Non-Hodgkin�s Lymphoma

Traditionally, researchers have differentiated Hodgkin�s Disease from the non-Hodgkin�s lymphomas, though both are malignancies of the lymphocyte cells of the immune system. For 2006, the American Cancer Society predicted 58,870 news cases of non-Hodgkin�s lymphoma, and 18,840 deaths. (1) This umbrella term actually includes well over a dozen different types that range from the very indolent, to very aggressive, potentially deadly disease.

Patient IL: A 15-Year Survivor

Patient IL is a 64-year-old woman from the Southwest who in the fall of 1987 first developed vague abdominal discomfort. When the pain persisted, in January 1988 her physician referred her for a CT scan, which revealed several large abdominal tumors. In January 1988 she underwent exploratory surgery, hysterectomy and bilateral salpingo-oophorectomy, with resection of two large masses attached at the mesentery together measuring 9 x 8 x 8 cms in diameter. The pathology report describes the lesions as consistent with diffuse mixed lymphoma, mixed small and large cleaved cell type, a very aggressive form of the disease.

IL then completed six months of chemotherapy with MACOP-B, an intensive regimen consisting of five different chemotherapy drugs and the steroid prednisone. Repeat CT scans in August 1988, at the completion of treatment, were negative and her doctors assumed her to be in remission. Subsequent scans were clear until May of 1991 when a CT picked up two nodules in the lungs, the largest in the lingula measuring 1.6 cm, the smaller in the left lower lobe measuring 0.6 cm. In addition, the report describes �small periaortic lymphadenopathy at the level of the kidneys� which had been noted on prior scans. A chest CT in July 1991 revealed a 2.5 by 2 cm. mass in the left hilar area, an abnormality of the lingula, and a left lower lobe mass:

1. Left hilar mass and posterior left lower lobe nodule.
2. Progressing mass and associated atelectasis or infiltrate in the lingula.

Although her doctors discussed resuming chemotherapy, IL as she says had �had enough.� After learning of our work from a friend, she then decided to pursue our program.

When I first saw IL in my office in September 1991, she generally felt well, and thereafter proved to be a very compliant patient. Six months after beginning her regimen, in March 1992, a repeat CT scan of the chest demonstrated a small pleural based density associated with the anterior left cardiac margin, approximately 1 by 1.5 cm in size, that had significantly regressed since the scans of 1991. And, the additional lesions previously described were not evident. An abdominal CT scan revealed �slightly prominent nodes on the para-aortic area measuring up to 1 cm in diameter� but no other worrisome lesions.

In September 1992, after she had been on her program a full year, CT studies of the abdomen and pelvis were clear, but the chest CT showed a �3.5cm x 2 cm density in the left mid lung and lower lung field which, according to the previous dictation, has increased in size significantly and, therefore, must be considered an active lesion��

When I discussed the findings with IL she seemed determined to continue with her nutritional program only, expressing no interest in pursuing any other treatment. After I made some adjustments in her protocol, she decided to forgo future CT scan studies. She said not only did they create enormous anxiety, but she had no intention of changing treatment whatever the tests showed.

Over the next decade, IL continued her regimen, with excellent compliance. She generally enjoyed good health, despite some ongoing problems I relate to her earlier chemotherapy, such as a persistent irregular heart rhythm and episodic respiratory symptoms, including shortness of breath with exertion. One of the drugs in the MACOP-B regimen, daunorubicin, has long been associated with heart damage in a significant number of patients, and bleomycin often provokes pulmonary fibrosis, sometimes years after treatment. In January 2004, she did undergo both cardiac and pulmonary evaluations which revealed no significant underlying disease. A chest x-ray at that time � her first radiographic study since the CT scan of 1992 � showed a �small left apical pneumothorax. Chest x-ray is otherwise radiographically normal.� The previously described masses seen on CT were gone, and I relate the area of collapse to bleomycin use years earlier.

IL today, now on her nutritional regimen over 15 years, continues in good health with apparent total resolution of her once aggressive disease. She enjoys her life, is grateful that she has lived to see her children grow, marry, and raise their own children.

