Tuesday, April 10, 2007

What's in a name?

My name written in Chinese.

I have been struggling with the names of things lately. Especially medical names. And this has led me on a small journey of discovery. The process began when my hematologist said, 'Don't look for peers in this disease. Your CLL is atypical.' I didn't ask follow-up questions then but later her remark began to peak my interest and I wondered in what ways it was different.

Well, one certain difference is that my diagnosis came from the severe anemia that hospitalized me in July and was later termed autoimmune hemolytic anemia (AIHA). Only about 10% of people with CLL present initially with AIHA although about 30% of those with CLL are at risk for it throughout the course of their disease.

I have a bundle of autoimmune issues that are non-hematologic but hematologists at Beth Israel and Dartmouth medical center have said these are 'probably' related to the CLL which 'corrupts' the immune system. But in reading on the web, I came across something written by Dr. Hamblin of England, one of the international lights on this disease, who wrote that non-hematologic autoimmune complications are rare in CLL.

The diagnostic report from Beth Israel stated that I was 'hypogammaglobulinemic' -- low immunoglobulins. For me, the IgA is low: only 47 (normal reference is 70-640). More reading on the internet yielded this: 'hypogammaglobulinemia is associated with complications in the progress of the (CLL) disease". For sure, it explains why I have that 'bundle of autoimmune issues' like large multiple painful mouth sores and chronic intestinal problems.
"AHIA and hypogammaglobulin do occur in the mutated subset, and in our experience hemalytic anemia maybe the presenting feature of low-count, stage 0 disease." Kay et al, 2002

In Boston, a flow cytometry test was done and my cells were found to be ZAP70 positive. However, there are many false negatives and false positives in this test has procedures have not been standardized or as David Arenson (www.clldiary.blogspot.com) says, the 'kinks' have not been worked out yet. Most experts agreee that the only laboratory where one is certain to get an accurate reading is UCSD.

Another test, the B2M in July was 2 and in March it was 3.5. Some experts believe that anything over 2 heralds a more aggressive disease. Other experts say a number of 4 is the indicator for a more aggressive disease. Others disagree. Still others say it not indicative of CLL at all. But there it is, increasing.

All winter long, I have experienced frequent and episodic fevers that run from 99.5 to 100 with no alteration in the white blood count. I have night sweats (but not drenching) and day sweats occassionally and episodically. And fatigue that can put me in bed for one or several days at a time. All three are 'B-symptoms'.

But the real ringer is that my CBC reports stay within normal ranges in term of white blood count and absolute lymphocyte counts. Typically, one would expect to see rising counts. Over the last eight months since diagnosis of AIHA, there has been consistent evidence on the CBC (LDH and reticulocyte counts) that I am still hemolyzing red blood cells -- but the balance is holding and I have been off steroids since October.
"The lymphocytes in the blood are part of the total lymphocyte mass in the body; they circulate through the bone marrow, spleen and lymph nodes. In CLL, they have derived from a single abnormal lymphocyte and have taken many years to reach a number that can be detected. The basic defect is a failure to die." Hamblin, 2007

Yesterday, I posed THE question to my local hematologist/oncologist in Portsmouth: could there have been a mistake in the diagnosis of CLL? He agreed that my disease didn't present in a consistent way and mentioned the possibility of "SLL". He wondered out loud whether I should have a re-take of the ZAP70 test and another bone marrow biposy.

I also posed the question to Dr. Hamblin on the CLLC Friends board; he mentioned "SLL".
I laid out my scenario to the membership of the CLL Forum; and several members mentioned "SLL".

SLL: small lymphocytic lymphoma. Not a leukemia because the disease is in the marrow and the nodes. It is the same disease biologically as CLL, treatment protocols are the same. But it is different in that it is not seen in the peripheral blood.

This begins to answer some of my questions.
Of course it also poses a few more.
Does the CLL/SLL difference matter?
Is the natural course of the disease the same or different?
Should I look for a second opinion from one of the 'experts'?
Which one?


old_mac said...

Hi Pat

I had a heck of a time understanding SLL and CLL. The best way to think of it is they are opposites.

CLL has clone sites in the marrow as you know and the cells grow and eventually spill out into the peripheral blood. Once in the blood they are free to move from the blood to the lymph system, and back and forth.

SLL starts in the lymph system and stays mostly in this system. As it develops it starts to move into the marrow. So one is moving outward, while the other moves inward.

However the most recent research suggests that the treatments for the two are quite different. While you haematologist shuffles around and suggests other tests, it is imperative that you get a handle on what you have CLL or SLL.

In light of what you are going through I suggest you get a second opinion from another medical centre.

Hope this helps

Chris Dwyer

Pat said...

Thank you so much for your informative comments--much appreciated. I do intend on getting a second -- third, I suppose -- opinion and expect that will be with one of the CLL consortium docs. BTW, I will be at the Ontario conference next week and am looking forward to it!! Pat

Lynn McGaha said...

Where can I find this recent research that suggests that the treatments for CLL vs SLL are quite different? Everyone else seems to say that the two conditions are identical at the molecular level and that by the time treatment is needed, both are presenting fairly much the same, and the treatments are the same. Lynn