Dear Dr. Saini: I wrote recently due to bilateral lung nodules (6mm, 9mm, 13 mm with SUV of 3.2)
I also had a CT abdomen that revealed mesenteric and retroperitoneal lymphadenopathy. I had a laparotomy of the abdomen and the pathology diagnosis is follicular Non-Hodgkin's Lymphoma. You asked the immunohistochemistry:CD79a - strongly positive; CD20-positive; CD10-positive; CD3-5-negative; CD23-negative; Ki67-positive, 30% staining; Bcl-2-strongly positive; Bcl-6-also positive; the above finding all in favor of follicular lymphoma. The histologic type is B-cell lymphoma, subtype, follicular llymphoma. The grade is Grade 1, 0-1% centroblasts per high power field. I am being treated with Rituxan once a week x 8 weeks,wait 6 months, then Rituxan once a week x 4 weeks, wait 6 months, etc. for 2 years. You stated before that the lung nodules are assumed to be caused by the same disease process as the abdominal nodes. The CT lung states: "Within the medial aspect of the right middle lobe, there are 2 adjacent well defined nodules. The larger nodule measures 13 mm and the smaller nodule measures 9mm. A 6 mm nodule is seen peripherally in the lingula." Do you still feel the lung nodules are related to the follicular lymphoma? I have read where the nodules are usually in the lower lobes. Can they be in the middle lobe and still be follicular lymphoma? Could they possibly be benign with the largest being SUV of 3.2? Is it possible for the abdominal nodes to be follicular and the lung nodules be malt lymphoma? Hope these are lymphoma and the Rituxan will take care of these as well as the abdominal nodules. Thank you. Lorrie
Follicular lymphoma is a slow growing tumor, with good response to the anto CD20 monoclonal antibody Rituximab based therapy.
Is there any specific reason that you think that you may be having two different cancers at the same time? It is much more likely that the lesions in the lung, lymph nodes, and elsewhere all have same underlying diagnosis.
Please be reassured that there is effective treatment available for FL in the majority of cases, and that you are likely to do well.
All the best, and God Bless!
No, there is no reason why I feel I have two primary cancers. I have never smoked but was raised in a smoking household and inhaled secondary smoke. What concerned me is that the oncologist said it is uncommon to have lymphoma in the lungs. Then, I read some articles that said lymphoma is usually found in the lower lobes and my nodules are in the middle lobes. Also, that lung lymphoma is usually MALT and not follicular lymphoma. Guess I am reading too much into this. I hope you are right and it is the same disease process that the Rituxan will decrease or eliminate. Thanks.
Primary lymphoma of the lung is rare, and spread of lymphoma from lymph nodes to lung parenchyma is uncommon.
You may like to wait for the next PET-CT scan to see how the lung lesions are responding. Based on that information, further steps may be planned.
Thank you for your prompt responses. Can you please answer the following 3 questions and perhaps ease my mind? The PET scan is a long way off .
1. Are my lung nodules in the lung parenchyma as described in my prior post?
2. Do you still think that the nodes are possibly from the same disease process namely lymphoma even if the nodules are in the parenchyma?
3. Is it possible that the 13mm nodule with SUV of 3.2 be benign?
2. I would assume that they are from the same disease. There is no compelling reason to think otherwise. If at all the lung nodules are not FL, they are much more likely to be benign than a second type of cancer.
3. It is possible that the lung nodule is benign. If the PET-CT response (size, metabolic activity) of this nodule is similar to that of other lymph nodes, you may be reasonably sure that this was FL. The only way to confirm the pathology of the lung nodule is to do a biopsy.
Laura, please do not focus too much on the lung lesion. I hope you have a good response when the next reassessment is performed!
Dear Dr. Saini,
Thank you for your prompt reply to my last question. In your response to question #3 regarding the possibility of the 13mm nodule being benign, you stated in your answer that if the size and metabolic activity of both the retroperitoneal nodes and the lung nodule is similar that the lung nodules could possibly be FL. However, the 13mm lung nodule had an SUV of 3.2 and the largest retroperitoneal node which was 1.6cm x 2.6 cm with the highest SUV being 8.6 proving to be FL. My worry is that these lung nodules can be a metastasis from another primary cancer elsewhere, although all my labs were perfect and the PET showed no other activity other than the one lung nodule and the retroperitoneal nodules and I have no other symptoms. My last mammogram was fine and my colonoscopy was fine. Do you feel the lung nodule can be a metastasis from something other than the FL? Thank you.
In clinical medicine, classical teaching says that a doctor should not look for two diagnoses when there is one unifying diagnosis to explain all symptoms and signs in a patient.
This concept is known as the "Occam's Razor". It relies on logic, reason, empericism, religion, and philosophy. In the words of Newton, "to the same natural effects we must, so far as possible, assign the same causes".
That is not to say that there cannot be two cancers occuring in the same person. In fact I have seen several such cases in my practice. However, these are exceptions. Only if there is reasonable doubt should we proceed to investigate such a possibility. In your case, the simplest way to prove/disprove two cancers would be to get a CT guided FNAC of the lung nodule.
You may like to read this wikipedia article: http://en.wikipedia.org/wiki/Occam's_Razor
All the best!
Thank you so much for your replies. My doctor doesn't have a reasonable doubt, but I do. He said he thinks it is lymphoma with a "remote" possibility of being another cancer. So perhaps I will wait for the follow up CT scan after the Rituxan tx. Thank you for the site to Occan's Razor.
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