The diffuse and diffuse mixed types represent particularly aggressive forms of lymphoma that frequently come back after even the most aggressive of chemotherapy regimens. Harrison�s reports that the disease recurs in nearly 50% of treated patients with this diagnosis, and of these, fewer than 10% will respond to additional chemotherapy. (2) Certainly this patient faced a grim future, once the CT scan studies in 1991 confirmed new disease.

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Patient LL: An 11-Year Survivor

Patient LL is a 54-year-old man who previously had been in good health when in July 1995 he developed severe chronic indigestion, abdominal pain and constipation. His symptoms did not improve despite a variety of medications and dietary changes. After he developed swelling of the left testicle in September 1995, he was referred to a urologist who ordered a CT scan of the abdomen and pelvis. The tests, done in October 1995, revealed:

extensive retroperitoneal adenopathy including retrocrural, periaortic, mesenteric and paracaval adenopathy. The nodes measure up to 5 cm in diameter individually and in conglomerate measure nearly 15 cm in transverse diameter and 8-10 cm AP�

An excisional biopsy of an enlarged cervical lymph node revealed nodular non-Hodgkin�s lymphoma (mixed lymphocytic/histiocytic type).

After the diagnosis, he received no orthodox treatment, instead choosing to follow our regimen. He was first seen by Dr. Isaacs in November 1995, and as he subsequently followed his nutritional regimen, he experienced a gradual improvement in his overall health. For a number of years, he avoided all testing until May 2001, when a CT of the abdomen and pelvis showed �Resolution of previously noted adenopathy. The study at this time is essentially unremarkable.�

This patient�s course has been very simple and straightforward. He was diagnosed initially with extensive stage IV moderately aggressive histology disease, refused all standard treatments, followed his nutritional program appropriately, and enjoyed complete regression of his cancer and long term survival. He is now 11 years from diagnosis, still in good health.

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Patient DC: a 12-Year Survivor

Patient DC is a 63-year old woman who 1992 first noticed a robin�s egg sized lesion in the right lower abdominal wall. She consulted her primary care physician, who suspecting a benign lipoma, suggested no testing be done.

Over the next three years, as the nodule remained stable, DC continued in good health, with no symptoms other than a single episode of night sweats and occasional pruritis. At one point, when she was found to be mildly anemic, her physician prescribed iron supplements.

In the fall of 1994, her gynecologist, after a routine exam, suggested a diagnostic evaluation of the abdominal wall lesion. A CT scan revealed a solid mass on the right lower abdominal wall, but no other abnormalities. Then in November 1994 the nodule was excised and described in the pathology report as 4.5 x 4.0 x 1.8 cm, consistent with �malignant lymphoma, diffuse, small lymphocytic type (well differentiated lymphocytic lymphoma) of abdominal wall.�

After referral to an oncologist, a subsequent bone marrow biopsy was clear, but she was again found to be anemic, with a hemoglobin of 11.8. In January 1995, she underwent repeat CT studies which revealed new nodularity in the left pelvis side wall and in the cul-de-sac, thought most likely representing new pelvic malignant lymphadenopathy.

The hospital Tumor Board then discussed the case and recommended a conservative approach initially, with regular follow up CT scans to assess disease progression. A bone scan in October 1995 was negative. CT scans in January 1996 demonstrated two lesions within the right lobe of the liver, the largest measuring 2.0 cm in diameter, that were thought to have been present on the prior exams. In addition, the radiologist noted �redemonstration of a large, inhomogeneous central pelvic mass with prominence in both adnexal regions,� as well as �thickening of and some inhomogeneity to the appearance of the left piriformis muscle when compared to the right��

Though her physicians still recommended a conservative approach, DC began investigating alternative approaches, learned of our work, and in April 1996 first consulted with me. When first seen, she reported no significant symptoms.

DC proved to be a determined and compliant patient, whom I don�t think has missed a dose of supplements in the 10.5 years she has been my patient. Periodically, I have recommended CT scans, which generally have showed no change in the pelvis lesions. Her most recent scan in May 2006 revealed the same �two small low density lesions within the liver�unchanged and measuring up to 1 cm.� In terms of the pelvic mass, the report states:

There is large lymphadenopathy contiguous with the left piriformis muscle, unchanged in size measuring 9 cm in length x 4.5 cm. in width. Again noted are areas of linear enhancement� There is a 4.5 cm. in length x 2.7 cm in width soft tissue mass in the proximal aspect of the left thigh which is slightly decreased in size�

The diffuse forms are among the more aggressive of the lymphomas, usually calling for aggressive chemotherapy. In this particular case, the consulting oncologists opted for a conservative approach, holding chemotherapy in reserve for a time the disease would inevitably progress. However, during the 10.5 years DC has followed her nutritional program, the disease has remained generally stable, with some recent regression.

