1. Introduction: Paul, Peter, Mike (Courtney out this month)
2. Guests:  No guests today
3. Case of the day:  Lymphoma patient. Workup, Treatment, & Result.
4. Lesson of the Day: Lymphoma: Hodgkins & Non-Hodgkins.
5. Cancer Questions: From Paul:  what is Car-T therapy?
6. Cancer News:  None today
7. Sign out 

paul_roach:

Hello everybody and welcome back to So Doc It's Cancer, a podcast to understand cancer, how it happens, how it's treated, how we arrive at a diagnosis and at a prognosis, cancer's impact upon a person's quality of life and how to move forward in your life after a cancer diagnosis. The show airs monthly and we welcome your engagement and feedback. Last month we brought in the subject of esophageal carcinoma. This month, we will be bringing in lymphoma. What was I supposed to say about your friendly?

michael:

Oh yeah, like you might say, please check that out at our host site, wherever that is.

paul_roach:

Oh yeah.

michael:

Or you can get it on the

paul_roach:

Apple

michael:

Google,

paul_roach:

and Spotify.

michael:

hopefully soon to be on Apple Podcasts near

paul_roach:

It's

michael:

you. Oh, okay,

paul_roach:

on Apple.

michael:

well then just tell them where they can find it. Now that may seem silly since they're already there, but really... Like, you have a channel on all these that works for all these things.

paul_roach:

Yeah, yeah, all

michael:

So

paul_roach:

right.

michael:

like, if I go looking for it, I'll find the first and second episode after today or whenever in which case just direct people to that.

paul_roach:

All right. These can be accessed at Apple and Spotify and other prominent podcast hosting sites. And for a single site, visit www.PaulBrianRoach.com. That's Brian with a Y. To access all your podcast needs. No, that's not going to work. Anyway,

michael:

I'll

paul_roach:

let's move

michael:

just

paul_roach:

forward.

michael:

say for information on various forms of cancer that we've covered.

paul_roach:

All right, for our information on various forms of cancer. Today, we'll turn it over to one of our co-hosts, Peter Schlegel, to discuss lymphoma. Peter.

peter_schlegel:

Hello everybody. Today I have the pleasure to talk about lymphomas, in particular non-Hodgkin's lymphoma. Lymphoma is one of the most

michael:

I'm going

peter_schlegel:

interesting.

michael:

to stop you, Peter.

paul_roach:

What's that?

michael:

I'm just, I'm sorry. We talked about like stage direction. I have the pleasure of talking to you about lymphoma. I'm going to back you away from the word pleasure.

paul_roach:

Yeah, yeah, yeah, yeah, yeah.

peter_schlegel:

I'm not.

michael:

I have the responsibility. I have the.

paul_roach:

Today everybody we're going to talk about lymphoma. Where it's car talk.

peter_schlegel:

Okay, hello everybody. Today we are talking about lymphoma, a very interesting cancer subtype to medical students and folks interested in medical science in terms of biology, behavior, resulting symptoms and treatments. From a patient's point of view, it's a weird cancer of lymph nodes. Although surgeons often make the diagnosis, surgery doesn't cure people. It tends to affect... both young and old, it can be aggressive, it can be very indolent and non-life threatening. It can be entirely silent or it can change someone's life overnight. It is a cancer that originates in the bone marrow generally or in lymph nodes and is associated with immunity. Cell of origin of the lymphoma is a lymphocyte which is central to immunity.

paul_roach:

So Pete, I'm going to stop you there for a second, and we're going to ask Mike about immunity. What do you think you know about immunity, and what should we explain?

michael:

Well, as I'm not a doctor, what I know about immunity is pretty limited, but my understanding is the defense system of your body. So wait,

paul_roach:

Exactly.

michael:

basically what I'm hearing Peter say is my defense system is under attack by a cancer. Now I'm not 100% because my high school biology was a long time ago. The lymph glands and the lymph nodes, where are they? What am I looking for? What is that lymphatic system?

paul_roach:

That's a good question. You know, Pete, how I describe it to people is that we're all about, you know, two thirds water. And I describe these things as water filtration plants that are positioned throughout your body. What do you call, when you're talking with patients, how do you describe lymph nodes?

peter_schlegel:

I discuss lymph nodes as regional immune systems. Example would be if you got an infection in your finger, often the lymph nodes in your armpits become inflamed just to fight the local infection feeding the finger rather than the whole body. Likewise, if you get a sore throat, you get a strep infection, the lymph nodes activate in your neck, which are localized, rather than activating the whole immune system.

michael:

So how many lymph nodes are there in my system?

paul_roach:

Very good question. A lot. It's like Monty Python. How much do

michael:

I'm

paul_roach:

you

michael:

going

paul_roach:

hate

michael:

to go

paul_roach:

the

michael:

to bed.

paul_roach:

Romans? Yeah, no, there are, I can't imagine hundreds and hundreds.

michael:

Okay,

paul_roach:

And they're

michael:

so

paul_roach:

about

michael:

this is.

paul_roach:

the size of an M&M. They're usually under a centimeter. Once they get over a centimeter in size, we start to wonder if these lymph nodes are okay. But they're...

michael:

So like I know my doctor when I go for my routine, my GM, GP, whatever,

paul_roach:

GP, GP.

michael:

the general manager of my body, he checks

paul_roach:

Yes.

michael:

the like around my neck, he'll do a quick like palpitate my neck or something. So

paul_roach:

Yeah.

michael:

that's all I ever knew. So you're telling me that there's hundreds more, and they're like little way stations that divide the body up so that if there's an infection somewhere, that's the first line of defense sort of.

paul_roach:

Exactly.

peter_schlegel:

Exactly. The lymph nodes are actually fairly limited on a physician exam so that when they, when a doctor wants to check out your lymph nodes, they can check your neck, your above your collar bones, your armpit, your groin area, but that's about it. And that's probably only represents about a 10th of the lymph nodes. And we call them lymph node stations or areas. Most of them are deep in the chest or in the abdominal cavity and serve as an immune system for your internal organs, basically.

paul_roach:

Yeah, they're around every organ that you've got. So let's say we're talking about your stomach. There's lymph nodes all around the whole circumference of the stomach. If it's your large intestine, same kind of thing. Small intestine, they've all got their little lymph nodes that they're draining to. And there's cells inside of these, and these cells have an immune function. There's a variety of different cells, but the ones with the immune function are called lymphocytes. Lymphocytes are born in your bone marrow, but they circulate in your bloodstream. You also have them in your lymph nodes. And when these lymphocytes go astray, when they get bad, you know, we're, we're, we're talking about here, lymphoma, when one of these lymphocytes becomes cancerous.

michael:

Well, how does that present itself to me? Am I just, I'm suddenly not able to fight off infection as well or how do I know that I need to go see the doctor about this?

peter_schlegel:

Well, there's a great range in different presentations of people with lymphoma. And we're gonna talk about a real life example of a patient that I recently took care of to discuss what they presented with. Again, there's lots and lots and lots of different ways that people can present. But the basic idea is that we have these enlarging lymph nodes that contain cancer. And as they grow, not only do they become a drain on the body, basically a... parasite, but because of their association with the immune system can dysregulate your entire body's immunity, cause fever, night sweats, catexia, and a number

paul_roach:

That's

peter_schlegel:

of other

paul_roach:

wasting.

peter_schlegel:

things like

paul_roach:

That's... So...

peter_schlegel:

that. Yeah.

michael:

Okay, so I'm gonna feel it, right? This isn't like a cancer that is gonna sneak up on me. I'm gonna feel this, is what you're saying. Like I'm gonna have sweats, I'm gonna be maybe something swollen. There's gonna be some physical properties that are gonna send me to see a doctor.

paul_roach:

The way

peter_schlegel:

Exactly.

paul_roach:

I would say with this cancer or any other cancer, there's general symptoms and then there's specific to the problem. So general symptoms would be fever, sweats, wasting away, weight loss, just loss of energy, or you're feeling sick. And then specific to lymphoma, let's say your ability to fight an infection is impaired, then you would go to your... your primary care physician and say, you know, I think I'm sick. And they check you out. And during the course of this, they say, I think you need to see Dr. Schlagle. How's that Pete?

peter_schlegel:

That sounds good. To answer Mike's question though, it can present in various ways. Sometimes people get a CT scan because of unrelated reason and they find that these lymph glands are enlarged. Sometimes on an examination, someone's just checking things, say I see a little bit of bump on your neck and they can find it from there. So sometimes it can become symptomatic. And other times there's no problems or the patient has nothing to be bothered by, so to speak.

michael:

Right, if it's not one of those like, I don't know, eight that you said, like neck, groin, armpits, I probably won't notice this, right? And.

