The FACS of Life

You knew it was only a matter of time before I had to use that corny title for a blogpost, but bear with me, it follows a coherent theme.

Other candidate titles for this post included:
      Dirty Hairy
      From Hairy to Eternity
      The Good, The Bad, and The Hairy
      Gone Today, Hairy Tomorrow
      The Cells that Wouldn't Die
      Protocol
      and Hair We Go Again

Simply put: you take the good, you take the bad, you take 'em both and there you have the FACS of life...

The Good:  The Rituxan treatments worked really well and as I wrote in my last post, the hairy cell burden in my May bone marrow biopsy was zero (although the bone marrow aspirate [liquid] showed 2.1% hairies).  Likewise, I just had a complete blood count last week and my counts are at historical highs since diagnosis, so my marrow is continuing to rebound and keep me healthy.

The Bad:  My FACS results from last week showed some hairies in the peripheral bloodstream (.02% of the peripheral blood monoclonal cells), but there are several reasons for why that may be.

The Theories:
     #1: It's very possible that the few hairies which were bound with Rituxan but not completely killed via apoptosis or immune system attack, were undetectable in prior FACS tests due to the effects of the Rituxan covering the surface.  Now that the Rituxan is flushing out of my system and coming unbound from the hairies, those cells are once again detectable.
     #2:  The cancer that wasn't killed by the Rituxan (some of the cells in the aspirate) are starting to proliferate again and seep into my peripheral bloodstream.

The analysis:
     Usually the simple answer is the correct one (unfortunately #2 is the simplest), but we are sailing in uncharted territory right now, and there is plenty of time to perform more tests over the coming months and really get a feel for what is going on.  Theory #1 is highly optimistic but still plausible, and it's still very possible that as my marrow rebuilds, my immune system will either keep the remaining HCL in-check or attack and destroy it.  Time will tell.

What's next:
     Given how well Rituxan worked the first time considering my HCL burden after Cladribine chemotherapy was still substantial, I believe I would benefit from a second round of Rituxan treatments if they are offered to me.  The possibility of adapting the protocol accordingly for my cohort is being considered (the simultaneous chemo/Rituxan cohort is allowed two rounds of Rituxan, but my delayed Rituxan cohort is currently allowed only one).
    In the meantime, I'm interested in seeing how my body will respond to the remaining hairies and feel that doing some more FACS tests to see if the burden increases or becomes undetectable again will help to substantiate or disprove theory #1.  Over the next few months, we'll run some more FACS tests and see what happens.  Let's hope my immune system kicks it.

Here's a slide show of my latest blood count results:

Since my last post in May, I've really been enjoying life.  Taking lots of time to be with the family, a trip up to Hershey Park, and enjoying the weekends when the heat or rain doesn't make that impossible.  It's been an incredibly happy time and given that the blood counts are continuing to improve, I really don't care about the few cells that were found in the peripheral bloodstream.

I should have another FACS in 4 to 6 weeks.  I'll let you know how it goes.

Moving the Rock.

The rock has moved!

I received my bone marrow biopsy results yesterday.  They read as follows: "No morphologic or immunohistologic evidence of residual hairy cell leukemia."  In other words, negative for hairy cell.  You may recall that the bone marrow infiltration in late October was still 30% six months after Cladribine chemotherapy treatment, just before receiving Rituxan.  The NIH Clinical Trial for new patients combining Cladribine and Rituxan has done a great job!  Excellent news to end one of the most awesome weeks of my life.

The only thing that can put a bigger smile on my face is this:

My daughters

My peripheral blood FACS was also negative for HCL.  The FACS for the  bone marrow aspirate is still positive for HCL (dropped from 4% in late October to 2.1% last week), but the CD20 absolute binding tests show a dramatic decrease in the binding capacity (dropped from a capacity of 80,000 molecules of Rituxan to 8000) because a large amount of Rituxan is now already bound to the existing CD20 proteins on the cells now that I've received Rituxan treatments.  This means it may still be working.  CD20 proteins are overexpressed on the outside of the hairy cells, and Rituxan binds to those proteins then kills the hairy cells.  A significant amount of the cells may continue to die over the next six months, and there is a possibility that the bone marrow aspirate will also test negative six months from now.

I am now in complete remission !!!

New Arrival!!!

I'm proud to announce the arrival of our second child.
She arrived today, 5/13/2010

Weight:  9 lbs, 8.3 oz.
Height:  21"
Ingredients: lots and lots of sugar, spice and everything nice.

Baby, Mommy, Daddy and her big sister are all happy and healthy!!!

Our new baby girl!

Benefits of NIH Hairy Cell Leukemia Trial Participation

I've read a lot of bulletin board posts with various insights regarding participation in the NIH Trial for Newly Diagnosed HCL Patients so since I'm participating in the trial, I thought I'd offer my own.

