9. Infection
  10.  
  11. On Routine evaluation
  12.  

In a typical case of aplastic anemia, blood counts are depressed. Platelets, WBCs and RBCs are reduced on a routine blood smear examination. However, diagnosis of aplastic anemia requires a bone marrow aspiration and biopsy, and it should always be done whenever this disease is suspected. Bone marrow usually shows ‘empty’ marrow and hardly any blood forming cells are seen. In addition, routine blood tests like Kidney function, Liver function , reticulocyte counts should be performed .

Aplastic anemia should be considered a medical emergency. Lives are lost mainly because grave consequences of severe drop in blood counts go unrecognized. It is very important to start treatment as soon as possible, before patient succumbs to an early infection. On the other hand if disease is mild and blood count is adequate, only observation and frequent follow up is required. Aplastic anemia can be cured by replacement of stem cells, that is, by bone marrow transplantation, or by immunosuppressive therapy.

Immunosuppressive therapy is an effective alternative treatment for patients who are not candidates for bone marrow transplant. Antithymocyte Globulins, which is made from horse are commonly used for this purpose. It is given over a period of 4 days and is usually tolerated well. However, some patients may develop infusional reactions which can be severe sometimes. Other common side effect is ‘serum sickness’ which develops few days after ATG therapy, and is characterized by mild joint pains. With this therapy 40-70% patients respond with hematological improvement and improved survival.

Bone marrow transplant from HLA matched sibling donor provides curative therapy for aplastic anemia patients. It is the treatment of choice for most of aplastic anemia patients. In the most favourable group, -Untransfused and uninfected patients, survival rates of 80-90% can be expected. Results with BMT have improved over time because of combination of factors, including better supportive care and better pre and post transplant regimens.

Other Questions

Chemotherapy (chemo) is the use of drugs to destroy or control cancer cells. These drugs can be taken by mouth or given in a vein or a muscle. They enter the bloodstream and reach all areas of the body, making this treatment useful for cancers such as multiple myeloma that often spread widely. There are many different types of drugs are used to treat multiple myeloma.

  1. Chemo drugs that may be used to treat multiple myeloma include
  2. Bortezomib
  3. Melphalan
  4. Thalidomide
  5. Lenalidomide
  6. Vincristine
  7. Cyclophosphamide
  8. Doxorubicin
  9. Liposomal doxorubicin
  10. Bendamustine
  11. Combinations of these drugs are more effective than any single drug. Often these drugs are combined with other types of drugs like corticosteroids or immunomodulating agents (drugs that will change the patient’s immune response).
  1. Chemo side effects
  2. Chemo drugs kill cancer cells but also can damage normal cells. They are given carefully to avoid or reduce the side effects of chemotherapy. These side effects depend on the type and dose of drugs given and the length of time they are taken. Common side effects of chemotherapy include:
  3. Hair loss
  4. Mouth sores
  5. Loss of appetite
  6. Nausea and vomiting
  7. Low blood counts
  1. Chemotherapy often leads to low blood counts, which can cause the following:
  2. Increased risk of serious infection (from low white blood cell counts)
  3. Easy bruising or bleeding (from low blood platelets or thrombocytopenia)
  4. Feeling excessively tired or short of breath (from low red blood cells or anemia).

Most side effects are temporary and go away after treatment is finished.

In a stem cell transplant, the patient gets high-dose chemotherapy to kill the cells in the bone marrow (including the myeloma cells). Then the patient receives new, healthy blood-forming stem cells. When stem cell transplants were first developed, the new stem cells came from bone marrow, and so this was known as a bone marrow transplant. Now, stem cells are more often gathered from the blood (a peripheral blood stem cell transplant).

Stem cell transplant is commonly used to treat multiple myeloma. Before the transplant, drug treatment is used to reduce the number of myeloma cells in the patient’s body Stem cell transplants (SCT) are autologous and allogeneic.

Autologous transplants

For an autologous stem cell transplant, the patient’s own stem cells are removed from his or her bone marrow or peripheral blood before the transplant. The cells are stored until they are needed for the transplant. Then, the person with myeloma gets treatment with high-dose chemotherapy to kill the cancer cells. When this is complete, the stored stem cells are infused back into the patient’s blood.

This type of transplant is a standard treatment for patients with multiple myeloma. Still, while an autologous transplant can make the myeloma go away for a time (even years), it doesn’t cure the cancer, and eventually the myeloma returns.

Some doctors recommend that patients with multiple myeloma have 2 autologous transplants, 6 to 12 months apart. This approach is called tandem transplant. Studies show that this may help some patients more than a single transplant. The drawback is that it causes more side effects and so is riskier.

Side effects

The early side effects from a stem cell transplant (SCT) are similar to those from chemotherapy and radiation, only more severe.

One of the most serious side effects is low blood counts, which can lead to risks of serious infections and bleeding. However majority of Myeloma patients tolerate transplant very well.

You are likely to have ups and downs during your post transplant period. During this time there are a few things that you can do to help your recovery and healing. Your immune system is not able to fully protect you after a transplant and it may take months to normally function. While some infections are minor, others can be life threatening. Here are few tips that might help you, but always follow advice of your transplant team.

  1. Protecting yourself from infection
  2. Keep your hands clean washing your hands is the best way of reducing infection. Wash your hands whenever you cone home after going out, whenever you touch a shared object like phone, before you take food and after toilet use. Please be strict with visitors and insist on using handrub before anyone touches you.
  3. Other tips Other important things to reduce infection is to take bath daily, using a separate towel, changing bed sheets at least once a week and changing clothes daily.
  4. Keeping your mouth clean Taking good care of mouth and gums may help in reducing infections and mouth ulcers. Some general tips include
  5. Clean your teeth at least twice a day with a soft brush and use alcohol free mouthwash as recommended
  6. Do not floss your teeth and consult your doctor before any dental procedure.
  7. Stay in a clean environment Until your immune system becomes absolutely normal, try to stay away from dust, plants, flowers, and large gatherings. This is because all these things expose you to fungal spores which can cause infections.
  8. Ask your family or friend to clean your room by mopping , instead of sweeping. Avoid being in the room where cleaning is taking place.
  9. Breathe clean air- This is a problem, especially in metros. HEPA filters can be used , but are not mandatory. Try to stay away from first hand or second hand smoke. Avoid any new construction in your house and stay away from insence sticks, oil lamps etc.
  10. Don’t have visitors who have flu, loose motion or vomiting. Avoid contact with anyone who had a live vaccine in last 2-4 weeks.
  11. Protect yourself when you go out Avoid crowds by going to places like malls, movie halls on weekdays when they are less busy.
  12. Avoid swimming in public pools and oceans and use protective gloves and wipes.
  13. Be alert for signs of infection You know your body better than anyone else, so you are the best person to watch for signs of infection. Some symptoms and signs to watch for are-
  14. Fever or chills
  15. Diarrhea
  16. Frequent urination and blood in stool or urine
  17. Abdominal pain, severe fatigue
  18. Bleeding
  19. Coughing, shortness of breath
  20. Light headedness
  21. It is very important to watch out for GVHD symptoms like jaundice, loose stools, pain abdomen, loss of appetite, skin rash, fever etc. Please contact your transplant team immediately if you experience any of these.