Is Bone Marrow Biopsy necessary to diagnose Hodgkin Lymphoma

We like to thank Dr Isabel Cunningham, MD for this timely notes. This is something worth knowing and relevant if you are about to undergo a Bone Marrow Biopsy for Lymphoma. No copyright violation is intended.

"Routine Bone Marrow Biopsy Has Little or No Therapeutic Consequence for Positron Emission Tomography/Computed Tomography-Staged Treatment-Naive Patients With Hodgkin Lymphoma".

J Clin Oncol. 2012 Nov 13;[Epub Ahead of Print], TC El-Galaly, F d’Amore, KJ Mylam, et al

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In a retrospective study of 454 patients with newly diagnosed Hodgkin’s disease, bone marrow biopsy did not change the treatment recommendation in any case. It may be argued that this test is now obsolete in Hodgkin lymphoma.


EXPERT COMMENTARY

Isabel Cunningham. MD

Good-bye to Marrow Biopsy in Diagnosing Hodgkin's? This careful study approached and answered a question that the era of advanced technology has brought to the clinician: why am I biopsying the marrow of this new patient?

In settings where PET/CT is available, the ability of this technique to accurately stage Hodgkin's was demonstrated in a cohort of 454 patients after verifying positive areas with biopsies.This work may result in an update in NCCN guidelines, and will be welcomed by patients and physicians 

SUMMARY
OncologySTAT Editorial Team

Accurate pretherapeutic disease staging is essential for the management of Hodgkin’s lymphoma (HL) because therapy differs dramatically for advanced-stage and early-stage disease.

The current Ann Arbor staging system for HL restricts routine bone marrow biopsy (BMB) to those with CT-assessed stage III/IV disease or stage II with adverse factors, and only if a positive BMB would change the planned therapy. Yet many facilities continue to include BMB in their routine staging workup of all newly diagnosed HL patients. Such a workup commonly includes whole-body [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT.

Danish researchers explored the value of BMB in patients with HL who underwent both pretherapy BMB and PET/CT staging. The cohort included patients from the Danish Lymphoma Registry whose pretherapy staging was performed at one of four Danish hematology centers from 2006 to 2011.

The 454 eligible patients included 27 (6%) with a positive BMB. A total of 106 patients (23%) had abnormal PET scans: 82 (18%) had focal skeletal lesions (20 unifocal, 10 bifocal, and 52 multifocal), and 24 had diffusely homogeneous FDG uptake involving most of the axial skeleton.

PET/CT scans found focal skeletal lesions in 23 (85%) of the 27 BMB-positive patients. Among the 427 BMB-negative patients, 59 had focal skeletal lesions and possible bone or BM disease detected by PET/CT. BMBs were negative in all 24 patients with diffusely homogeneous skeletal FDG uptake.

Of the 27 BMB-positive patients, 5 were upstaged from stage III to stage IV (the other 22 had already been diagnosed with stage IV disease by PET/CT). BMB was negative in all patients with stage I/II disease as assessed by PET/CT.

Focal skeletal PET/CT lesions identified positive and negative BMB with a sensitivity and specificity of 85% and 86%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) of PET/CT for detection of positive BMB were 28% and 99%, respectively. The low PPV probably reflects the large number of false-negative BMB results due to sampling errors rather than a large number of false-positive PET/CT tests.

If both PET/CT lesions and positive BMB were considered separately sufficient to detect true bone/BM disease, PET/CT proved significantly better than BMB, with a sensitivity of 95% vs 31% for BMB, and overall diagnostic accuracy of 99% vs 87% for BMB.

The results showed minimal added diagnostic value from routine BMB. PET/CT staging not only identified patients with HL who had a positive BMB but also found suspicious bone/BM lesions in several patients with negative BMB. The high negative predictive value of 99% makes PET/CT a reliable method for identifying patients who are unlikely to benefit from BMB. Importantly, none of the 454 study patients would have been assigned another treatment based on BMB results.

I found these protocol is a good option if you are searching treatment of NHL and HL. Something simple and possible. The use of dichloroacetate (DCA).

Here is an article from Hindawi Publishing Corporation at their Journal Of Oncology.

"DCA is a by-product of water chlorination [6, 7] that inhibits aerobic glycolysis. It has been used in medicine for over 30 years [8] as an investigational drug to treat severe metabolic disorders such as diabetes and hypercholesterolemia [5, 9] as well as the treatment of congenital lactic acidosis in North American children [10]. 

The bioavailability [11] and pharmacokinetics [12] of DCA have been well researched over several decades in adults [6], children [13, 14], and animals [15]. 

As a medicinal, DCA is generally well tolerated from dosages between 10 mg/Kg and 50 mg/Kg, although prolonged exposure is associated with peripheral neuropathy [16]. 

Its activation of the pyruvate dehydrogenase enzyme (PDH) of the mitochondria decreases glycolysis and reactivates glucose oxidation, a favorable approach to ameliorate lactic acidosis [9].

DCA therapy is also available at Medicor Cancer Centre in Canada.
(Do not miss these latest data on DCA therapy)
Additional positive outcome using DCA.

Other forms of treatment can be view by clicking on the image below.

Thank you for reading.
Good health is a habit.