While I have the advantage of living close to NIH, I've been in touch with many patients who have had to deal with the logistics of participating in the trial from all over the country.  Here are many of the trades people make when considering trial participation:

Trade #1:  Can I afford to travel to or stay at NIH for 8 weeks of Rituxan treatments?
         Fact: You don't have to.  Rituxan can be administered by your local doctor.  You only need to travel/stay at NIH for the first week of chemotherapy treatment.  NIH will send the Rituxan to your local doctor and coordinate the administration free of charge.

Trade #2:  My local oncologist can provide the Cladribine and Rituxan combination, so there's no need to participate in the trial.
         Fact: While local administration of the Cladribine/Rituxan combination is becoming more common,  most insurance will only cover the cost of 4 weeks of Rituxan.  By participating in the NIH trial, you'll receive up to 16 weeks (2 cycles at least 6 months apart with 8 weekly rounds per cycle) of Rituxan free of charge.  Most insurance companies view the free NIH-provided Rituxan and expected increase in remission as a major cost-savings and will cover the entire cost of local Rituxan administration (local Dr. time and facilities costs).  Since Rituxan effectivity is dependent on the size/radius of the remaining clumps of hairies, long-lasting remission and eradication is much more likely with 8 cycles per treatment than with 4.  Independent adminstration of Rituxan without monitoring minimal residual disease (MRD) in a clinical trial setting does not provide an effective means of treating the disease.  Once the trial is completed,  local oncologists will be provided with the most effective combination therapy treatment.
      
Trade #3:  The trial doesn't provide any major advantage.
          Fact:  Prior trials in Italy combining Rituxan and Cladribine resulted in a significant increase in complete remissions and elimination of minimal residual disease (MRD).  It is believed that this may increase the duration of remission, which is being studied by the NIH trial.  The NIH hyper-sensitive MRD test is able to detect 1 hairy in 1 million mononuclear cells -- 100 times more sensitive than a standard FACS.  This is a significant advantage -- allowing Rituxan to be administered at a point when it will be most effective.  This also means that Rituxan will only be administered if it is necessary.  Only NIH can perform this test!
                    Whereas most doctors aren't proactive in following their patients and wait until blood counts   indicate the need for re-treatment, Dr. Kreitman will actively study your progress and treat the earliest signs of MRD, which may possibly increase the duration of your remission (one of the hypothetical effects being studied).

Trade #4:  There are risks associated with Rituxan.  Cladribine is highly effective in most patients, so I'll do that for now and only take Rituxan later if it becomes necessary.
          Fact:  Data indicate that 40% of patients relapse after only 10 years of single-drug chemotherapy.  To prevent significant bone marrow suppression, it's desired to limit a patient to two treatments of purine analogue chemotherapy (Cladribine or Pentostatin).  The prevailing theory is that Rituxan is most effective when used in conjunction with a purine analogue so that the clumps of hairies are unclumped/diffused prior to administering it (being studied by the trial).  This allows Rituxan to destroy the individual hairy cells immediately instead of slowly peeling the outer layers of the hairy clumps (resulting in a direct additive effect vs. a percentage of the remaining load).  Don't lose this advantage by deferring Rituxan treatments until after chemotherapy is no longer viable.  One look at my ANC plots (see prior posts), and you can see I owe my overall strong response to the Cladribine/Rituxan combination.

Trade #5:  I can't afford to travel to NIH.
        Fact:  A lot first-time patients deal with the cost/benefit trade-off of travel to NIH, and rightly so.  Once accepted into the trial, NIH will cover the costs of all subsequent travel for the patient (spouses and children are not covered).  Angel Flight and the Air Charity Network offer flights to patients in financial need.

Trade #6: I can't afford accommodations while at NIH.
       Once admitted to the trial, NIH will provide free accommodations through their in-patient hospital.  While qualifying for the trial, you may need to spend two nights at a local hotel.   Current rates for the Bethesda Marriott are approximately $139/night.  You'll find that the current commercial rates are often better than the NIH negotiated rates, so ask for both.

The best way to make a fully informed decision is to gather as much information as possible.  Dr. Kreitman is always available and will quickly respond to your questions.  Email him at kreitmar@mail.nih.gov.

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Turbulence

The approach for my soft landing has been suddenly interrupted by some unexpected turbulence. I had a CBC and FACS performed on Monday. For the most part, my counts were good, but as shown in the plot below, the one exception was a doozy -- my absolute neutrophil count dropped dramatically from 1.97 two weeks ago to .81 on Monday. This sudden drop definitely had me concerned, but to my relief the other counts are still good -- the lymphocyte level remained steady, my platelets increased slightly and my liver enzyme levels are now well within the normal range.