peter_schlegel:

for the most part, but occasionally you can get pain if there's a large amount, you can get dysfunction of different organs because of this tumor and what it does from you. There's really no black and white in terms of you have it, you don't. And I'm gonna try to share just one example of what had happened with a patient who had a lymphoma. And this particular lymphoma tends to be on the very aggressive side of things. We certainly have many other examples of people who have a much less aggressive course, much more slow and not causing problems to the point where we really don't wanna do anything as a doctor that our treatments would cause more harm than good. And we say, well, we really don't think we wanna do anything about it other than just kinda let us run this course. And perhaps at some time, it's gonna get big enough, bad enough that we're gonna have to do something. And of course that's a tough pill to swallow for someone who wants to be proactive and do everything they can for their health.

michael:

I know that that happened with my father in the late stages of his life that the doctor basically said well we see this thing but we're gonna watch it because we don't want to take any action right now we'll just wait and kind of see and in the end he died before you know of other things before that became an issue is my understanding but I did have a question and that was Paul you started out saying that they're about the size of an M&M how big do they get when cancers.

paul_roach:

They become at least anything bigger than an M&M. It go from an M&M to a peanut M&M. And from there, it could get to be, the biggest ones I've seen are like golf balls. Maybe larger, I think I've seen some larger ones as well. But they can get really big.

michael:

And is this something like kind of the way Peter, you were describing it is if I have a cut on my finger, then the lymph node in my armpit activates. If I have a lymphoma, are all of my hundreds of lymph nodes getting larger or just, you know, like something close by a problem,

peter_schlegel:

Yeah.

michael:

like just the one in my armpit or something?

peter_schlegel:

Yeah. Generally, they tend to be localized first, and then over time, as they grow and develop and become malignant, they spread and enlarge elsewhere. That has to do with the stage. And we talked about that a little bit in the first chapter of our podcast series when we talked about esophageal cancer, that we have very specific ways of staging and determining the spread. But they typically start off localized and over time. that they spread, break off, metastasize, and grow elsewhere. Kind of like a weed that throws off both roots, if you will, and also little seedlings that go elsewhere and grow.

paul_roach:

So

michael:

Well those

paul_roach:

let's try

michael:

cells...

paul_roach:

this. Let's try a fictitious patient. And we'll just walk all the way through that and see what that looks like.

peter_schlegel:

All right, I had a gentleman I saw some years back who had been a Vietnam veteran and had been exposed to the herbicide Agent Orange, which we know as a carcinogen and has been linked with several cancers. He, over a course of about two, three months, became increasingly tired, not able to do things around the house. napping, sleeping 10 hours a night and waking up exhausted. Started developing some night sweats and didn't want to eat. He also had some back pain and when his back pain became bad enough, he went to the emergency room. At the emergency room, they did all the tests, including some laboratories. And when they drew the laboratories, they said, hmm, this guy's very anemic. His red blood cells were very low.

paul_roach:

And that helps explain the fatigue, wouldn't you say? It's one of the reasons.

peter_schlegel:

Absolutely, he looked pale and just did not have the red blood cells in his body. Well, he also complained of back pain and they did some x-rays and they wound up, like they often do, do a CT scan and lo and behold he had some large lymph nodes deep in his abdominal cavity. If I can remember correctly, they were three to four centimeters, which in English translates to about an inch or two. In the hospital, he was there about three days or so, two nights, they gave him some pain medication, they gave him some transfusions, and they got word back from the radiologist reading the scan that said, hmm, this might be lymphoma, might be a good idea to get a biopsy.

paul_roach:

So he's in the ER and all he knows is that, hey, I'm wiped out. I'm just exhausted. I'm pale. They do some blood work. They do some imaging and they start to think this might be a blood cancer. Do you think they figure that out right in the ER?

peter_schlegel:

I think there was a pretty good idea of that with the night sweats and there are infections that can cause that, even COVID can do that. Tuberculosis can cause it, sometimes an infection in the bone, they call it osteomyelitis. All those sort of things can cause the same sort of symptoms so that when people go in the emergency room, they have no idea what you have really. And so they have

paul_roach:

Peace.

peter_schlegel:

to go through these blood tests and images and so forth to figure out.

paul_roach:

Do you remember in med school, Dr. Templeton used to talk about itis, oma, and emia. This was our second year of med school, and he used to drill that into us. He was our pathology teacher. And a person would come in with these kinds of vague symptoms, and one of the first things your physician has to do is figure out is it an itis, such as inflammation, of some kind. Is it an oma? The word ends in oma. uh... so like tonsillitis is inflammation of your tonsils carcinoma is is a cancer is it some sort of cancer causing the problem or is it anemia such as like uh... a problem with your blood uh... we had a little bit got more involved after that but those are the big three do you remember that pete?

peter_schlegel:

I do, I do. That was a long time ago, but it did really teach us a lot about being a physician and to be critical in terms of analyzing the clinical situation and trying to figure out what it is to do the differential diagnosis, to pinpoint what we're dealing with, and then once we get that pinpointed, we can make a diagnosis and do appropriate treatments.

paul_roach:

So our guy goes from the ER up to the floor, and he's on the floor, and the med students are poking and prodding him, and the residents and the attending physicians, and he gets some blood transfusions, and then what happens up there?

peter_schlegel:

Yeah, for this...

michael:

Is any of that going to help? Just, sorry, like is getting a blood transfusion going to

peter_schlegel:

Yeah,

michael:

alleviate

peter_schlegel:

well, absolutely. Yeah.

michael:

any of the...

peter_schlegel:

The guy could not even, I didn't specify this, but just walking from his bedroom to the kitchen or whatnot, he being shorter breath and his pain was so intensity hadn't slept for like a week or two, other than just a quick cat nap for 20 or 30 minutes. Um, he had been given, um, some ibuprofen at one point and a couple of hydrocodones laying around the house, but really didn't do anything. And. He was quite miserable actually. So when he's in the

paul_roach:

and

peter_schlegel:

hospital, they give pain medications, IV fluids, give transfusions just to kind of get him back into shape and those things actually help quite a bit.

paul_roach:

And I think Mike's point is like, why would given blood help? And the answer, if I'm not mistaken is because of his lymphoma, his normal blood production capacity has been limited. And so his blood level was low. Is that correct?

peter_schlegel:

That's how I would think of it. That was better said than I did. I believe his hemoglobin was down to about six and in English, that means that he only had about six pints of blood as opposed to 13 or 14 than a normal male should have. So if you ever think about going to the blood bank and donating eight units of blood, that's about how

paul_roach:

Yeah.

peter_schlegel:

he felt at the time.

michael:

It sounds

peter_schlegel:

And

michael:

like he's borrowing blood cells though, right? So it's gonna help him feel better, but is that potentially masking like, wow, God, doc, thanks for the transfusion, I feel fantastic. And now, you know, if they don't figure out what the actual problem is, he could go home thinking he's good and he's actually potentially lengthening the amount of time before he gets actual treatment.

peter_schlegel:

Yeah, absolutely.

paul_roach:

Well, yeah, yeah. So your blood is made in your bone marrow. And so if there's a problem and your blood cells last about 120 days. And so if there's a problem with your bone marrow, the cells you've got start declining. Every day you lose one 120th of your blood.

michael:

Well,

paul_roach:

So if you're

michael:

help me

paul_roach:

having...

michael:

figure out how did I get from, you guys were talking about lymphoma, but now we're talking about, I'm in the blood marrow. Are there lymph nodes in the marrow that are, how are my limbs affecting this blood production in my marrow? So, I'm in the blood marrow. I'm in the lymph nodes. I'm in the blood marrow. I'm in the lymph nodes.

peter_schlegel:

That's a great question and that'll segue into why we wound up doing a bone marrow biopsy a little bit later. We talk about the blood as an organ and most people don't learn about blood as really being part of an organ system until late into medical school. But the blood system is a liquid organ. The origin is considered the bone marrow. and it communicates with the spleen and with the lymph nodes. And in this particular case, this gentleman had the lymphoma infect his bone marrow and caused the bone marrow just to not work very well because it was occupying the area, it was invaded, it was overtaken. And as a result, the bone marrow just went kaput. And it couldn't develop any more red blood cells. Do you

michael:

Okay,

peter_schlegel:

do

michael:

so

peter_schlegel:

this?

michael:

wait, sorry. This is when you were talking about earlier where the lymph node will have a problem. So it's now leaking out or it's starting to spread a little bit. Instead

paul_roach:

Aha!

michael:

of going to other lymph nodes, it's going to the bone marrow?

peter_schlegel:

Correct.

paul_roach:

Yes. So,

michael:

Okay.

paul_roach:

so what one of the hallmarks of cancer is it can invade locally. And the other hallmark is it can invade. Distantly. So for example, next month, we'll be talking about skin cancer. And if there's a problem on my skin, shouldn't be a big problem, right? I can just cut it out. But if it goes distant, you know, into my brain as well, that gets harder. You cut out my brain and before you know it, I'm, you know, worse than I already am. So, with the lymphoma, the cancer begins wherever it begins, but in this particular case, it moved into the bone marrow and it overtook the bone marrow. And then the bone marrow couldn't do its normal job. of creating more red blood cells and more white blood cells. Have I

michael:

