Case history: follicular lymphoma at 40

PUBLISHED : Tuesday, 20 November, 2012, 12:00am
UPDATED : Tuesday, 20 November, 2012, 4:04pm

Anson Wong, 40, noticed a small, painless lump on the right side of his neck but paid it little attention as it did not bother him. He ignored the lump, which was 2cm to 3cm in diameter, for about six months.

Wong (whose name has been changed for reasons of patient confidentiality) noticed that the lump sometimes shrank and at other times increased in size. When it remained enlarged, he decided to seek medical attention.

His doctor did not like the look of it. Enlarged lymph glands on relatively young men can indicate a number of medical concerns, including tuberculosis and some cancers. Nasopharyngeal cancer is a particular concern as it is 25 per cent more prevalent among southern Chinese than it is among people in other parts of the world. Wong was given a blood test and had a biopsy using a procedure called fine needle aspiration. Unfortunately, the test results were inconclusive.

However, Wong was referred to Dr Raymond Liang Hin-suen, director of the Comprehensive Oncology Centre at Hong Kong Sanatorium and Hospital, for further investigation. Liang decided to remove the affected lymph gland for a biopsy. It showed that a type of immune cell - B cells - in Wong's body had gone awry and were multiplying uncontrollably. He had lymphoma, or cancer of the lymphatic system.

There are as many as 35 types of lymphoma. Although some of them may appear similar, they function differently and respond to different therapies.

Liang found Wong was suffering from follicular lymphoma, where cells group together to form follicles, or spherical structures with a cavity within.

Follicular lymphoma is a slow-growing or indolent cancer. It exhibits subtle warning signs, including enlarged lymph nodes, fever, weight loss, sweating and fatigue. Although it is slow-moving and responds well to treatment, low-grade lymphomas like this are hard to eradicate.

What was unusual was that follicular lymphoma typically affects people over the age of 55, and Wong was only 40.

Liang needed to know how widespread the disease was. A Positron Emission Tomography-Computed Tomography (PET-CT) scan was used to detect areas of unusually high metabolic activity in Wong's body. Such activity is indicative of cancer.

The scan results were alarming. The cancer had travelled extensively through the lymphatic system and many lymph glands in Wong's chest and abdomen were affected. One of the glands was so swollen that it was obstructing his ureters, causing his kidneys to balloon.

A bone marrow biopsy showed that cancer had penetrated his bone marrow. Wong had stage four follicular lymphoma as the disease had spread outside his lymphatic system.

Despite the alarming findings, Liang assured Wong that even with advanced follicular lymphoma, there was no immediate threat to his life, and the disease tends to respond well to treatment.

This would include chemotherapy and monoclonal antibody therapy. Monoclonal antibodies are made by identical immune cells cloned from a parent cell. They bind to a specific type of cell (in this case the B cells at the root of the lymphoma) and stimulate the immune system to attack and destroy those cells. But Wong had reservations. He and his wife had been hoping to start a family and he was worried that chemotherapy would affect his fertility. Chemotherapy has been shown to reduce the number and quality of sperm. So, Wong's sperm was collected and stored before chemotherapy began.

Wong was also found to be a hepatitis B carrier, like 10 per cent of Hong Kong's population. There was concern the combined cancer treatment could reactivate the virus. So Liang gave Wong an antiviral medication concurrently with the cancer treatment to protect his liver.

Liang put Wong on a monoclonal antibody drug and a new chemotherapy drug, which is more effective at controlling the lymphoma than other regimens.

After the first dose of the drug, Wong suffered an allergic reaction in the form of a fever. But this was readily controlled with the use of steroids.

Three months of treatment yielded encouraging results - a repeat PET-CT scan showed the cancer was gone from his lymphatic system and bone marrow. Wong continued with another three months of treatment, after which he was put on the antibody therapy every two months for the next two years.

However, follicular lymphoma has a nasty habit of resurfacing after years in remission. Wong will need to be screened and monitored regularly to guard against a relapse.

In the meantime, Wong is enjoying his restored health and making plans to extend his family.