Dear Patient,

I am sorry to hear about your ill health.

Thank you for writing in for an opinion regarding your treatment. I have reviewed your reports that you attached with your mail. You definitely have a Non Hodgkin's Lymphoma, Large B Cell type (based on your node biopsy and IHC) and you have been started on the standard regimen with RCHOP. However a large majority of our elderly patients are unable to take Adriamycin (Doxorubicin) and therefore end up receiving only RCVP (Rituximab, Cyclophosphamide, Vincristine, Prednisolone). You do not lose any significant effect due to stoppage of Adriamycin hence you do not need to worry. The cardiac problems secondary to Adriamycin is more worrisome. Your oncologist has been very prudent in his decision to stop the offending drug.

You can continue on RCVP for the remaining 4-5  cycles. You should be getting an interval assessment PET scan after 3 cycles to see whether there is adequate response to treatment.

Concerning your abdominal pain, since you mention the hernia, it is a matter of concern. Please see / inform your oncologist at the earliest about the abdominal pain and the hernia. Sometimes the hernia can get strangulated and cause all the symptoms that you have described including the vomiting.  Taking pain killers would not be the right way to manage this situation. A strangulated hernia can cause gangrene of the bowel necessitating emergency surgery which can be quite risky in the scenario of a person on chemotherapy.

If Hernia is not the cause for pain then other conditions may have contributed to it, like the Vincristine injection which is notorious for it especially in diabetics and people of extreme age. Generally supportive measures are adequate for managing this pain.

Do feel free to write back if you have further queries.

Wishing you the best outcomes for your treatment.

Best,

Dr Wesley M Jose

Medical Oncologist

Dear patient,

I am really sorry to hear about your ill health.

I have reviewed your medical documents (Endoscopy /Biopsy / Liver FNAC / PET CT scan). The cancer of the lower esophagus that you are suffering from is in an advanced stage. It has already spread to the liver as your FNAC report confirms. This is a stage 4 cancer. 

I agree with your treating doctors who have decided not to do surgery. Surgery does not have any advantage in this situation.

The next best option is to consider radiation concurrently with chemotherapy. But I notice that you are receiving radiation therapy alone (already planned for 10 days). I believe this could be because you are 75 years of age and may not be in the best of health to receive a combined chemotherapy and radiation treatment. It depends on your treating doctors assessment of your health and ability to bear aggressive treatment.

Your difficulty in swallowing and the pain is because of the cancerous growth obstructing the lumen of the esophagus. If the radiation dose is effective you should have a relief from these symptoms in about 4-6 weeks.

Meanwhile you have to realize that the treatment of stage 4 esophageal cancer is only palliative. You cannot cure this disease at this stage.

If you are physically fit then you can have chemotherapy after you complete the radiation treatment. This will help in reducing the tumor both in the esophagus and also the liver leading to a better quality of life. However if you are not fit enough to take injectable chemotherapy then you can opt for oral tablets of chemotherapy once your are able to swallow. This also can provide you some comfort.

If you however decide not to take any chemotherapy medicine, it will be a good idea to get in touch with a palliative care physician who will be able to help you stay symptom free.

Please feel free to write back, if something is not clear.

Wishing you the very best.

Wesley M Jose

Medical Oncologist

Dear Patient,

I am really sorry to hear about your health issues. But I should compliment you for your meticulous presentation of your history. You have done it very well and it has made things easy and very objective for me to answer.

This is what I have understood this far. You had an incidentally detected high grade ductal carcinoma in situ (DCIS) in September 2015 for which you had a nipple sparing mastectomy with implant reconstruction. You were advised Tamoxifen but no further treatment was done. You were disease free for two years and in September 2017 you had a recurrence of DCIS in the preserved nipple areola (USG and MRI breast were negative), for which you had a surgical excision and complete removal of the nipple, following which no further treatment was done.

My 2018 you developed painful nodules in mid chest and USG picked up two lesions close to implant. Biopsy was suggestive of invasive duct carcinoma. You underwent a left radical mastectomy. The tumor is grade 3. There is discrepancy in ER / PR / Her2neu report between initial biopsy and later pathology of the surgical specimen. There is also a discrepancy between numbers of reported nodules in USG versus pathology. The pathology did not show nodal metastasis (0/9) and PET CT did not reveal any systemic metastasis.

(Guess I have got most of what you have said; correct me if I have missed something)

Now about your concerns.