I'm

paul_roach:

summarized

michael:

gonna ask a crazy

paul_roach:

that okay?

michael:

question. Yeah, that's great.

paul_roach:

All right, cool.

michael:

But just I know I'm getting a little off track here and I promise I'll get right back on. What

paul_roach:

Oh no,

michael:

you're

paul_roach:

we're

michael:

describing though

paul_roach:

meant

michael:

is

paul_roach:

to go off track. This is the whole point of this.

michael:

what you're describing is there's a problem that initiates in the lymph gland and then the the damaged cells sort of break away enter under the bloodstream or they somehow move around the body and they find something else to attach to. In this case, what you're talking about is the marrow, but is it possible that that lymph gland spreads its bad cells and they just get into the blood system and they go and they affect the liver? Does it matter? I thought it would have gone lymph node to lymph node first. That cell recognizes itself in other places in the body, but you're saying it can just go anywhere and potentially infect anything in any system.

peter_schlegel:

In terms of the stages of lymphoma, we go from stage one to stage four, and generally stage one lymphoma means one or two lymph nodes in a local area. Stage two means that there's several lymph node stations. That's what the medical term is, that they go from the armpit maybe to under the clavicle to close to the windpipe, the trachea, so it's localized. Stage three means that it's gone across the midline of your body across the diaphragm. That's what the kind of the equator is for the lymphoma classification system. And the final stage, stage four, is when it gets into the bone marrow or into organs. So it certainly, like you said, can go into the liver, but more commonly, it is attracted to the bone marrow. So when someone has lymphoma, that's one from the lymph nodes to the bone marrow, then it's stage four, and it means it's more aggressive. complete body disease rather than a localized, like a stage one or perhaps a stage two.

michael:

Okay, so my initial kind of concept that a bad lymph cell breaking away from a lymph node will actually find probably another local lymph node, and then sort of like a little cluster will happen, and then it'll start to sort of spread outward as you hit stage three and stage four.

peter_schlegel:

Yeah, we

michael:

Or

peter_schlegel:

don't

michael:

no. Ha

peter_schlegel:

completely

michael:

ha

paul_roach:

Exactly.

peter_schlegel:

understand

michael:

ha.

peter_schlegel:

that, but there is an evolution of cancer where it starts as maybe not quite as aggressive, but it kind of accelerates in terms of mutations and nastiness, if you will, over time.

michael:

Alright, but now we're back in the marrow for this patient. And

peter_schlegel:

That's

michael:

that means

peter_schlegel:

where they.

michael:

he's got to be stage three or stage four when he's coming in to see you.

peter_schlegel:

So

michael:

Right?

peter_schlegel:

we're gonna go back to the patient case and I'll kinda walk you through this a little bit. So the patient wound up having some large lymph nodes but in the back of his abdominal cavity. So he wound up getting what they call a CT guided biopsy, went down to radiology, they got him lined up in the table, said, ah, look at this big lymph node, three to four centimeters, we can hit that with a needle. So they got them all lined up, they. avoided the spinal cord, the vertebrae, the aorta, and put the needle into that. Now it's a really skinny little needle, so they were able to get some cells out of it. Generally, it's very diagnostic. It'll tell you what's going on, and that's really the gold standard in terms of what kind of lymphoma this is. I often tell my patients that it's like a subset of a dog. Do we have a toy poodle, or do we have a Rottweiler, a German Shepherd, whatever the case would be. but by doing the biopsy you can confirm that it is lymphoma. And then secondly, often what subtype it is. And in this particular case, the patient had the biopsy and upon the biopsy, he was better from a pain point of view. The hospital says, well, we're done doing what we need to do to you in terms of getting pain controlled, getting you transfused. You can leave the hospital and follow up with the oncologist. in a week and he'll go over the biopsy results and then tell you what to do. And in fact, that was what, what had happened. So I saw him in the office a week later. He went home with a pill bottle full of oxycodone or whatnot, and used those to get by for the next couple of days. And of course suffered, but had something that he could at least sleep in and function with.

paul_roach:

And you know, Mike, to get back to your earlier question about the lymph node or the exhaustion. In this case, it sounds like the cancer began in a lymph node deep inside, but there's no way to know for the patient that that's happening. Cause it's deep inside. It's not like it's under your jaw where you can feel it. And it wasn't in this case until it had evolved and had gone on and reached the bone marrow. and shut down production of blood cells that made him anemic and exhausted, and then he goes to the ER, that's when the patient starts to really experience symptoms and where this whole story kind of begins.

michael:

Okay, you guys are scaring me right

paul_roach:

I'm

michael:

now

paul_roach:

sorry, so sorry.

michael:

because I'm always looking, I'm participating here and I'm thinking, oh, I'll learn things that I can do that I can talk to my doctor about. And he's like, hey, how's my lymph system? When I go see my general practitioner, are they checking this for me? Is this just one of those battery of tests for my blood or whatever? And I'm just unaware? Because... I gotta tell

paul_roach:

Yes.

michael:

ya, if I can't know about this until it's that far, that scares me. So how is it being checked earlier for me?

peter_schlegel:

Yeah, I'm going to twist your question and not really address it head on, but the vast, vast, vast majority of people that have back pain, have a slipped disc, have some arthritic changes, have a pinched nerve, all that sort of stuff that people live with, go see chiropractors, take ibuprofen, eventually have to go talk to a neurosurgeon about it. It is only the rare patient who has lymphoma. or cancer of that matter that presents with back pain. But that is really what differentiates good doctors from bad doctors that they wanna ask you further questions. They, anything else happening with your back pain? You say, oh, I got night sweats and I lost 20 pounds. There should be some red flags going up in the health provider's brain to say, hmm, we better do some scans. We better look harder into this. Whereas, eh, I just had back pain. If you've had it before, oh yeah, this happened about six months ago when I was playing softball or whatever. But I think the key really is to say, are there any other associated problems other than back pain?

michael:

Okay, that's interesting, you know, because I don't know if it's just me or there's this sort of stoic kind of quality where I go to the doctor and like, are there any problems? I'm like, nope.

paul_roach:

Yeah,

michael:

But I mean,

paul_roach:

you don't want them

michael:

I

paul_roach:

to

michael:

might

paul_roach:

find

michael:

have

paul_roach:

anything

michael:

back pain

paul_roach:

out.

michael:

and I might have the occasional night sweat, but I'm not putting that together. So basically what you're telling me is I have to divulge a lot more. I have to tell my doctor, well, you know what? Yeah. I don't know that they're connected, but I have, you know, I don't know, a buildup of

peter_schlegel:

Yeah

paul_roach:

Well,

michael:

I can't, yeah, you know,

paul_roach:

to keep...

michael:

I mean, that sounds silly, but I should really be telling them anything that I notice because they'll put together what I'm not. So that's right.

paul_roach:

I think to keep it from unnecessarily alarming everybody, most of the time our various headaches or sniffles or back pains or minor weight fluctuations are just that. They're just the ordinary events that happen in the course of day-to-day life. When you start getting things... forming a constellation. That's when your physician can really make a difference and tie together certain things that you may not have realized. Like let's say I've got this back pain and it's just persistent. It's completely different than any other back pain I've seen. Then the physician needs to go in there and ask a bunch of questions and figure out, is this just musculoskeletal strain or is there more to the story? Just like Peter was saying, with the weight loss and the night sweats. This particular patient had a group of symptoms with back pain, weight loss, night sweats. Then they do a blood test and he looks pale and the blood test shows he's got anemia. That's when the doc says, aha, there's enough to build a case on here. We better not send this patient home. We better take him inside.

michael:

All right, well that brings me back to my earlier question though, is when I just go in for my regular checkup, does any

paul_roach:

Yeah.

michael:

of that stuff, you know, I'm unaware of it, but is the doctor checking, at least, you know, cursor early, cursor, are they doing a quick check on my lymph system?

paul_roach:

Yeah, they're

michael:

Or no.

paul_roach:

gonna, they're gonna feel your neck. They're gonna reach inside your armpits and it's okay. They're gonna be right there in your groin, but it's okay, cause they're doctors. And they're gonna feel your belly and your spleen. And they'll probably, you know, get periodic blood work from time to time. And they're also just gonna ask basic questions. Not to be underestimated is the importance of that. Like overall, how are you feeling? Is your health getting better? Is it getting worse? You know, if they say, Oh doc, I'm feeling horrible. I'm sluggish and, you know, start describing all these things. They might start looking harder into certain things. We were like, Oh no, I just, you know, I just bike road 40 miles and I'm, you know, never feeling better. I'm sleeping well and eating like a horse. You know, they are going to be less concerned and less worried that things are falling apart.

peter_schlegel:

