what treatments for relapse lymphoma

I think I have relapsed Diffuse large b cell lymphoma. My PET came back with lung and abdominal nodes enlargement and high activity. I l also have the cough and itch. No other B symptoms. I had R-CHOP 3 years ago and went into remission. The oncologist is going to have a needle biopsy of one of the abdominal nodes in a few days but they are usually inconclusive. I am probably not eligible for stem cell therapy as my lungs are bad from sarcoid and the first chemo and I have hepatitis C.

What other types of therapy are available?

[Mochadelicious]

I'm so sorry to hear about your situation.  Have you talked to your doctor about Bexxar or Zevlin?  These are similar therapies that often get good, long term results.  You might research these options and then speak to your doctor about them.  I'm not sure if they are a good option for you, particularly with your other medical issues, but it's worth looking into.  

When you say you're going to have a needle biopsy of an abdominal node but they are usually inconclusive, do you mean in general or you have had this done before and the results were inconclusive?  Can they do an excisional biopsy (take the whole node out) to get a better sample?  

[jb0072011]

Last time I had 3 biopsies and all were inconclusive. When they took out my spleen they got a positive result. The doctor told me many times they dont get a big enough sample size. The other option is open abdominal surgery where they remove whole nodes but that is much more invasive. He said that Zevalin and Bexxar are used prior to stem cell transplant after the high dose chemo part. They are not approved for relapsed DLBCL treatment by themselves and the studies that I have seen had poor outcomes when someone had already used R-CHOP and relapsed then used radioimmunotherapy. Still worth a shot!

[Ken_PA]

Hi, my father had Zevalin 3 years ago and I became rather familiar with it. In fact, I ended up rewriting large parts of the Zevalin article on wikipedia.

It is so expensive and apparently so powerful that it can seem very promising. But I guess my point is that if it isn't approved for your situation, you're not likely to get it - so I'll go ahead and tell you that in my father's case it did nothing. In fact, after the pilot dose and before the treatment dose, I'd said to the nuclear doc that it wasn't going to work... because I could see that it wouldn't go where it was supposed to. That likely was due to what you've mentioned: previous treatment with rituximab means that the B-cells might be CD20 depleted.

Aside from that, as a creative solution I'd think about asking for R-CHOP, but without the adria that you probably can no longer have. Then scan after a few weeks to see if it's working.

Or I would look on clinicaltrials.gov to see what's in the pipeline. Maybe something like ICE or some fludarabine protocol.

Maybe even bortezimib:
http://meeting.ascopubs.org/cgi/content/abstract/25/18_suppl/8031
(But don't drink tea with bortezimib.)

Or thalidomide (yes, that same drug that caused all the birth defects years ago):
http://cancerhelp.cancerresearchuk.org/trials/a-trial-looking-at-thalidomide-for-non-hodgkins-lymphoma-that-has-come-back-or-is-proving-hard-to-treat

or maybe an mTor inhibitor.



As far as an FNA, if it shows positive, then you know - but if it's negative that can't be relied on. I'd get a copy of the report rather than waiting for your next doc appt.

You can also look into endoscopic biopsy.

I'd also wonder if the lung involvement on the scan is nodular, does that then tend toward relapsed sarcoidsosis rather than lymphoma, which might typically be diffuse in the lungs.

[jb0072011]

WOW you seem very knowledgable, even more than me! The PET showed a few nodes in the lung active (SUV around 3) with parenchymal involvement (that had a SUV of 9.6, the largest in the PET). Yes the DDx could be the sarcoid as pointed out by the radiologist if it was only the lungs. BUT the nodes in the upper abdominal area, specifically the periportal, peraorta, and peripancreatic area that lit  up with SUV's of around 6, not huge but up from 4.1 9 months ago and they also increased in size a little to 1.8cm. Tommorrow I will get the needle biopsy and hope that they find something one way or the other. I will wait for the report as you suggest although I am having this done at Bumrungrad in Bangkok as I live and worked in Vietnam ( where oncology is witch doctor medicine). Thanks for your advice

[Ken_PA]

Glad to have been of a little help. I did notice that you do seem very knowledgeable yourself.

Another thing is that certain scans can often tell a lot about a node. For instance. if large areas are hypoechoic that gives a clue. But if there is a "fatty hilum" then IIRC that means it is almost always benign. I'd guess your biopsy can't be guided by ultrasound because it's too deep. So if they use MRI maybe they can see some clue at the same time the biopsy is done?

Also, AFAIK from a few years ago, SUV magnitude can perhaps give an indication of cancer vs infection, but that's controversial. Maybe that's changed since back then.

Mark me if I'm wrong but I'd say that an SUV of 20 is high, and some get >60.

Also, I was told that successive PETs should be from the same machine, else you can't compare SUV changes so reliably. OTOH I'd guess that the size measurements from the combo CT are reliable.

2 other possibilities/guesses:
a) some infection got into your lungs and the ab nodes are reacting -- doesn't seem likely though, for
b) your previous chemo (and/or any chest radiation back then?) created a problem

Good luck with the biopsy results. It'd be nice if you can find time to post back with what happens next.

[jb0072011]

Well the radiologist did not want to do the needle biopsy after careful review of the CT/PET, too dangerous. I then elected a laporascopy and was sent to a surgeon. He refused because too much scar tissue in the area from a previous splenectomy. So the final decision: WAIT till something more reachable shows up. THAT SUX. I went to another oncologist for a second opinion, same.Said no B symptoms, not that large of SUV values (well had some 6's and 1 10). He said that it was probably sarcoidosis. Man I hope none of you have had both lymphoma and sarcoid like me. It makes getting a diagnosis a *****. So I am taking prednisone which does help the breathing and energy (low dose 5mg/day) and will repeat the PET in 3 months. I have to treat myself as no doctor around here (SE Asia) is familiar with sarcoid. Thanks for your help

[Ken_PA]

Sorry to hear that things went that way. Maybe doing a PCR (looking for tiny traces of that BCL DNA mutation) would let you know which way things stand?

Also, though 5mg pred is low I'd still think about the glucocorticoid effects and how that relates to any resulting tendency toward hyperglycemia. When my father was on 60mg (and even 80mg or pred), he had his postprandial BG kept fairly low,  by avoiding high GI foods. It's not intuitive - e.g., prunes are good but raisins are bad, and whole wheat bread is pretty much the same as white bread.

[KayBee24602]

Radioimmunotherapy (RIT) is a common form of treatment for relapsed and refractory lymphomas. There are two radioimmunoconjugates (RICs)-ibritumomab tiuxetan (Zevalin) and tositumomab (Bexxar)- used in RIT. Both compounds have an average of 30% complete response rate and 70% overall response rate, and many patients achieve long-term durable response rates.

The most common adverse event associated with Bexxar and Zevalin treatment is reversible myleosupression and hematological toxicity. Zevalin and Bexxar conditioning regimens result in a toxicity profile similar to that seen with chemotherapy conditioning alone. The clinical practice of Bexxar and Zevalin radioimmunotherapy is an effective and safe adjunctive treatment for patients with NHL refractory/relapsed to conventional treatment.

Zevalin can, also, safely be administered in an outpatient setting and does not impose any radiation safety restriction.

Here are the articles I used to gather this info. Hope it helps!

https://www.medify.com/insights/article/16997176?utm_source=medhelp&utm_medium=forums&utm_campaign=intlgst-v1

https://www.medify.com/insights/article/19543946?utm_source=medhelp&utm_medium=forums&utm_campaign=intlgst-v1