In many of our patients, regardless of the cancer type, tumors resolve, as in the case of Patient LL above. At other times, as with Patient DC, the tumors can remain stabilized for years. I have never been able to offer a reasonable scientific explanation why this should be so, why sometimes large tumors regress remarkably, at other times in other patients the tumors don�t grow or spread, but don�t disappear either.

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Patient DK: A 7-Year Survivor

Patient DK is a 48-year-old woman who prior to developing cancer had a long history of lower back pain treated conservatively with acupuncture, massage, yoga and swimming, modalities which offered some relief. In 1993, when her pain worsened, she underwent laminectomy of the L2-L3-disc. Postoperatively her back pain, although reduced, did not resolve completely. In November 1993 she underwent an MRI of the lumbar spine which showed L5-S1 disc bulging, and some degeneration in several other lumbar discs. In addition, the radiologist noted left para-aortic adenopathy. The patient then consulted with an oncologist at New York Hospital-Cornell, who recommended a CT scan, which, in December 1993, confirmed enlarged left para-aortic lymph nodes, though the patient was not informed of the findings.

Since she didn�t hear from her oncologist, DK assumed �everything must be fine.� Thereafter, she did well until mid 1998, when she developed gradually worsening fatigue, associated with recurrent upper respiratory infections. In the fall of 1998, she consulted her primary care physician, who detected a right parotid mass as well as cervical lymphadenopathy. Initially, her internist was not concerned, assuming the enlarged nodes related to her most recent bout of the �flu.� But, when the adenopathy failed to regress, DK consulted the oncologist she had seen years earlier at New York Hospital. The physician referred her for an MRI of the neck in March 1999, which revealed two 1 cm lesions in the right parotid gland as well as enlarged upper cervical nodes. A CT scan of the chest in April 1999 demonstrated abnormal hilar nodes, the largest measuring 17x12 mm. CT scan of the abdomen revealed:

a chain of enlarged nodes (2-3 cm�) in the left paraaortic region from the level of left renal hilar vessels�.extending into the proximal left common iliac chain. Largest node at L3 level measures 3x2 cm.

A biopsy of the parotid lesion then confirmed malignancy �consistent with a B cell (non-Hodgkin�s) lymphoma.� A bone marrow biopsy was clear.

With the diagnosis established, the oncologist recommended a �watch and wait� approach, holding off chemotherapy for a time when the disease worsened. DK then sought a second opinion at Memorial Sloan-Kettering, where the slides were reviewed and the diagnosis confirmed. The Memorial oncologist suggested two options, the conservative, no immediate treatment approach, or a course of aggressive chemotherapy.

DK then met with a third oncologist, a lymphoma specialist at New York Hospital, who recommended no treatment initially, but that the scans be repeated in October 1999 to assess disease status.

DK, with a long interest in alternative medicine, knew about my work and decided to consult with me. When we first met in June 1999, she had obvious cervical adenopathy. Thereafter, she followed her nutritional regimen initially with great determination and good compliance. Follow-up CT scans in March 2000, when she had been on her therapy only nine months, showed substantial improvement. The report for the CT scan of the neck states:

Appearance of regression in intraparotid nodes on the right.

The CT of the chest showed:

Interval complete regression in adenopathy. There is no evidence for active lymphoma.

The CT scan of the abdomen indicated:

Interval virtually complete regression in adenopathy. There is no evidence of active lymphoma.

The CT scan of the pelvis revealed:

Interval complete regression in adenopathy. There is no evidence for active lymphoma.