I typically ask quite a bit about functionality. And for this particular patient, and he hadn't done any of his work activities through mowing the lawn and doing some shop projects for three weeks. And so his wife kind of let on, hey, you know, there's been some big changes going on. So I really think that it's important that you kind of get a full picture. And if you're rolling around, you're going to work, you're driving, everything's fine, you're sleeping through the night like you normally do. There's... Probably not a concern about cancer. However, if you start losing function you start Having pains that you've never had before the character is different You get night sweats You see some blood somewhere. Those are the things that that should bring alarm or concern to present to your doctor But everyone gets some fatigue everyone gets some back pain. Everyone gets some belly pain. Everyone gets some headaches Everyone gets some some stress, but the the issue really is Are there new different things? Are they progressive? Are they associated with changes really in your life?

michael:

All right, I mean, I'm not the person to speak about this, but I know someone who suffers from night sweats. And it's a

paul_roach:

friend.

michael:

woman and she's about 50 years old.

peter_schlegel:

Hehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehehe

michael:

So, you know, that's menopause as far as she knows. But based on what you're saying is, all right, so she's exhausted because she's not sleeping through the night. And she's suffered from hot flashes and sweats and everything. But if her quality of life otherwise, if she's able to do the things that she's doing, then chances are it's menopause and she's not, like it isn't this constellation as you called it earlier, Paul. So, I mean, I guess that's the trick for you doctors. I mean, you have to make sure that you're not diminishing somebody. If this woman showed up and said, oh, you know, I have all these things, you're like, oh, you got menopause. Maybe she could have lymphoma under that though too, right?

paul_roach:

I love this question. I actually did four years of primary care before I went into surgery. And this is a really, I think, essential aspect of primary care, is figuring out, you know, that one out of 100 or whatever, where it's just routine normal business, this is routine menopause, or is there something more important going on? And I think that's... not something that we can answer within the context of a radio show, but I do think that that comes to the heart of the problem of your initial diagnosis, you know.

michael:

So

paul_roach:

Is

michael:

it goes to

paul_roach:

this...

michael:

what Peter was saying then, add on, how's your life quality? Not just the symptoms so much, but is there more? Have you seen a change or a big turn in your life in addition to those things? Right, Peter?

paul_roach:

And it's also, yeah. And it's also where getting to practice medicine in a modern Western facility makes you look really good because you may not be sure, is this just ordinary routine stuff or is this something? They're after you, Mike. Or is this something of much greater importance? The things that can come to your rescue as a clinician are the laboratory tests and the imaging that we have available to us now. So let's just say I meet a patient, I'm a primary care physician or a PA or nurse practitioner, and I'm not sure if this person is just going through the ordinary stuff or if there's something extraordinary going on, I can order some lab tests and some imaging and that might give me the answer. And then these things go up stepwise more and more and more. So the first set of tests and whatnot, you say, aha, this person has a problem with their lymphocytes or their blood. Then they go upstairs to the hospital where they explore them some more. They do more tests. They even do a bone marrow biopsy. And then they look at it under the microscope and they say, aha, this is a lymphoma. It's a subtype of lymphoma called non-Hodgkin's. There's Hodgkin's and non-Hodgkin's, and I don't really know the difference, to be honest. We'll leave that to Pete. But it's a subset of lymphoma called non-Hodgkin's, of which there are many subtypes as well. And by looking at the microscope and doing some fancy biologic studies, we can tell you which subtype it happens to be. How'd I do, Pete?

peter_schlegel:

You did excellent. I am going to leap

paul_roach:

You're

peter_schlegel:

into...

paul_roach:

not just saying that. You're not just saying that,

peter_schlegel:

No,

paul_roach:

are you? You're

peter_schlegel:

I would love

paul_roach:

making

peter_schlegel:

to talk

paul_roach:

sense.

peter_schlegel:

about the difference between Hodgkin's and non-Hodgkin's, but the point of this show is not to have a medical school lecture, which I would be happy to give.

michael:

Well, now I'm curious, can you give me like a one, you know, 30 second, one is this, one's that.

peter_schlegel:

Yeah, Hodgkin's disease tends to occur in much younger demographic. People in their teens, 20s, 30s, it tends to present much more with what we call B symptoms, which means these fever, night sweats, weight loss sort of symptoms, much more what we consider inflammatory, that the body is responding some sort of evil chemicals in the body that are associated with the immune system. whereas non-Hodgkin's tends to become more and more common as you become older. Of course, there's a lot of overlap between the two. It does turn out that Hodgkin's disease was one of the first cancers that was actually successfully treated, even in stage four with chemotherapy. So from a historical point of view, it's something that medical oncologists love to talk about in terms of our success. You know, having said that, there is a lot of overlap between the different lymphomas, and we can get you all confused in terms of the nomenclature. And is it B cell, is it a T cell, is it aggressive, is it non-aggressive or indolent? But suffice to say that lymphoma is just a, is a very interesting disease from a doctor's point of view, and it can be just very odd. in terms of how it presents and shows itself and how it comes to the physician and to the patient's perspective.

michael:

Take

paul_roach:

Pete.

michael:

me back to the bone marrow of your patient.

peter_schlegel:

Yeah, can

paul_roach:

Hey,

peter_schlegel:

I

paul_roach:

before

peter_schlegel:

take a

paul_roach:

we

peter_schlegel:

few?

paul_roach:

go ahead,

peter_schlegel:

Yeah.

paul_roach:

Pete, quick question. You had earphones on before

peter_schlegel:

Mm-hmm.

paul_roach:

and they're not on now.

michael:

What happened?

paul_roach:

Are you speaking into a microphone or no microphone?

peter_schlegel:

I have the $90 microphone and it asked me whether I had

paul_roach:

Okay

peter_schlegel:

headphones or not and I said, no, are you hearing? And I couldn't connect my earphones to the Bluetooth at this point.

paul_roach:

No problem, no

peter_schlegel:

Are you

paul_roach:

problem.

peter_schlegel:

hearing

paul_roach:

We'll

peter_schlegel:

much?

paul_roach:

just, sounds good to me. I'm just wondering if in post-production I'll be here, but it sounds really good.

michael:

Yeah, it sounds fine.

paul_roach:

All right, so let's head back to your patient,

peter_schlegel:

Can

paul_roach:

Pete.

peter_schlegel:

we take a couple minute break here? We've

paul_roach:

Yeah.

peter_schlegel:

been rolling for what, yeah, just you want to just take a couple minute break and then we'll get back and then just kind of re-chat in terms of where this is going. Cause I know I took you off the idea in terms of more of the outline and just more of a presentation of a patient. And then along the line, letting Mike kind of interject and just kind of

michael:

I

peter_schlegel:

more

michael:

may

peter_schlegel:

having

michael:

have screwed

peter_schlegel:

a conversation.

michael:

your... Maybe

paul_roach:

I

michael:

I

paul_roach:

think

michael:

should

paul_roach:

this

michael:

read the

paul_roach:

is

michael:

outline.

paul_roach:

a lot more car talk than last time. So I kind of

michael:

Yeah,

paul_roach:

like this way.

michael:

okay.

peter_schlegel:

So how about it's two minutes and then we'll get back and then we'll talk, we'll just chat, and then we'll go back to the show.

paul_roach:

Two minutes and then we'll wrap it up over the next 15.

peter_schlegel:

Okay, sounds good.

michael:

Paul and I will do our Oak Park jokes podcast

paul_roach:

Yeah.

michael:

segment for our

peter_schlegel:

I'm

michael:

third,

peter_schlegel:

up.

michael:

Paul's third podcast venture.

peter_schlegel:

Hehehehe

paul_roach:

No.

michael:

Where you at now, Paul?

paul_roach:

So on the corner of South Boulevard and Harlem.

michael:

Oh my God, right there.

paul_roach:

Right there, yeah, where

michael:

Oh, is that

paul_roach:

it's

michael:

one

paul_roach:

this

michael:

of those

paul_roach:

big

michael:

big, big

paul_roach:

building.

michael:

new, it's a big new building.

paul_roach:

Yeah,

michael:

You're

paul_roach:

yeah,

michael:

above

paul_roach:

and it's.

michael:

that crab place and there was a

paul_roach:

Yes,

michael:

bit, yeah. Okay.

paul_roach:

that is right down there. And they have lots of exciting adventures after the hour of about 10 PM.

michael:

I would imagine. I tried to go there one time and I was not served basically.

paul_roach:

Yeah.

michael:

I was like, hey, that sounds cool, there's a new place, I'm gonna go check it out. I wasn't really welcome.

paul_roach:

No, I don't doubt it. And there's a little Italian restaurant right next door. And then there's a fancy Italian restaurant across the street.

michael:

Yeah, okay, I know where you're at though. How do you like it?

paul_roach:

Like it a lot, it's just too expensive.

michael:

And

paul_roach:

And

michael:

the

paul_roach:

also

michael:

goal is...

paul_roach:

the train right there, we get a lot

michael:

Oh yeah.

paul_roach:

of kind of dangerous characters. All right, Pete, are you back?

peter_schlegel:

I'm back, yep.

paul_roach:

All right, so how should we segue back in? We'll just say, all right, Pete, let's go back to your patient.

peter_schlegel:

All right,

paul_roach:

