Tuesday, December 2, 2008

Day 2 and Lymphoma 101

Steve and I are sitting at Dr. Wisch’s office with an adorable lady named Frida and her daughter; it looks like Frida isn’t winning in the cribbage game, but her spirits are high. It’s a full house in the chemo chairs today – I’ll probably get bumped out to the waiting room soon.

Today, Steve receives the “CHOP” part of the R-CHOP cycle which is part A of the regimen (part B will be the inpatient Ara-C in 22 days). “CHOP” is not a Ronco product (nor, I reckon, does it only cost $9.99) but it is:

cyclophosphamide (brand name cytoxan, neosar)
Adriamycin (doxorubicin / hydroxydoxorubicin (ref))
Vincristine (Oncovin)
Prednisone (sometimes called Deltasone or Orasone)

This is the real-deal chemo, and will make him nauseous and lose his hair… he did want to add that not having “bad hair mornings” upon wakeup should have been on the Top 10 list he created yesterday. And Thursday is the day Steve will get his super short buzzcut; apparently his hair will fall out within a couple of weeks.

By popular demand, here’s some of the science behind what we’re learning right now. It has been helpful for me (“helpful” is a relative term) to know about the mechanics, especially as I know a bit about the immune system given my boys’ autoimmune issues. I’ll just say that my learning curve is still steep, and while this is all logical it is still hard to really comprehend. And I’m sure I’ll be tweaking this as I understand more b/c it may not pass a medical professional’s muster…

Lymphomas are a cancer that start in the lymphatic system (our bodies’ first line of defense); they are officially a blood cancer b/c the lymphatic system and the blood cell-forming system in bone marrow are closely related. There are actually three types of lymphocytes (lymphatic cells) that travel around the body: T cells (created in the thymus), B cells (created in bone marrow) and Natural Killer/NK cells. B lymphocytes make antibodies in response to foreign antigens, especially microbes. Antibodies basically attach to a microbe, thus making it possible for other white cells to recognize the antibody and ingest it into the cell along with the attached microbe. The cell then kills and digests the microbe. So, the background here is that B lymphocytes – by their very nature – are mutating all the time. (This adds to the complication in treating a B-lymphocyte cancer, because we need those lymphocytes to mutate, in the future, for the right reasons but not to mutate for the wrong reasons. This is a different mechanism from an organ cancer which happens when a bad cell is formed and divides and divides to form localized tumors)

There are two kinds of lymphomas: Hodgkins and non-Hodgkins. There are then more than 30 non-Hodgkins lymphomas (NHL). 90% of NHL’s are B-lymphocyte lymphomas, including mantle cell; there are 14 different kinds of B-cell lymphomas. (Mantle cell is one of the rarer of the B-lymphocyte lymphomas) Are you confused yet? Just wait!

Dr Hochberg had a great way of explaining how the immune system has evolved and needs to work. Basically it has two jobs: to respond to threats (bacteria, pathogens) and not to respond to every protein or cell in the body (b/c that can cause autoimmune disorders like rheumatoid arthritis).

So, imagine a Chinese food menu (Steve commented to Dr Hochberg that he hates Chinese food, but I like Chinese food so I stuck with the lesson) with 9 soups, 8 salads, 12 appetizers, 6 chicken dishes, 11 beef dishes, 7 starch dishes, etc. Imagine all the possible combinations that the system would need to remember; and by the way, it’s all arranged in a linear way with enzymes cutting and rearranging the DNA. So, just imagine how many opportunities there are for mistakes to happen with all those combinations.

In Steve’s case, a mutation developed (a bad menu combination) and his immune system missed that bad cell. (And then it spread – because the lymphatic system is, indeed, a system) Literally, the DNA was rearranged; the system reached into chromosome 14 and matched it to Cyclin D1 for those of you interested in the detail.

The single biggest factor for lymphoma is age – because mistakes are more likely the longer the system is at work. Other activations of the immune system (such as HIV, or autoimmune disease) might show an immune system fragility. The former is Steve’s case, not the latter. In fact, mantle cell lymphoma usually occurs in people much older than Steve – just adding to how special and unique he is.

Seriously – the main concern with mantle cell lymphoma is that it has a notorious track record of coming back and being harder to treat the next time… hence the reason, we are raising our non-alcoholic glasses to the geniuses behind the Nordic Regime (more on that in a future blog)

On a lighter note, my friend and colleague Jengie shared some important insight into Mighty Mouse: “A quick fun fact about Mighty Mouse and my family - When my grandmother first came to this country she was a private nurse to Mr. Paul Terry, the original Mighty Mouse cartoonist. Basically he adopted my grandmother, mom, aunt and uncle and they lived on his estate when they immigrated here from the Philippines. My uncle, who is a great artist, was very influenced by Mr. Terry and he even went on to become a toy designer. My family tells great stories about him.”

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