Professor, Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center
How is T-cell lymphoma diagnosed?
A T-cell lymphoma diagnosis requires a tissue biopsy, which would typically be taken from a lymph node or another site. Special stains are used on the tissue samples to further diagnose the type of lymphoma. There are many different types of non-Hodgkin lymphoma. About 15 percent of non-Hodgkin lymphomas in the United States are T-cell lymphomas. These T-cell lymphomas are identified by how they look under a microscope and their reaction to special stains used on the tissue to obtain the diagnosis.
Can you describe some of the different subtypes of T-cell lymphoma?
There are many different subtypes of T-cell lymphoma. In general, they are broken down into those that occur in the lymph nodes, blood, bone marrow, or in extranodal sites. Some can be very slow growing (indolent) such as some types of skin lymphomas, while other types of T-cell lymphomas that occur in the lymph nodes or organs are very fast growing (aggressive). So, there is a wide variety of different subtypes of T-cell lymphomas.
What is the most common subtype?
The most common subtype of T-cell lymphoma is called peripheral T-cell lymphoma not otherwise specified, which is the type most frequently seen in the clinic. It is possible that there are several different subtypes within that category, but we do not have enough information at this point to know what all of them are. Additionally there is anaplastic large cell lymphoma (ALCL), angioimmunoblastic lymphoma, cutaneous T-cell lymphoma (CTCL) and a host of less common subtypes.
Is there anything in the symptoms or presentation of the patient that would make you suspect T-cell versus B-cell lymphoma?
T-cell lymphoma is usually found in certain locations such as the skin (CTCL), but it can also be found in any of the other normal sites, as well as in the lymph nodes and organs. As such, the lymphoma type cannot be clearly identified by its symptoms or presentation alone but must be based on a tissue biopsy.
What are some of the available treatment options for T-cell Lymphomas?
Treatments for T-cell lymphoma are based upon each different subtype, the stage and location of the lymphoma, and the age and overall health of the patient. Typically, more aggressive lymphomas are treated with a combination of different types of chemotherapy and perhaps stem cell transplantation. For the more indolent or slow-growing types of T-cell lymphoma, treatment may include radiation therapy or some other types of oral chemotherapy or topical therapy. There is a wide variety of treatment options based upon each patient's specific diagnosis.
Are there any targeted therapies used to treat T-cell lymphoma?
Histone deacetylase (HDAC) inhibitors are targeted therapies used for treating some T-cell lymphomas. There are some other newer targeted agents that inhibit other pathways that we are attempting to study in T-cell lymphoma. However, many of them are still in clinical trials are and being developed.
Are there any targeted therapies that you are particularly excited about?
I think therapies that target the HDAC pathway in conjunction with other drugs targeting other pathways, such as the NF-B pathway, are encouraging. A combination of different drugs targeting different pathways is probably going to be the way forward with this and other lymphomas.
When would stem cell transplantation be considered?
Typically, stem cell transplantation is used for relapsed (the disease returns) aggressive T-cell lymphoma, such as peripheral T-cell lymphoma not otherwise specified or angioimmunoblastic T-cell lymphoma. In these cases, an autologous (when the patient is his or her own donor) stem cell transplant is usually performed. Sometimes a stem cell transplant is used as an aggressive treatment for a younger patient's initial therapy. For relapsed T-cell lymphoma, an allogeneic (someone besides the patient is the donor) stem cell transplant is sometimes used, but this is mostly for aggressive subtypes. Stem cell transplants are not typically used for patients with more indolent T-cell lymphoma subtypes, but there is always an exception such as in a younger patient. So, the decision for stem cell transplantation is really tailored to each individual patient and his/her specific diagnosis.
What are some of the advantages of patients participating in a clinical trial?
One advantage is that patients in clinical trials typically get access to newer drugs that would normally be inaccessible to patients for several years. Additionally, patients are usually monitored much more carefully in clinical trials than patients undergoing standard treatment, so they may be provided with more thorough checkups and follow-ups.
Potential disadvantages are the side effects that patients may experience from some of the new drugs where the outcomes are unknown at the time they are being tested. However, clinical trials are typically only conducted in cases where standard treatment has not worked or where there is enough information available about the drug to test it in patients at earlier stages of their disease.
How did you become involved with the Lymphoma Research Foundation, and why would you recommend that patients become involved with the organization?
Over my 25 years of experience in treating patients with lymphoma, I have been involved with many different societies and advocacy groups to try to help patients acquire new treatments and information. I have been a member of the Lymphoma Research Foundation's (LRF) Scientific Advisory Board for many years and helped with some of their educational conferences for both patients and physicians. In my experience, LRF is a wonderful organization. They provide excellent educational programs for patients and personal support when possible, offering education and information about clinical trials, new drugs, and general disease information. I think LRF is a great organization, and I am so glad to support it. I encourage patients with lymphoma to find out more about LRF and the many ways they can provide support and assistance.
Is there anything else that you feel is important for patients with T-cell lymphoma to know?
Patients should ensure they have the right diagnosis and treatment plan. Whenever possible I think it is important for patients to get a second opinion about their pathology, and perhaps about their treatment, because this is a very rare type of lymphoma. Patients should ask their doctor how often he or she has treated that particular type of lymphoma and ensure that the pathology report is sent out so they have the correct diagnosis.
How would a patient go about getting a second opinion?
If patients want a second opinion about their pathology report, they can request it through their oncologist. They can tell their doctor that they want a second opinion on their pathology reviewed by a specialized hematopathologist who specializes in lymphoma, which is then requested from where the biopsy was performed. Additionally, if a patient goes to another university or somewhere else for a second opinion, they automatically get a second opinion on their pathology because it is reviewed at each location. So, this would be a way for patients to receive a second opinion about both their diagnosis and pathology report at the same time.