We'll

peter_schlegel:

let's

paul_roach:

do that.

peter_schlegel:

go. Yep.

paul_roach:

All right, okay, three, two, one. All right, Pete, let's head back to your patient.

peter_schlegel:

All right, we're gonna talk about the pathologist. The pathologist read the biopsy, and unfortunately we didn't find anything. It was just a bunch of scar tissue. They said, we need more tissue. We need to have a bigger chunk to be able to evaluate. So I saw the patient in the clinic and talked about what was going on, and I said, you know, I'm concerned about lymphoma. And because of the anemia, I think there might be something in your bone marrow. We talked about different things in terms of an open biopsy. which would require a general surgeon or oncologic surgeon to go in there, but that was a big deal. So he agreed to do a bone marrow biopsy. So we gave him a little propofol and got

paul_roach:

which is

peter_schlegel:

into

paul_roach:

an

peter_schlegel:

it.

paul_roach:

anesthetic.

peter_schlegel:

Yeah, so we basically did a conscious sedation, rolled him on his belly, and we did the biopsy on the back of his pelvic bone. And it sounds kind of nasty to do a bone marrow biopsy, which it is, but with sedation, it worked out well. You typically suck out about a teaspoon of marrow from your pelvic bone after using a large needle to get through the surface of the bone, the cortex, as we call it. and then you take a sliver about a quarter of an inch, half an inch lawn, and then send that to pathology. And pathology does some magic looking at that with all sorts of technologies. But the long and the short is the patient had diffuse large B-cell non-Hodgkin's lymphoma, which is a very common and aggressive form of lymphoma. It is more of a German shepherd to a Rottweiler in terms of aggressiveness on the. the scale of if it was a dog, it was considered

paul_roach:

So it's

peter_schlegel:

a.

paul_roach:

not a labradoodle like mine.

peter_schlegel:

No, not a Labradoodle, not a Beagle, not a Chihuahua. This is something they can hurt you. Not quite like a Doberman, which you see occasionally, but it's something that should be of concern. The patient asked me, why don't we find this on the biopsy of the lift out in the back of the abdominal cavity? My reply was I believe it was a burnt or scorched earth kind of picture. When you have very aggressive cancers, they tend to burn out so that nothing survives. They're so chaotic, they grow a little bit and then they die and there's just really nothing left. So when they did a skinny little needle biopsy, all they came up with scar. But when you do a bone marrow biopsy, you get a teaspoon of marrow that was enough to give the pathologist enough information. Now

michael:

When you

peter_schlegel:

if

michael:

say

peter_schlegel:

you.

michael:

scorched earth, does that mean that that lymph node is, like that whole thing was consumed by cancer and it's just like kind of a lump of, like is that one gone? Like did he lose a lymph node in the middle of

peter_schlegel:

Yeah,

michael:

his body?

peter_schlegel:

it is fairly interesting. A lot of these aggressive cancers are associated with cell death called necrosis. And the necrosis is basically scar tissue. I mean, there's nothing living there. So that these cancer cells that are very aggressive tend to be very unstable, chaotic, and they don't survive very well, believe it or not. Now, they grow in such a rapid fashion. It's almost like fire. but on the other hand, they tend to burn out pretty quickly.

michael:

Well, I was starting to get a question which was, because you had said, hey, I'm suspecting lymphoma, so let's go check your, because of the anemia, let's go check and do a bone marrow biopsy. So I thought, okay, does that mean that there's two things now? The lymph node is having a problem and now the bone is having a problem and do you doctors have to now deal with these two things? Or, basically what you're sort of saying is, that lymph node sort of destroyed itself and you now only are dealing with. the bone marrow cancer.

peter_schlegel:

Yeah, I think the first point I would make is that it's all connected, that the cancer is involving the blood system. So whether it's the bone marrow or the lymph nodes, it's contaminated, all of it, and the seeds are kind of spreading throughout the whole body, particularly in that system.

paul_roach:

Thanks for watching!

michael:

But how do you target two cancers that are happening? I mean, it sounds

peter_schlegel:

Excellent.

michael:

like it started

paul_roach:

Ah,

michael:

with one, it split into two.

paul_roach:

this, this is a very good question. So what happens is the cancer begins somewhere and then let's say it moves to the regional lymph nodes. And then from the regional lymph nodes, it moves even farther. With every move, there can be more and more genetic changes and the cancers can get more and more different. And this is where oncology can become so difficult. because even if you find treatments that cure 99% of the tumor cells that zap or somehow dismantle, somehow dismantle 99% of the tumor cells that are in your body, there's still that 1% that is still raging and you've got to come up with something to figure some kind of solution to address that last 1% or else it just carries the process forward.

peter_schlegel:

To address the question of the cancer, we've identified at stage four, it's involving the bone marrow by evidence of the bone marrow biopsy, as well as the lymph nodes that are enlarged. And because at stage four, it involves the whole system, so we generally would think that we need a treatment that involves the whole body. Now, there are other treatments of lymphoma in terms of radiation or surgery, but... we would rely on medicines because we believe that it's everywhere. It's in the bone marrow, it's in lymph nodes. There's no way that we can localize the treatments, even if we have fancy schmancy radiation, we say we can get this part of the bone marrow, this lymph node or whatever. So we do wind up using chemo and that's exactly what the patient went through.

michael:

Okay, so that's going to address any different types of cancers all throughout the body that may have, because it might not, it's moved to the bone marrow, but it might have also moved someplace else as well. So you're attacking that cancer, start as lymphoma everywhere.

peter_schlegel:

Yeah, the chemotherapy is a whole body treatment. It's basically a poison that we know that the cancer is growing very, very quickly, very aggressive. And by infusing a patient with a poison, we know that the cancer will be a hundred times more metabolically active and therefore eat say a hundred times more of the chemotherapy than the rest of the body. It's kind of like saying, well, if You drink a beer, no big deal, but if you drink 100 beers, you're going to die. And that's kind of what happens to lymphoma because it's so aggressive. It's so metabolically active. It's so proliferative that it just grabs up gobbles, all this poison. And in doing so it's, it destroys itself.

michael:

That

peter_schlegel:

And

michael:

sort

peter_schlegel:

so

michael:

of makes

peter_schlegel:

that

michael:

sense.

peter_schlegel:

was what we did. And based upon clinical studies, we use something called R-chop and it involves three different chemotherapies, it includes prednisone and rituxan, and they all kind of work a little bit differently, but the long and short is you try to poison the crap out of the cancer, and in doing so, it shrinks, and in many cases, kills the cancer.

paul_roach:

So I think of chemo kind of like crop dusters, you know, buzzing over the crops, just spewing out all of that poison and the healthier plants can survive and the weeds can't, you know. You know, you know,

michael:

or the insects and pests, like a pesticide

paul_roach:

I know

michael:

coming

paul_roach:

that's

michael:

over.

paul_roach:

I guess a bad analogy

peter_schlegel:

Thank you.

paul_roach:

because I'm really worried about the butterfly issue right now, but there you have it.

michael:

All right, now.

peter_schlegel:

It's infinitely complex if I was to tell you, well, what do we exactly do with the chemo? Well, it's a long infusion. The patient comes in and we give the drug called rituxim, which is what we call a targeted therapy. It's oriented just to the outside of the lymphoma cell, and we infuse that over a couple hours. When that's done, then we use a combination of three different chemotherapies that are basically the toxins and trying to. poison the cancer. The reason why we use three is because two is better than one and three was better than two and after you get to a certain point then you're going to cause more harm than good.

michael:

Now, Paul's a surgeon. And I think we talked about this last time that you would start with Paul, right? You would start with a surgeon. Is there a way to find this early enough to cut out a bad lymph node? Or do we pretty much the way it works, you're almost automatically going into chemotherapy.

peter_schlegel:

Yeah.

paul_roach:

Well, my role, my role would be mostly in helping diagnose. So the person comes into the ER, they're run down, they're worn out, they're not feeling very well. And oh, by the way, they've got this lymph node. And if for some reason, by sticking a needle into it, that doesn't work, you can have your friendly surgeon go in and remove a lymph node.

michael:

but not to

paul_roach:

And then

michael:

cure.

paul_roach:

you can look at that. No, that's really just to diagnose it. You know, it used to be you had to remove a lymph node to diagnose it. Now things have gotten a bit better and you can do a lot of this with just needle biopsies. But still sometimes you need the whole lymph node in order for the physician in the laboratory, the pathologist to be able to look at the architecture of the lymph node and look at throughout the whole thing. You send it down fresh to the pathologist and they do whatever they do. and then they come back with the diagnosis.

michael:

Okay,

paul_roach:

So

michael:

but

paul_roach:

that's where

michael:

again,

paul_roach:

I would

michael:

last

paul_roach:

get

michael:

week,

paul_roach:

involved,

michael:

last week we were

paul_roach:

but I don't

michael:

a

paul_roach:

cure

michael:

month.

paul_roach:

it.

michael:

