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Persistent fever, enlarged lymph nodes and lethargy: Signs of lymphoma and how early detection may improve outcomes

Originating in the body’s lymphatic system, lymphoma is a blood cancer that causes an enlargement of the lymph nodes, liver and spleen. According to SingHealth, it is the fifth most common cancer in males and the sixth most common cancer in females in Singapore. 

There are many types of lymphoma. Worldwide, the most common form of lymphoma is diffuse large B-cell lymphoma (DLBCL), a type of fast-growing non-Hodgkin’s lymphoma. Senior consultant of haematology at Parkway Cancer Centre Lee Yuh Shan discusses the symptoms, treatments and prognosis for this disease.

Q. Who is more likely to get DLBCL and how is it diagnosed?

In general, lymphoma can affect anyone. However, certain groups of people are more prone to developing the disease. These include people between 60 to 65 years old, those with low immunity, HIV patients, those who have been infected by the Helicobacter pylori bacteria (a common cause of stomach ulcers) or the Epstein-Barr virus (a member of the herpes virus family), as well as those exposed to high levels of radiation and certain chemicals. Although there is some loose family association, lymphoma is generally not hereditary.

The disease is diagnosed from biopsies of the lymph node or bone marrow, as well as a blood test using a technique known as flow cytometry.

Q: What are some symptoms of DLBCL to take note of?

Lymphoma can present with a variety of symptoms such as persistent and enlarged lymph nodes in the neck, under the armpit and other parts of the body. Other symptoms include prolonged fever, lethargy, night sweats, weight loss, skin rash, difficulty in breathing due to a tumour in the chest and raised levels of lymphocytic white cells. While these symptoms are not specific, if the symptoms persist for more than two weeks, seek medical advice early.

Q: What is the outlook for DLBCL and is it potentially curable?

Although an aggressive disease, DLBCL has one of the best outlooks for patients. It is very well studied, with accomplished first-line treatment options as well as good therapy options in later lines using a more targeted approach in the event of a relapse or if the patient does not respond to first-line treatment. 

There is a fairly good chance of long term remission or cure with first-line treatment alone. If the disease comes back after first-line treatment, a second-line treatment would be planned to help patients to reach remission again. However, the chances of reaching a second remission are less favourable especially in high-risk disease. Therefore, timely diagnosis and effective frontline treatment are crucial.

Q. What are some of the treatment options for DLBCL?

For the past two decades, multiagent chemotherapy in combination with immunotherapy have been the initial standard treatment approach. This first-line treatment is administered every three weeks for four to six cycles. Despite extensive trials, limited progress has been made in improving patient outcomes in the first-line over the last two decades. Recently, a new approach with additional immunotherapy showed an improvement in response and better disease control as compared to the conventional approach, and longer follow up is underway to assess survival benefits.

Q: How often does DLBCL relapse after initial treatment and are there further treatment options available in such cases?

While many patients are cured with first-line treatment, up to three out of 10 people with DLBCL do not respond or suffer a relapse. Conventional second-line treatment includes chemotherapy and high dose chemotherapy with autologous stem cell transplant, where the patient’s healthy blood stem cells are used to expedite recovery of bone marrow from high dose chemotherapy.

There are also some new targeted agents like chimeric antigen receptor (CAR) T-cell therapy, which uses cells in the patient’s own immune system to fight the disease. While these later-line therapies help to improve outcomes, the burden of relapse is still high. A better first-line approach is likely to close the gap and potentially reduce the burden of relapse for patients and the healthcare system.

Q: How should patients continue to care for themselves following successful treatment?

After successful treatment, patients need another two to three months to recuperate. This is the best time for them to slowly regain their fitness with gently escalating exercise before returning to their work and social lives. They should also eat well, incorporating a balanced diet with more protein to help increase their strength. To reduce the risk of a relapse, patients should continue to keep their regular physician’s appointments to monitor their health.

 

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