Q and A

Question

Should I have a stem cell transplant for non-Hodgkins lymphoma?

Hi,

I got plasmablastic non-Hodgkins lymphoma (NHL) about a year ago. At the same time I was diagnosed with HIV,with a CD4 of 48.

After chemotherapy,the cancer was in remission. However, 10 months afterwards a small cist was dicovered and I went on another more fierce chemo regime. Again after chemo the CT scan revealed no cancer.

My CD4 after 10 months on Atripla was 178. The doctors requested a stem cell transplant, which failed to yield bone marrow cells after treatment with G-CSF.

Now they are trying a drug called mozobil, to stimulate the growth my stem cells. But this drug is not registered in South Africa, and it’s very expensive.

Should I not rather discard the stem cell transplant and wait for my immune system to recover?

I gained 130 CD4 cells in the first ten months on ARVs.

What would be a safe threshold for my CD4 for my body to keep the cancer at bay?

I do not want to endure the pain of a stem cell transplant if my immune system is recovering.

Answer

I’m very sorry to hear about your recent diagnosis. Finding out you have HIV is never easy but finding out you had cancer at the same time must have been very difficult. Do you have any support to help you during this stressful period?

Unfortunately there is no evidence that increasing your CD4 count will extend the period that your cancer stays in remission (especially following second line chemotherapy). The recovery of CD4 count after chemotherapy helps with reducing the risk of opportunistic infections and new AIDS defining malignancies. But it doesn’t mean the cancer won’t come back.

The evidence for autologous stem cell transplants in second remission of plasmablastic lymphoma does not exist, it just seems like a sensible idea. Most clinicians would suggest that second-line treatment for relapsed aggressive NHL in the general population should be with induction chemotherapy followed by high dose chemotherapy and autologous stem cell transplantation (if the induction chemotherapy works).

In your situation the induction chemotherapy was used to shrink down the relapsed lymphoma as much as possible. The high dose chemotherapy with stem cell transplant would be used to try to eradicate and remaining often microscopic lymphoma. If only the induction chemotherapy is used then it is not much more that the first line treatment really and we know that the first line treatment was insufficient to cure the lymphoma. The absence of active residual disease on scans does not mean that there is no need for the high dose chemotherapy and stem cell transplant.

This is a difficult area and to answer your question I consulted a UK specialist in HIV related cancers. The information he gave me suggests that the treatment your doctors have suggested is the same as would be offered in the UK. It’s important that you talk through your concerns with your doctors though. With their help you can weigh up the pros and cons of going ahead with (or avoiding) this treatment.

Further information about non-Hodgkin’s lymphoma:

Macmillan Cancer Support

I-Base side effects guide

4 comments

  1. Roy Trevelion

    Hi Gibson,

    Unfortunately i-Base doesn’t have resources to answer more questions on transmission and testing. But all these FAQs are answered at this link.

  2. Gibson

    I had been having unprotected sex with a girl who was HIV positive without my knowledge but the girl was on arvs,,,,after a while she revealed to me that she was positive and had stopped taking medication 4 months ago,,taking this obviously that I was positive, I kept on having unprotected sex with he for 2 months where I went to have and HIV test and my results were negative,,, after a while I started having achy muscles and joint pains does that mean that am positive?

  3. Rebecca McDowall

    Thanks for your email. I’m very glad to hear from you again, but I’m sorry to hear that you are having a difficult time.

    I have contacted an HIV oncology specialist at London’s Chelsea and Westminster hospital. He is the same doctor that I consulted in answering your previous question.

    Mark has assured me that it is normal for platelets to take longer to engraft than white cells. He has alsp said that for more patients whose white cells recover their platelets will also recover with time. Whilst patents are recovering it is normal to be treated with platelet transfusions if the levels drop below 10, but the risk of bleeding is pretty low when platelet levels are over 10. Proffessor Bower’s advice to a patient in your situation would be to sit tight, and continue with this treatment.

    Of course it’s up to you to decide how to go forward. It’s important to discuss your concerns with your doctors and make sure they keep you informed about your treatment.

  4. dion

    Hi Rebecca,
    Thank you very much for your help.I have decided to go on with the stem cell transplant,and was just released from hospital before christmas.Though I engrafted white blood cells and red blood cells,I still do not engraft platelets,which gives me great concern.My conditioning regimen included 350 Grey of total body irridation and 5000mg of cyclophosphimide.I receive a unit of platelets twice a week at the hospital.The doctors say I should not not be concerned,it can take up to 2 months to engraft platelets,but I am not so sure if they tell the truth.I received my own stem cells,2.7 million,on the 3rd december.my white cell count is about 1.5.Red cell about 3 and hemoglobin 7.6.My question is,what should I do ? Should I wait for platelet engraftment,or consider a allogenic transplant ? Every time I visit hospital my platelet count is 11 or 10.and after 12 hours after platelet transfusion about 40.should I prepare myself for death ? I can’t receive platelets forever,and what other options do I have.The doctors tell me all the time because I have HIV my stem cells are not the best,and because I used Plerixafor as a G-CSF,I should expect poor results,but was not told that before the transplant.I feel I killed myself with this transplant ! Please tell me what options I have,or should I prepare for the worst ?

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