As DK continued her nutritional therapy, she experienced a gradual improvement in her overall energy and well being. When in mid 2001 she went through a period of severe personal and professional stress, her compliance with therapy fell off somewhat. On exam, I could see clearly that the neck disease had worsened. CT scans in October 2001, 19 months after the documented disease regression, showed little change in the chest, abdomen and pelvis, but increased �pathological adenopathy in the right neck.� After I lectured her about the need for diligent compliance, for a time she seemed more determined, but the stress continued unabated and her compliance varied. At times, she might have been doing 50% of the therapy and a CT of the neck scan in January 2002 revealed continued progression in the adenopathy. The report of the abdominal and pelvic CT scans describes:

Mixed behavior of nodes with periaortic nodes slightly less prominent and hyperplastic nodes in the small bowel mesentery more prominent�Interval appearance of focal splenic lesions�

This time, we talked about the need for complete compliance with all aspects of the regimen, regardless of the difficulties in her life. Fortunately, her oncologist did not insist that chemotherapy begin at once, since she had previously responded so well to my treatment. DK renewed her dedication to the regimen, with repeat CT scans in January 2003 confirming the benefit. The neck CT showed �Substantial decrease in the extensive adenopathy in the right neck.� The abdominal CT scan indicated:

Interval disappearance of small splenic lesions and slight decrease in sight of spleen�No pathologic adenopathy is seen in the abdomen or pelvis.

Thereafter, she followed the therapy as prescribed, and continued doing well. A neck CT in March 2004 revealed:

Complete regression in pathologic and borderline sized neck nodes.

The CT scans of the abdomen and pelvis were completely clear, as the official report describes:

There is no other interval change and no evidence for active lymphoma in abdomen and pelvis.

Unfortunately, her stress level subsequently increased markedly and after a long-term relationship dissolved, for a number of months she went off her program completely. Her energy worsened, her sleep became disturbed. Predictably, a CT scan of the neck in February 2006 showed �New and progressive adenopathy along the right jugular chain and posterior triangle.� CT scans of the chest, abdomen and pelvis showed recurrent disease.

She is now again on her program, determined once again to get well, and clinically the enlarged neck nodes are regressing. She feels stronger, more energetic, more positive.

Though DK has not followed a straight and narrow path, her course does say much about our treatment. When she complied fully, her extensive disease regressed completely. When her compliance fell off, the disease recurred, then again regressed when she resumed her full protocol. Over the years, her disease status has correlated precisely with her compliance.

Patients, including mine, do not lead perfect lives. Often, they must deal with many life stresses above and beyond their cancer, stresses which can influence mood, motivation and dedication to treatment. But DK, despite her lapses, has generally done very well over the past 7.5 years on her nutritional program, has successfully avoided all chemotherapy and radiation, and currently feels strong and healthy.

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Patient LR: An 11.5-Year Survivor

Patient LR is a 60-year old woman with a history of an insulinoma, diagnosed in 1977, treated effectively with partial pancreatectomy. Her doctors recommended neither chemotherapy nor radiation after surgery, and thereafter she did well until December 1993 when she first noticed swollen lymph nodes under her chin. When the swelling did not regress, in January 1994 she consulted her internist who suspected the problem related to infected gums. She was referred to a periodontist who performed gum debridement, but when the lymph nodes enlarged further in February 1994, she returned to her internist who prescribed penicillin, without effect. About that time, she first developed significant night sweats that persisted for a week, as well as abdominal pain. Her physician referred her for an ultrasound, which revealed a large 7 cm cystic mass in the tail of the pancreas which a CT scan confirmed. The radiologist thought the lesion consistent with a benign pseudocyst, and when a needle biopsy proved inconclusive, her doctors recommended no further testing.

Because of the persistent enlarged lymph nodes in her jaw, in April 1994 LR consulted an ENT specialist who did not initially suggest biopsy, but in June, LR noted new inguinal adenopathy. At this point, the patient�s internist prescribed a course of Cipro for what was now thought to be cat scratch fever, which antigen testing did confirm. Although the nodularity persisted even after she completed a course of Rifampin, her primary physician remained unconcerned. When the adenopathy progressed throughout September, LR again returned to her doctor, who again told her �not to worry.� In one of the physician�s notes from the time, he described her as �borderline hysterical.�

Finally, LR decided to consult the surgeon who years earlier had resected the insulinoma. In October 1994, this physician � somewhat more disturbed by the adenopathy - removed a nodal mass from the posterior neck-right shoulder junction that proved to be �Follicular lymphoma, predominantly small cleaved cell type (nodular poorly differentiated lymphoma).� Experts at the Pathology Laboratory of the National Institutes of Health reviewed the slides and confirmed the diagnosis.