Yeah, so we were talking about that before, that there's times where if you get your surgeon involved early, he can cut the offending tissues out and that might be it. And then it moves on and it gets into Peter's world. And then the third option was Courtney, who's not with us tonight, but in radiation. Is this radiation treatable? Or is this all pretty much, Peter, this is all really in your world.

peter_schlegel:

Most of the cases wind up in the medical oncology chemotherapy world. Regarding radiation, if there's just a cluster of lymph nodes in the neck or the armpit, then the patient may be amenable just to some local radiation therapy to destroy the lymphoma, including the fingers and the little metastases that may have once had some lymph nodes close by. But.

michael:

So it's the stage, if it's stage

peter_schlegel:

Yeah,

michael:

one or two,

peter_schlegel:

that's why it's

michael:

okay.

peter_schlegel:

so important that we determine this spread, this stage, and then we can pinpoint the best treatment, which for most people is more the whole body or chemotherapy.

paul_roach:

When you use surgery or when you use radiation for anything, it's gotta be something that is local because you can't remove a lot with surgery. You can remove an organ or a part of an organ, but you can't go and just cut out every cancer cell a person might have. So as long as the cancer, whatever type of cancer it is, and with the blood cancers, it doesn't work at all because it's blood. Uh, there's either solid or organ tumors or, or blood type tumors. Those are the two big categories. But for radiation, if it's in a region, the radiation can be helpful, but if it's something that could potentially be in your whole body, you can't radiate a person's whole body, it's, it's too much radiation. So the surgeon can, like if there's an item that needs to go. and the surgeon can go in and remove it, whether it's in your brain, whether it's in your nose or in your chest or in your belly or wherever, the surgeon can go and get that thing out. If it's going to benefit from radiation, it has to be in a discrete location that you can zap with radiation. You're not going to give whole body radiation in general. If Courtney was here, I'm sure he'd have some exceptions. But And then if it's something like a lymphoma where it could be anywhere in your bone marrow, anywhere in any of your bones, or it could be in your lymph nodes that have crossed the midline, you know, they're not just early stage, it's later stage and they've moved from stage one, two to three to four. You definitely need chemo because that's the only way you're going to reach all the different cells wherever the heck they may be.

michael:

Alright, there's one other thing that even in my layman world I've heard of, which is a bone marrow transplant. Is that something that is used to treat lymphoma? And

peter_schlegel:

Absolutely.

michael:

if so,

peter_schlegel:

That,

michael:

before...

peter_schlegel:

yeah. So in terms of treatments of lymphoma from a systemic or whole body or medicine point of view, that we started off in probably the 50s and 60s with chemotherapy, the good old, what we call Cytoxic. And the origin begins with nitrogen mustard and kind of goes from there, but we've been much more successful. And less of a nuclear bomb attack. But we still use the good old fashioned chemotherapy, you lose your hair, nausea, vomiting, weak immune system. So things have evolved from, we call it say toxic or cell toxic, we're just basically poisoning, to targeted therapy. And there's a drug called Rituxan that is just a, what we call an antibody that's oriented toward the top of the lymphoma cell. And there's much less collateral damage, it's kind of like a silver bullet. Bone marrow transplants have been replaced by what we call stem cell transplants, but in a way it's just a gimmick to give more chemotherapy and protect the stem cells. And we basically store the stem cells in a freezer, and this would be a discussion in and of itself. But the idea is that with the stem cell transplants, you can just give higher doses. Now having said that, there's something called allogeneic bone marrow transplants or semtel cell transplants, where you take bone marrow from somebody else and use their immunity to help fight the cancer and indeed just totally replace the whole blood system, the bone marrow's in its entirety and give you someone else's. And we typically use that more in a leukemia and bone marrow cancers view.

paul_roach:

So

peter_schlegel:

I think for the

paul_roach:

if the lymphoma has invaded the bone marrow, what I think you're describing is, how do I get it out of the bone marrow, right? And so I think what Pete's describing is you give them so much chemo that you wiped out the bone marrow. And in that circumstance, person's gonna die if you don't rescue the situation in one of two ways. One way is you give them back some of their stem cells. Stem cells are kind of like the queen bee of a beehive. And so what the medical scientists do is they harvest a few of your stem cells, not the cancer cells, which is tricky. I don't know how they do it. But

michael:

So it's

paul_roach:

they,

michael:

like a primary cell, right? It's

paul_roach:

yeah, yeah.

michael:

like, it's

paul_roach:

And then

michael:

the cell

paul_roach:

they give

michael:

from which

paul_roach:

those

michael:

all other

paul_roach:

back.

michael:

cells are built, yeah.

paul_roach:

Right, and so they zap your bone marrow with chemo, and then they give you some stem cells back. And then hopefully those can repopulate your body before you pass away. The other option is through, you know, big data in modern life, you get somebody else's bone marrow and, and you put you, they put that into your bloodstream and that populates your bone marrow and it starts you back up again. How's that

michael:

Okay,

paul_roach:

Pete?

michael:

but you've already killed all the cancer with chemo. Like

paul_roach:

Ideally,

michael:

you can't just,

paul_roach:

theoretically, yes.

michael:

yeah. Okay.

paul_roach:

Is that right?

peter_schlegel:

Yeah, yeah, Paul, I liked your explanation. It's better than I could have given.

paul_roach:

Oh, stop.

peter_schlegel:

What I'd like to do is talk a little bit about this patient who's now been diagnosed with stage IV B and we call it B instead of A because he's symptomatic. And we say, yeah, you got lymphoma, diffuse large B cell. We have really good treatments and 80, 90% of the time we can shrink this. And among those people that have shrinkage, as many as half will have durable or long-term cures. And it's a very amazing thing to see 80 to 90% of the people have big-time shrinkage of their cancer, and of those people, half go on to be cured. So who wouldn't want that? So this particular patient got the infamous R-CHOP therapy. It was administered in the IV chemo suite over a period about six hours or so. You got the whole lecture about... .. Sorry about

paul_roach:

Whoops.

peter_schlegel:

that. So we better do a little editing in. So the patient started with the chemotherapy in the outpatient chemotherapy suite and over about eight hours had the rituxan and the chop given, left at the end of the day, felt quite a bit better because of the prednisone. Then he had to take about a couple more days of the prednisone and lo and behold, he felt as good as he. has in like six months. He was able to sleep, didn't need his pain medications, his night sweats went away,

michael:

with

peter_schlegel:

and

michael:

just

peter_schlegel:

even his

michael:

one

peter_schlegel:

backpack.

michael:

chemotherapy session?

peter_schlegel:

Yes.

michael:

Really? I

peter_schlegel:

Yep,

michael:

thought they'd last,

peter_schlegel:

everything

michael:

I mean.

peter_schlegel:

just

paul_roach:

That's.

peter_schlegel:

shrunk.

michael:

Maybe I'm just remembering like old Dr. Wellby MD things and

peter_schlegel:

What,

michael:

this is my level

peter_schlegel:

what?

michael:

of knowledge,

peter_schlegel:

Yeah, there

michael:

but

peter_schlegel:

is

michael:

it

peter_schlegel:

a whole

michael:

always seemed

peter_schlegel:

range

michael:

to take...

peter_schlegel:

of different chemotherapy responses, but in lymphoma, we tend to see that it's extremely aggressive, grows very quickly, but then when we can kill the cancer, it kills, it dies very quickly as well. It's very dramatic and very fulfilling to the patient, obviously, to know, hey, you know, we're making big headway. And of course, talking to the patient a week later, it's just like, wow, I'm glad you're feeling so good.

michael:

So is that due to what you were talking about before where there used to be the nuclear bomb version of chemotherapy and now it's more targeted to those cells so that you're able to actually kill the cancer with just one? I'm going to assume there's some people that have to

peter_schlegel:

Yeah.

michael:

have a few more but there's not that long series of months of treatment.

peter_schlegel:

Right, well we can destroy with every cycle of chemotherapy, I don't know, 90, 95% of the cancer. But the problem is that there's millions and trillions of cells. So even if you knock down 99% of them, you go from a trillion to a billion, there's still a lot of cells there. But anyway, that makes a big difference because those little fingers aren't pushing on the bones. That there's a dramatic decrease in all these evil. chemicals that the lymphoma is dumping into the system. Now having said that, you do have the toxicity from the chemotherapy, but it's the lesser of two evils. You want the evils of the chemotherapy or the evil of the lymphoma. And when people are affected with advanced lymphoma, causing all of these things, they're like, wow, this is really dramatic. So he actually had a very dramatic response to the first treatment and felt like he did six months ago, a year ago with this treatment.

michael:

Wow, that's amazing.

peter_schlegel:

Yeah.

michael:

Now does he have to go back periodically, then I assume, like every six months to be

peter_schlegel:

Yeah.

michael:

retested and see if he's, because you need to see if those billion cells, like he got them all, or if there was 10 cells and they've grown now to be a million cells again.

peter_schlegel:

