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CASE 1: PRIMARY CUTANEOUS FOLLICLE CENTER B-CELL LYMPHOMA
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- Treatment
- Tolerability
- Patients Description of Treatment
CASE 1: PRIMARY CUTANEOUS FOLLICLE CENTER B-CELL LYMPHOMAA 51-year-old female presented with 2 lesions on the left lower leg in May 2008 at the oncology department of a large tertiary hospital (Aberdeen Royal Infirmary [ARI]). She had first noticed in the summer of 2007 a lesion in the left upper Achilles region, which increased in size and became red. In autumn 2007, a similar lesion developed over the mid shin of the same leg, and in the weeks leading up to presentation, a couple of much smaller satellite lesions appeared around the anterior lesion. Histopathology confirmed grade 1 follicular B-cell lymphoma (Figures 1 and and2).2). Staging computed tomography (CT) scan (chest, abdomen, pelvis) reported no intraabdominal or pelvic lymphadenopathy but showed one 2.7 × 1.7 inguinal lymph node, which was not biopsied. Stage was pT2bcNxM0.26 Hematology, biochemistry, and trephine bone marrow biopsy were essentially normal. IgH gene rearrangement analysis found clonality, confirming B-cell lymphoma; T-cell receptor (TCR)-β–ve; TCR-γ very weakly polyclonal. Cytogenetics: t(11;14) and t(14;18) translocations were not tested. The patient was generally well; she had no history of injury or infection and no B symptoms, such as fatgue, night sweats, weight loss, or pruritus. She had longstanding assumptive skin lipomas in different areas of the body but had been generally healthy, had a grown daughter, worked as a movement therapist, was a non-smoker, drank no alcohol, took no regular medications, and reported no allergies. In view of the multicentric lesions, with satellites and possible regional node involvement indicative of advancement, it was recommended she undergo systemic immuno-chemotherapy with 6 cycles of cyclophosphamide, vincristine, and prednisone plus rituximab (R-CVP) and involved-field radiotherapy on completion of the cycles. Although the patient was not opposed to this treatment in principle, she decided to keep it in reserve and improve her immunity with ME treatment first. On presentation for ME treatment in June 2008, the patient had a posterior lesion in the left proximal Achilles region measuring 5 cm × 4 cm (Figure 3) and an anterior mid shin tumor measuring 4 cm × 2 cm (Figure 4), with a number of surrounding satellites, each < 1.5 cm. The 2 large lesions were raised, red, and warm to the touch. The overlying skin was thinned but intact. There were no signs of deep tissue infiltration; she reported no pain, and no neurological deficits were ascertained. The left leg was well perfused, but there was pitting edema around the lesions and the ankle.
TreatmentTreatment with ME (using Abnobaviscum fraxini) comprised a combination of IV, intratumoral (IT), and subcutaneous (SC) applications over 12.3 months and IV and SC application over another 8 months. Details are shown in Table 1. Treatment was subdivided in an induction phase, wherein febrile reactions to ME are elicited, and a postinduction phase. ME treatment was combined with whole-body hyperthermia (WBHT)—a technique to increase core temperature to 39° to 39.5°C for 2 to 5 hours with water-filtered infrared A radiation under controlled conditions. The skin lesions were not directly targeted. She had no other cancer treatments and was not taking any medications. During induction, the patient had 4 febrile responses of ≥38.5°C lasting < 24 hours with maximum readings of 38.5°C (after day 3); 38.7°C (after day 4); 39.1°C (after day 8); and 38.6°C (after day 11). For the IT approach, the lesions were injected from the healthy skin margins to avoid breaking the paper-thin skin overlying the bulging tumors. The volume of ME fluid often exceeded 20 mL (20 mg/mL/ampoule) and was injected evenly intraand perilesional while repositioning the needle during injection. After IT treatment, the lesions responded with immediate postinjection swelling and inflammation, followed by clinical resolution of inflammation, and over the course of treatment, the lesions successively appeared less inflamed. The rate of regression seemed slightly accelerated after starting WBHT (day 37), and after 4 months, there was a clear overall improvement. The lesions continued to show injection-associated fluctuations, and the posterior lesion resolved first. The lesions steadily decreased in volume, consistency, and redness. The remission was assessed by visual inspection and palpation and confirmed by 3 independent clinicians from 3 different clinical settings, including the ARI. The overall fitness and stamina of the patient improved. Re-scanning in May 2009 reflected “No significant supraclavicular, axillary or mediastinal … retroperitoneal or pelvic lymphadenopathy; as before, there are inguinal nodes the largest of which is on the left and measuring 1.3 × 1.8 cm. This node was documented as 2.7 × 1.7 cm on staging.” Routine full blood count and biochemistry were normal. Given the favorable clinical signs of control, the IT injections were discontinued at 12.3 months. Combined IV and SC ME treatment with WBHT continued for another 8 months, and the lesions continued to regress. The areas blanched eventually, leaving depressed (posterior, Figure 5) and level (anterior lesion, Figure 6) hyperpigmented areas. Conventional therapy was deferred indefinitely. At last review in December 2011, the patient was doing well and remained in remission; the appearances were similar to those from June 2011 (Figures 7 and and88). TolerabilityFever was associated with sickness (grade 1) and grade 2 to 3 fatigue. The subsequent combined IV/IT administrations elicited fatigue (grade 1–2) for 1 to 3 days. No hypersensitivity was observed. SC injections elicited site responses of 4 cm to 5 cm erythema for < 2 days. The intralesional injections with concentrated ME were uncomfortable, with fluid pressure and pain for a few minutes, but did not require analgesia. Inflammatory responses (erythema, swelling, tenderness) and (transient) increase of edema of the lower leg lasted for < 2 days and were treated with cooling applications. The patient had no phlebitis at cannulation sites. Patient's Description of TreatmentThe patient in this case described the treatment experience as follows: With the initial fevers and fluctuating energy levels, my treatment was intense, exhausting and it was the only thing I could do during that time: but not a burden and a meaningful experience. During one of the high fevers an old traumatic experience became disentangled and I have felt freed up since; I now feel better than before my cancer, physically and emotionally. I also felt empowered by the working together with my doctors to develop the best treatment for me. I am very grateful for my new health! |