In late October a CT scan of the chest revealed �marked lymphadenopathy in multiple mediastinal, left hila (sic), retrocrural and axillary areas�consistent with the clinical diagnosis of lymphoma.�

An abdominal CT scan showed: �There is extensive adenopathy in the abdomen and pelvis, with lymph nodes ranging up to 3x4.4 cm and 4.6x6 cm.� A gallium scan documented extensive uptake in the mediastinum and abdomen.

Shortly thereafter, in November 1994, LR began chemotherapy with CHOP, a standard lymphoma protocol, at a local academic medical center. In late December, after she had completed three cycles of the proposed course, CT scans demonstrated improvement, but not resolution, in both the chest and abdomen, reported as: �Interval decrease in size of adenopathy within the right paratracheal group, subcarina, left axillary and retrocrural nodes�� In the abdomen the radiologist noted �lymphadenopathy has decreased by more than 50% since exam of 10---94 consistent with partial response to chemotherapy.�

In March 1995, after LR had completed the full six cycles of the regimen, CT scans indicated some continued response to therapy, but definitely not complete remission. The chest CT showed �Slight continued improvement in right paratracheal lymph node disease with stability of disease elsewhere�� The abdominal CT revealed:

When compared to previous examination, the lymphadenopathy appears stable except for an apparent worsening in the region of the root of the mesentery�

With chemotherapy completed but her disease not in remission, LR began investigating alternative approaches, learned of my work, and first consulted with me in April 1995. Her exam was unrevealing, except for multiple palpable right cervical lymph nodes.

She thereafter began her program with great determination. In November 1995, restaging with CT scans of the chest, abdomen and pelvis confirmed significant improvement:

No significant mediastinal or hilar adenopathy is identified. The lungs are clear without evidence for masses�Retrocrural adenopathy seen on the previous examination is now not identified. Small periaortic and mesenteric lymph nodes are identified which have decreased in size since the previous examination�

CT studies in February 1996 showed no evidence of recurrent disease, as did subsequent scans over a period of two years. Throughout this time, she was noted to have, on exam, several small right cervical nodes. In May 1998, the oncologist who followed her along with me suggested a biopsy of one of the neck nodes, which did reveal residual lymphoma described as �Follicular, mixed small cleaved and large cell type�� At that point, the oncologist recommended, along with my therapy, a course of Rituxan, a monoclonal antibody treatment designed specifically to attack lymphoma cells. I felt the treatment unnecessary since she had already responded so well to my regimen, but the oncologist was persuasive and I did not push the case. So, in the spring and early summer, she completed four cycles of the drug, which she tolerated with minimal difficulties. On exam, her cervical nodes regressed completely. CT scan studies of the chest, abdomen and pelvis in September 1998 reported �No evidence of recurrence.� CT scan of the neck showed �Multiple small subcentimeter lymph nodes bilaterally which have decreased in size and number since the previous study.�

Since 1998, LR has done exceptionally well, now 12 years from her original diagnosis of stage IV lymphoma, and 11.5 years from her first visit with me. She has enjoyed generally excellent health with no recurrence of her once widespread disease. The most recent PET/CT scan in April 2006 documented:

There is no PET/CT scan evidence of recurrent or metastatic disease.

Her course is unusual, both in terms of the long-term survival and the near total resolution of the disease as documented by CT scans after only six months on her nutritional therapy. In 1998, before she completed a course of Rituxan, scans of the chest, abdomen and pelvis had been clear. I suspect her neck nodes eventually would have resolved without Rituxan. Studies do show that 35-50% of patients with follicular lymphoma that relapse after chemotherapy will have some response to the drug, though the duration of effect is variable with few long-term remissions. (2) In any event, in this case the disease had nearly completely resolved before her oncologist urged in 1998 she proceed with Rituxan, at the time a fairly new, and highly promoted, drug.

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1. What are the key statistics about non-Hodgkin lymphoma? at Accessed on November 12, 2006.[Article]

2. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo, DL, Jameson JL. Harrison�s Principles of Internal Medicine, 16th Edition. New York: McGraw-Hill; 2005:650-1.

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