1. USG missed a tumour of 1.7 cms size: Ultrasound examination is dependent on the operator and machine resolution, therefore not as robust as a MRI Breast. I note that you are young (44 years) and premenopausal. In younger people the breast is denser compared to an older post menopausal lady and therefore a small lesion may be missed. Moreover you had a silicon implant the second time the USG was done which again could have added to the confusion. An MRI is always better in people of your age, to have clarity and objectivity on the issues of number and size of lesions in breast. In 2017 you did have a MRI Breast; I am unable to explain why it did not pick up the DCIS lesions. I am assuming it might have been due to the technique used, use of lower resolution sequences or absence of contrast enhancement. Your radiologist would be able to answer that better than me. The report in the pathology however is the gold standard and therefore should be given more weightage.
2. Discrepancy in biopsy report: There can be 3-4 % discordance between the needle biopsy and the surgical specimen. It also could be tumour heterogeneity between the three different nodules. We can make that out only if we do the ER / PR and Her2neu in each of the nodules.
3. Tumour trying to hide: I am not really sure whether it is a case of the tumour being smart and trying to hide or is it whether the tests are unable to pick them up at a very early stage! However I am convinced that you are getting the standard treatment for the given scenario. This is a local recurrence and therefore I would agree with your oncologist in going ahead with chemotherapy and Trastuzumab. The weekly Paclitaxel (for 12 doses) with Trastuzumab (to complete one year) would be my choice too since it is the best for early ER PR Her2neu positive disease. The chemotherapy has to be followed by Radiation treatment and extended Tamoxifen. The Radiation treatment, Tamoxifen and Trastuzumab will overlap.
4. Ensure No recurrence: The extended Tamoxifen treatment is a good way of trying to avoid a recurrence. But to be practical no doctor could ever give you a complete guarantee of no recurrence.
5. What could have been done differently: Looking back it is easy to say you should have done things differently but truthfully you would have received the same sort of advices if you were at any other centre. You could have taken Tamoxifen at the onset, very well understanding the risk of endometrial and thrombotic issues, but most patients do refuse tamoxifen treatment if informed about the adverse effects, which you too did.
6. What for future: Please go ahead with the planned chemotherapy and the Trastuzumab treatment followed by Radiation and Tamoxifen which we believe should keep you going without trouble.

Please feel free to write back to me f you have any further queries.

My Best

Wesley M Jose

Medical Oncologist

Dear patient,

I am sorry to hear about your present state of health.

I have gone through your reports. Please send me the pathology report of lymph node biopsy and immunohistochemistry (IHC) test.

RCHOP is the best treatment right now for non hodgkin's lymphoma (NHL - DLBCL), with involvement of the bone marrow and the spleen. This is the treatment given even in the best centers in the world.

The RCHOP treatment causes some discomfort including tiredness, hair loss, nausea, vomiting, body pain and headache, numbness of hands and feet and so on. You might be receiving growth factors to improve your blood counts and that might be adding to the pain that you feel. The pain is temporary and will subside.

After you complete 3 cycles of treatment, you will have to do a PET scan again to confirm the response to the treatment. Most patients do have a good response and I hope the same happens to you too.

Do get in touch if you need any further information.

My Best,

Wesley

Clinical Associate Professor,
Department of Medical Oncology
Cancer Institute,
Amrita Institute of Medical Sciences
AIMS P.O. - 682041
Kochi, Kerala, India 

Dear patient,

I am sorry to hear that the bone marrow test has shown Acute Lymphoblastic Leukemia. Since I do not have any other information / reports (flow cytometry / Cytogenetics / CSF study etc), I will give you a brief idea about the treatment with the available information.

ALL is a curable cancer of childhood. The treatment is primarily done with chemotherapy medicines. The treatment lasts for almost 2.5 to 3 years. The initial 6 months would include intense treatment which aims to put the disease in remission. The common treatment schedule that is followed in a large majority of centers is called the BFM protocol. Depending on the risk category (Standard / Intermediate or High risk) the treatment and slightly different schedule of medications. There are three initial phases of treatment called Induction, Consolidation and reinduction (lasting 6-7 months) following which a maintenance treatment is carried out lasting for another 2 years.  The chemotherapy medicines has manageable side effects. The initial treatment is done on an in patient basis. During the first six months of treatment you will have to stay close to the hospital so as to reach the emergency in case of any difficulty. 

Do feel free to contact if you need any further information. It will be good if you could send me the remaining reports, so that I can have a better clarity in advising you. The treatment can be done at any oncology center. The best center for treatment is CMC Vellore and Tata Memorial Hospital Mumbai. (I am not sure where you are from).

My Best,

Wesley M Jose