My FACS results came in on Thursday and were still negative -- no detectable hairies in the peripheral bloodstream.  Everything else is good, but the neutrophils have dropped suddenly about 14 weeks after my last Rituxan treatment (12/28/09).  What's going on?  The initial direction from Dr. K is to wait until my marrow biopsy on May 10th to evaluate the marrow function, but after some more investigation, my best guess is that I've experienced a side-effect of Rituxan known as Rituxan related late onset  neutropenia (RRLON). 

A cursory evaluation of the available research papers on RRLON indicates that in a lymphoma study in which patients were treated with both chemo and Rituxan, 23 of 107 patients experienced some form of RRLON.  The typical median ANC nadir point was .61, and required 4 weeks to recover.  I've asked Dr. K for his opinion and a response is pending.  In my opinion, another CBC by next Wednesday would make sense to quantify the nadir and determine whether I'm still on the downturn or moving toward recovery.

I'll keep you posted.
BTW:  here's an interesting article regarding the health care debate ;)

Update:
Just had another CBC today (4/29) per my request, and the news is good!  The late-onset neutropenia (LON) has resolved and all my counts are in great shape (except the platelets).  I'm very confident that this was a Rituxan-related event and pleased that my neutrophil level is now well within the normal range.  As you can see in the ANC plot below, the neutrophil level is almost close to the peak level since I've started collecting CBC data.  Even better, my WBC is the highest it's been in years considering that prior to treatment a large percentage of the WBC consisted of hairy cells.  I'm very happy!!!

Soft Landing

I just had another complete blood count (CBC) on Monday and things look like they're stabilizing. The platelets are still low but within a normal range for remission and since they're stable, I'm happy. I was hoping the neutrophils would increase, but they're still in a normal range although they went down slightly over the past month. As you can see in the plots below, my counts have pretty much come in for a soft landing, and stability in the normal range is a good thing.

Following up on the liver enzymes: they're slightly back up over the normal limits, so I don't think the chamomile tea was a major contributor. I ate some foods with wheat and walnut ingredients a few days before the test (birthday and wedding celebrations), so that may have something to do with it. A fatty liver can cause gluten intolerance and low platelets due to decreased production of thrombopoietin, so I may still be fighting some fatty liver issues.

The weather last weekend was great! I got out and rode my bike 22 miles on the C&O Canal on Sunday. I'm anxious to push for 40 next weekend!

A Hairy Update

The past two months have been great! The February snowpocalypse gave me an opportunity to test my stamina shoveling and snowblowing, and I felt great afterward. I even shoveled out my neighbor's driveway. My FACS tests continue to show 0% hairy cells in the peripheral blood stream, and I'm still waiting for my next bone marrow biopsy in April to see if all evidence of hairies in the marrow has disappeared. I think it has. The Rituxan after the chemo really did the trick.

I continue to limit gluten in my diet and have stopped drinking herbal tea (specifically chamomile). Correspondingly, my liver enzyme levels returned to normal on my last blood test in February. I'm very interested in seeing if they continue to stay down when I go back in on the 22nd, now that I've stopped the tea. Interestingly, my platelets and neutrophils also came down a bit after stopping the chamomile, which is anecdotally tied to increasing neutrophils, but all my counts are still in the normal range.

I'm anxious to start riding my bike along the C&O canal again. Yesterday, I rode 20 miles in an hour using the "Pike's peak" profile at the maximum resistance level on my exercise bike. I would never have been able to do that level of resistance at any time before in my life. I really think I had HCL (and some other issues) "in-check" and undiagnosed for a long time before being diagnosed. I'm anxious to get outside and see what I can do now that it's warming up.

Life is definitely more normal now, although I'm not sure that's necessarily good. I spend a lot less time researching HCL. Still, I try to keep up with the latest news. For those who are interested, here's a link to a hairy cell video lecture by Dr. Kreitman, "Updates on Therapies for Hairy Cell Leukemia", on the current state-of-the-art of HCL research.



We had a 4D sonogram of baby girl #2 on the 7th (Cladribine did not reduce my fertility and may have improved it by eliminating the effects of chronic leukemia).  She was very shy and wanted to bury her head from view but we got several good peeks, and she looks a lot like her big sister. We're very excited to meet her in person in May.

Next Friday, the 19th, is my birthday and coincidentally the day my sister Elena is getting married. It'll be a great celebration with the family, and Claire is excited to be a flower girl with her cousin Olive. The next day, Saturday the 20th, marks 1 year since my diagnosis. I'm grateful to be celebrating it.

My latest labs look good. I'm going back in on the 22nd for another set, so I'll probably update the charts and publish them here when I get that data.