is "House" accurate?

I was watching an episode of the House tv show.  As usual, a PT had a mystery condition. After some failures at diagnosis, the junior docs next suspected lymphoma, and so ordered chemotherapy - to see if there was any improvement.

I had a family member with NHL, and so the concept of ordering chemo without a definitive diagnosis seemed ludicrous to me. They didn't even order flow cytometry, they were just ready to start giving whatever drug (which was not specified, so it might have even been Adriamycin for goodness' sakes). Is such a thing possible???

Even if it *were* a very mild biotherapy like rituximab, would any doc ever take such a course? Not to mention: what insurance would even pay for such a speculative approach?

But, I might be wrong, so I'm asking :)   Thanks for any elucidation.

[Kamal S Saini, MD, MRCP (UK), DM]

Hi,
Interesting question!
It is usually not acceptable to order a "therapeutic trial" of a course of chemotherapy for an undiagnosed condition.
In other medical conditions, it is sometimes acceptable to do treat without absolute diagnosis (for example in suspected cerebral tuberculosis or malaria, in emergency conditions like febrile neutropenia etc). In a very few cancer conditions (like brainstem glioma), biopsy is sometimes not possible, and appropriate local therapy may be initiated.
I have not watched the episode mentioned by you. But the diagnosis of lymphoma is usually straightforward. If previous FNAC/biopsy was negative, a PET-CT would have been helpful for identifying the lymph node most likely to be diagnostic; and a repeat sampling is mandated.
Why do you think adriamycin was given? Was the infusion red colored?
And by the way, Rituximab (MabThera) is also associated with many adverse effects, and should be given only in accepted indications.
All the best!

[SonnyC]

Thanks for the answer, Doctor.

On the show, they didn't actually get to the point of giving the chemo. But as far as I know, giving Red Devil might still be probable TX here. In that tv episode, there were no visibly enlarged nodes, and they did not do a PET to look for internal nodes. I'm not quite sure in memory, but I think the symptom was colon bleeding.

I can tell you are from Europe just by your use of MabThera :)  instead of Rituxan. My father had had 6 weeks of that, and even of Zevalin, for his Mantle Cell NHL.

Thanks again to you!

[Kamal S Saini, MD, MRCP (UK), DM]

Hi,
You should attribute this minor inaccuracy in the TV show plot line to "creative license" and smile indulgently and say "Hey, I spotted that blooper"!
About your father, I hope he is doing well after Zevalin. Mantle cell lymphoma is very challenging to treat.
Good Luck!