AST is from Tanjung Balai, a town on one of the islands in Riau, Indonesia.
In April 2018, this 48-year-old man — a smoker of some 30 years standing — went for a routine medical checkup in Johor Baru, Malaysia. He had no symptom whatsoever.
An X-ray during the checkup showed something in his lung. A trucut biopsy of the right lung mass was done immediately. Histomorphology and immunoprofile pointed to a low grade lymphoma of BALT.
Bone Marrow Aspirate and Bone Marrow Trephine showed normocellular marrow (meaning, in contains a normal number of cells; neither hypocellular nor hypercellular).
(Bone Marrow Aspiration and Biopsy: The procedure known as trepanning, or trephination, of bone is the oldest surgical practice that continues to have clinical relevance in modern times. There are 2 main types of bone marrow test: 1) bone marrow aspiration — doctor sucks some liquid bone marrow cells up into a syringe. 2) bone marrow trephine biopsy — the doctor removes1 or 2cm core of bone marrow in one piece. Usually both of these tests are done at the same time. These tests are often done to find the reason for many blood disorders and may be used to find out if cancer or infection has spread to the bone marrow).
AST was referred to an oncologist of the same hospital for follow up treatment. He was sent to another hospital for PET/CT scan. The results of the scan done on 23 April 2018 indicated:
- FDG avid mass right lung, 8.4 x 5.9 x 8.1 cm.
- FDG avid nodule apicoposterior segment lower upper lobe, 1.0 x 0.8 cm.
- Bronchieactatic changes seen in both lungs.
- No mediastinal mass lesion or lymphadenopathy.
AST underwent chemotherapy. The drug regime used was: R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin (hydroxydaunomycin), Vincristine (Oncovin) and Prednisolone (a steriod).
Each cycle cost RM11,000. He received a total of three cycles at three-weekly interval. The treatment completed on 14 June 2018.
After this initial treatment, AST’s father died (due to old age) and as a result he took a break from chemotherapy.
A repeat PET/CT scan was done on 15 August 2018. The result showed:
- Previous FDG avid mass right lung has reduced intensity and was smaller 6.5 x 4.9 x 5.5 cm.
- Previous FDG avid nodule apicoposterior segment lower upper lobe disappear.
- New two FDG avid nodules at posterior lower left lobe, 1.5 x 1.0 cm and 1.1 x 0.9 cm.
- New right paravertebral mass lesion, 0.8 x 0.6 cm.
- Multiple cysts both lung fields unchanged.
Impression: progression of lesions with new lung metastases left lower lobe and small right paravertebral mass.
AST received ten times of radiation on the chest. This cost him RM 5,000.
He was told to go for more chemo. He refused. His daughter found CA Care in the internet and decided to seek our help.
You may wonder why I document this case. Here is the answer. For more than two decades of helping cancer patients, lung cancer is one of the most common that I get to see. And these are carcinoma type of lung cancer. During these years I did come across a few cases of lung cancer of the sarcoma (not carcinoma) type.
Primary lung sarcoma is very rare, accounting for less than 0.5% of all lung tumors. Then this week, I encountered a pulmonary BALT lymphoma, a first case in over twenty years.
I came home and started to learn what this BALT lymphoma is. Here are some information about this type of really rare lung cancer.
- BALT means Bronchus Associated Lymphoid Tissue. It is a lymphoma found in the lung. Actually there are two types of lung lymphoma — BALT and MALT lymphoma. MALT stands for Mucosa Associated Lymphoid Tissue. The most common type of primary pulmonary lymphoma is MALT lymphoma.
- Most pulmonary lymphomas are low-grade B-cell lymphoma.
- Primary pulmonary lymphoma is rare, accounting for 0.5% of all lung tumors and less than 1% of all lymphomas.
- They are generally indolent (causing little or no pain) with good prognosis.
- Patients with BALT lymphoma have an excellent prognosis. Interestingly, surgical treatment, radiotherapy, chemotherapy, or combinations of these strategies all seem to achieve good results.
- The most frequent reported symptoms in patients with BALT lymphoma include dry cough and difficult breathing.
- Patients may also present with fever, night sweats and weight loss.
- Since many patients are asymptomatic or present with vague symptoms, there is often a delay in diagnosis. It is believed that, in approximately one-third to one-half of the patients, the disease is discovered incidentally on X-ray.
- About 14% of patients may have bone marrow involvement.
- Since this is a slow-growing disease, it has excellent response to surgery, chemotherapy or combined treatment. Treatment provides excellent prognosis, with extremely low mortality rates. There is a report that pulmonary BALT lymphoma was successfully treated with eight cycles weekly Rituximab.
AST and his daughter came to consult us in October 2018. He looked “healthy” except for a bit of cough and difficulty in breathing. After hearing his story, I told AST that his lifestyle is reckless. While still on chemotherapy, AST told me that he was riding motorcycle up the rugged hills in the rain. This resulted in infection. I emphasized to AST that he needs to adopt a more “healthy and restrained” lifestyle if he wants to live without problems.
I cannot say what is going to happen next but after reading what pulmonary BALT lymphoma is, I want to “believe” that the herbs and a change of lifestyle can help him. But ultimately, it all depends on AST, whether he is willing to help himself or not.
Update: AST came back to see us again after a month. He took the herbs and keep to the diet without any problem. He did not suffer any healing crisis. Did his health deteriorate this one month after defaulting on chemotherapy? No. Did he feel better after taking the herbs? Yes.
AST said he has more energy after taking the herbs. His cough is also resolved. He can now take a deep breath. Before the herbs, his breathing was swallow. AST said he would NOT go for anymore chemo. He is happy following our therapy.
Watch this video.
P/S: As I am writing this story, a lady came to your centre. She was diagnosed with MALT lymphoma.This is also my first encounter with this type of cancer. In this case, the MALT lymphoma “attacked” the inner lining of her eye lid. How could that be? I wonder what has become of our world today. I hope to be able to write about this story in the near future.
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