Yeah, correct. So we, the typical protocol is you get the chemotherapy about every three weeks, every 21 days for six cycles. And of course there are variants of that, but that's usually considered a full course treatment. So 18 weeks, about four or five months, something like that.

michael:

Oh,

peter_schlegel:

And

michael:

OK.

peter_schlegel:

most cases, people get response, there's great shrinkage and a lot of those people are cured. And so After his chemo, he looked good. We saw him a week later to check things out, see his blood counts, see how he did with chemo, how was the nausea, all that. And we could spend hours talking about just the side effects of chemotherapy, but suffice to say that he was feeling much better after just one cycle of chemotherapy.

michael:

Okay, so I thought that you were saying that you could just have one session. That's not the case. You just feel a lot better after one session that because it's become that much more effective,

peter_schlegel:

Yeah,

michael:

but you still have

peter_schlegel:

well...

michael:

to go through months of it.

peter_schlegel:

Yeah, we essentially knocked down the 90%, 95%. So if we would do a CT scan at that point, instead of seeing that four centimeter lymph node or two inch lymph node, you'd see that it shrunk to several millimeters or a half a centimeter, five millimeters, something like that, there'd be a significant decrease. And that has to do with just how aggressive these lymphomas are. and how sensitive they are to chemotherapy.

michael:

Um, well, then that sounds like this is a cancer that's kind of well healed,

peter_schlegel:

You.

michael:

H E E L not healed like you guys do.

paul_roach:

Ah.

michael:

Um, meaning that, well, well, I'll flip it back the other way. You have in a way it's a, it's a solid treatment. So last time we were talking about, uh, new therapies, we were talking about getting into a study. Is that something that even exists for this now? Or is it pretty much you know how to treat it?

peter_schlegel:

Yeah, well the

paul_roach:

Well,

peter_schlegel:

bad

paul_roach:

I think

peter_schlegel:

news...

paul_roach:

that's a nice segue into the CAR T therapy question. But go ahead, Pete.

peter_schlegel:

Yeah, so the bad news on this particular patient is after we had given him the chemotherapy and he had response, I got a report back from the pathologists. And these days we have what we call hamato pathologists. So these are pathologists who just study the blood system. So they look at lymph nodes, bone marrow, blood spleen. That's kind of their expertise. It's, and they have their own. science if you will and it's it used to be a quite a Subjective field where people just look at these things on a microscope and say I think it looks like this They describe it as small or large diffuse follicular blah blah blah But it wasn't very objective and it wasn't very reproducible and it didn't predict very well, but now there's very objective Scientific studies that can get to the DNA Did that really drives the cancer and so the pathologist? a MADO or blood pathologist reported that it was a double hit mutation, which denotes that it's a high risk. It's when we say that 90% of the people have excellent response, it means that 10% don't. And unfortunately, he was the double hit positive patient. And sure enough, after about two weeks, his symptoms in terms of the back pain, the night sweats, the poor energy returned back to him. And his laboratories did not improve at that point. And we did a CT scan and nothing really had changed. Now it had shrunk previously for a week or two, but then it came back. We were in a bad situation calling this primary refractory disease, which is something you never want to hear. And just two weeks ago, we're saying, you know, 90% of the people have good shrinkage of those. Half of them are cured, but he was on the other half of this. And of course,

michael:

the

peter_schlegel:

the...

michael:

other 10%. You guys are good at medicine net math.

paul_roach:

Ah, yeah.

peter_schlegel:

Yes, indeed. So the bad news is he was not responding to his therapy, that it was somewhat immune, it just didn't work. So he wound up being admitted to the hospital again for pain medications, he had to be given intravenous morphine and so forth. It turns out that steroids works very well as a temporizing measure to shrink things. You know, prednisone is used for people who have a... a flare of rheumatoid arthritis or a bad skin rash or something like that. But it does work, so we wound up giving him some steroids and tried to figure out what's going on. I said, yeah, it's primary refractory lymphoma and gave him high doses of chemotherapy. They're a little bit different than the chop that I had given him before and quite a bit more toxic in terms of the nuclear. assault, we were just adding a bigger arsenal. And indeed he did have results and did feel better after the chemo and it was a bit more durable, but due to the fact that this was a primary refractory disease, we wouldn't suspect that we're gonna be able to keep this under control for very long.

michael:

Is there anything, I guess going back to that, is there a study, is there some cutting edge thing that he can look at or

peter_schlegel:

Yeah,

michael:

try and become a part of?

peter_schlegel:

so back five years ago, if you would have talked about this patient, we would be talking about high dose chemotherapy and bone marrow transplant, or it's evolved to stem cell transplant. And in that particular case, it's just a way to give people higher doses of chemotherapy. The transplanting someone else's marrow hasn't been found to be very effective in these lymphoma cases. But to answer your question. The newer treatments are immunotherapy. It's to use your immune system to fight the cancer.

paul_roach:

sort of to use your immune system to fight your immune system. is this

peter_schlegel:

Exactly.

paul_roach:

is a cancer of the immune cell.

michael:

This is T cell therapy.

peter_schlegel:

Exactly.

michael:

And the only reason I know that, because as you put in the introduction that I'm a graphic designer, I actually designed the cover of a medical journal from the University of Chicago where I had to make a superhero T cell. You

paul_roach:

Wow,

peter_schlegel:

I'm

paul_roach:

did

peter_schlegel:

sorry.

paul_roach:

you put your face on it?

michael:

know, it was just a cartoon face. Thank you.

paul_roach:

Ah.

michael:

But I did, you know, from just doing that, I did learn a little bit about that, which is. kind of what you're talking about. And that was cutting edges probably five years ago. Yeah. Explain it for me again,

peter_schlegel:

Yeah, well,

michael:

even

peter_schlegel:

there's

michael:

though I...

peter_schlegel:

two forms of a immunotherapy that have become very vogue and very effective and just very exciting from a cancer doctor and a cancer patient point of view. The first one is much more common. It's called a checkpoint inhibitor, ketruda, Opdivo are kind of the two leading drugs in that drug category. We use that for lung cancer, for malignant melanoma. for head and neck cancers and even some subsets of colorectal cancer. Much more commonly used. The type of treatment I'm going to be talking about is something called CAR-T. And what CAR-T is, is basically bioengineering the immune system to fight the cancer. And it utilizes, well let me back up and talk about what CAR-T is because I as a physician, hate when people use initials and don't explain what the CAR T means. So it means chimeric antigen receptor T cell.

michael:

Oh, totally clear.

peter_schlegel:

Yeah,

paul_roach:

Yeah, now

peter_schlegel:

so

paul_roach:

I understand.

michael:

Now I got.

paul_roach:

Yeah.

peter_schlegel:

anyway, so chimeric

paul_roach:

Let's stick with car T. Yeah.

peter_schlegel:

CAR

paul_roach:

Yeah.

peter_schlegel:

T, all right. So what we do with the CAR T is we harvest these T cell, lymphocytes through a machine generally in the blood bank or an infusion center that takes these T cells out. Then we take these T cells into a laboratory and add a DNA to encode the T cells

michael:

These are,

peter_schlegel:

to

michael:

sorry,

peter_schlegel:

fight.

michael:

just

peter_schlegel:

Yeah.

michael:

briefly. When you're saying T cells, my understanding of that is they're a form of a white blood cell, the kind that actually fight infection and, right.

paul_roach:

Yeah. So,

michael:

Okay, so that's what a T cell is. Okay.

paul_roach:

so, so my, my, you know, as a, as a non-hematologist,

peter_schlegel:

Hey, Paul,

paul_roach:

non-oncologist,

peter_schlegel:

can

paul_roach:

I

peter_schlegel:

I stop? Stop, stop.

paul_roach:

I was gonna give you one of my analogies, yeah.

peter_schlegel:

Let's go back. Can I start off? And I was going to talk about the chimeric, you know, we can just delete that part. I kind of flailed

paul_roach:

Well,

peter_schlegel:

on that.

paul_roach:

I think it's all right, but I think we should wrap it up soon. Uh, cause I

peter_schlegel:

Okay.

paul_roach:

also, my family's coming back here in a minute, but, but let me, let me answer Mike's question about.

michael:

them.

paul_roach:

Yeah. Mike. So, so the way I try to describe these different T and B cells and whatnot to patients is kind of like different versions of police. So you might have a policeman who's walking on the beat. You might have a policeman on a bicycle or a motorcycle, a policeman in a squad car or a paddy wagon, and I can

peter_schlegel:

Hehehehe

paul_roach:

say that cause I'm Irish. you know, the big box that holds a bunch of people in at the same time. And so, you know, you have different versions of white blood cells of these, these, uh, sort of policemen of your blood. And so the T cells are one kind and the B cells are another kind and, you know, antibodies that are circulating are a third sort of, uh, device that your body creates in order to neutralize, you know, invaders and That is my sort of thumbnail sketch of what these terms kind of represent.

michael:

Do you sell a heavy hitter then?

paul_roach:

Yes, actually the other thing, some of these T cells are kind of like, if you want to use a different analogy, like on a football team, like I think of the helper T cell as a quarterback of the team, you know. So Pete is a helper T, a quarterback or, you know, more

peter_schlegel:

Most

paul_roach:

like

peter_schlegel:

definitely,

paul_roach:

a.

peter_schlegel:

the whole HIV crisis was brought about by a deficiency in the CD, the T cells. Yeah, yeah, without the T cells, we would die of overwhelming infection in a very short period of time.

michael:

So

paul_roach:

So

michael:

you

paul_roach:

they

michael:

were

paul_roach:

sort

michael:

saying

paul_roach:

of

michael:

that they take the

paul_roach:

organize

michael:

T cells

paul_roach:

and direct.

michael:

out. But so they want those directors and they, and Pete, you were saying that they cull them, they take those T cells out and then what happens?

peter_schlegel:

Yeah, so we removed the T cells in a laboratory. They transfect and they put a foreign

michael:

They do what

peter_schlegel:

DNA

michael:

now?

peter_schlegel:

that they transfect. They're able to put foreign DNA into the T cells to program them to

paul_roach:

That's

peter_schlegel:

do what they

paul_roach:

called

peter_schlegel:

want. So, we

paul_roach:

transfecting.

peter_schlegel:

removed the T cells. We removed the T cells. So the transfection involves taking foreign DNA, inserting that into somebody's T cells, and then we'll take those T cells that have been expanded, they multiply them in a P-traditional lab, and basically take these T cells and infuse them back into the body. And interestingly enough, they go right to the surface of the lymphoma and fight those lymphoma cells in a very specific way. Some people

michael:

And

peter_schlegel:

call

michael:

this is your

peter_schlegel:

that

michael:

own body, right? So the risk is lower and the chance of it rejecting, your body rejecting this new element is less because it's just sort of been encoded into the DNA of something that is already part of you.

peter_schlegel:

Well,

michael:

Is that?

peter_schlegel:

it's very

paul_roach:

Yeah.

peter_schlegel:

bioengineered to be fighting the bad part of your body, which is the lymphoma. And there's a specific part of the lymphoma that kind of identifies it to make it, they call the CD19, but that's the target for the vast majority of these CAR T treatments for lymphoma. And I believe there's three of these CAR T therapies on the market right now. It's

paul_roach:

So

peter_schlegel:

a big

paul_roach:

Mike,

peter_schlegel:

deal.

paul_roach:

if this was a sci-fi movie and your family was on a ranch, right? And you're being attacked by zombies and there's thousands

michael:

Okay.

paul_roach:

of zombies and there's only 10 of you guys. And you don't know how the audience is nervous. You're all gonna get wiped out by the zombies. So then here's where the sci-fi part comes in. And this is actual, like I don't know how people figured out how to do this, but then they sort of... take some of your family out of the ranch magically, let's say, and then they give them ninja powers and then they multiply them over. So now that you've got 10,000 of your own family members inside the ranch, they put them back and then you fight the zombies and you win.

michael:

Gotcha.

paul_roach:

But it expands,

michael:

A clone army. This is Star Wars stuff.

paul_roach:

it's,

michael:

It's

paul_roach:

yeah, it's clone stuff.

michael:

fighting with

paul_roach:

It's,

michael:

the clone

paul_roach:

this

michael:

army.

paul_roach:

is,

michael:

Got it.

paul_roach:

yeah, it's probably where they got the idea, actually.

michael:

Now that sounds very fancy. What are the odds of me, if I need it, getting that therapy? Is this so cutting edge new that I'm not likely to see that? Or is it now I can get it if I need it?

peter_schlegel:

Kind of both, it is difficult to get. You have to go to a academic medical center that specializes in complex immunotherapy. Often the stem cell or bone marrow transplant centers carry this. I practice in a smaller city. We generally have to go to a larger city, University of Washington in Seattle would be the place that we would refer our. people too that need this treatment. And from what I'm aware, there's just a handful of people with this expertise because it's a very tricky and complex therapy involving laboratories and the ICU even and the patient and the doctor and all this coordination.

paul_roach:

If I'm not mistaken, it was all developed at the NIH, and I think it was to the tune of over a billion dollars figuring this one out. But they did

michael:

the

paul_roach:

it.

michael:

NAH.

paul_roach:

NIH, National Institutes

peter_schlegel:

Yeah.

paul_roach:

of Health in Washington,

peter_schlegel:

Yeah.

michael:

Okay.

paul_roach:

D.C. Yeah.

peter_schlegel:

So, we were talking about CAR-T before and what's the definition, what exactly does CAR-T stand for? And it's chimeric antigen receptor TSA, blah, blah, blah. But Chimera is a combination hybrid therapy that has a female fire-breathing creature with a lion's head, a goat's body, and a serpent's tail. And the English translation means an impossible creation. The way I look at it is we've taken our own T cells and then we've inserted the ability to fight lymphoma with foreign DNA. So we kind

paul_roach:

That's

peter_schlegel:

of have

paul_roach:

pretty

peter_schlegel:

the

paul_roach:

amazing.

peter_schlegel:

best of both worlds. We have our own T cells that can fight. They're not so smart against this lymphoma

michael:

But

peter_schlegel:

in your

michael:

it

peter_schlegel:

body.

michael:

normally doesn't.

peter_schlegel:

No, no. No.

michael:

So they're basically hijacking the immune system, adding this super ninja power that you're talking about. Because it normally, it would just, it's just floating around with all this lymphoma, basically ignoring it. And

paul_roach:

Once

michael:

so you

paul_roach:

it

michael:

take

paul_roach:

happens,

michael:

some out

paul_roach:

yeah.

michael:

and you basically say, no, no, no, no, you can't ignore it. You're now chimeric.

peter_schlegel:

Hehehehe

michael:

We've turned you into a new beast. And you have... lymphoma fighting ninja powers. That's interesting.

peter_schlegel:

impossible

paul_roach:

Yeah,

peter_schlegel:

creation.

paul_roach:

and I think that's a good point to wrap this up because once we've got soaring ninja powers, I don't know how we can top that.

michael:

Right.

peter_schlegel:

Yeah, so every treatment has its pros and cons, and this can be really tough on people. They can be in the ICU, they can have fevers, 103, 104, they can have all sorts of short-term problems. But the long and the short is it's about 50% effective with these people with primary refractory or relapsed lymphoma, which is a very scary, scary population to take care of with. all heard that, hey, you might do really well, but they turn out to be on the short end of the stick. And

michael:

Alright, so that's the 10%.

peter_schlegel:

they only get referred there because they were the ones who failed the first line.

michael:

50% of the 10% can get the effective treatment through this. So basically you're at now a 95% effective treatment rather than a 90% effective treatment, basically.

peter_schlegel:

Well, the medical system does some pretty incredible stuff with people with lymphoma, but yeah, it's hard to really look the statistics all that critically, but when you're a patient, you want the CAR T because not only can it knock the lymphoma out, it can provide people a long-term cure. And so who wouldn't want that? And using your

michael:

Um.

peter_schlegel:

own immunity to do that? Sign me

michael:

Crazy

peter_schlegel:

up, serve

michael:

question,

peter_schlegel:

it.

michael:

sorry, crazy question for the future. Will it come to the point where we can bypass the chemotherapy and go right to the T cell therapy?

peter_schlegel:

At this point the CAR T has been found to be effective in death what we call hematological malignancies. There are some leukemias and other forms of lymphoma, but it hasn't been found to be effective in the vast majority of common cancers, the colon, the pancreas, the lung, the breast, the ones that you hear about a lot. So the...

michael:

But even for lymphoma, can I look to a future where I can avoid chemotherapy and they can just give me the Super Ninja cells?

paul_roach:

Yeah.

peter_schlegel:

Perhaps we've made a tremendous amount of progress in the last five years with lymphoma, but at this point, we don't know. It can be pretty toxic. Everyone wants to avoid the cytoxic chemotherapy, the nuclear attack, but having said that, this amine therapy

paul_roach:

It does work.

peter_schlegel:

can

paul_roach:

Yeah.

peter_schlegel:

cause some problems too. So we'll just have to figure it out. But as it stands, the... The price tag on these CAR Ts are well over a million dollars. And so, you know, that's going to be another issue that we'll have to contend with. But, you know,

paul_roach:

And

peter_schlegel:

what

paul_roach:

also

peter_schlegel:

else?

paul_roach:

the chemotherapy is tried and true over many decades and it works many, many times.

michael:

when it's cheaper.

paul_roach:

and a lot cheaper. All right, so with that, I think we'll wrap this up and I'm gonna thank all our listeners once again for tuning in. And if you have a topic you would like to have us discuss or comments or feedback, please either log on to www.PaulBrienRoach.com. That's Paul, B-R-Y-A-N-R-O-A-C-H.com and click on the contact page or send them directly to letters at PaulBrienRoach.com. And next month we'll be talking skin cancer. Signing

peter_schlegel:

Excellent.

paul_roach:

out.

michael:

Thanks, gentlemen.