Cancer happens when the immune system is weak and the proliferation rate of certain cell type accelerates and remains unchecked. By the time a tumour is discovered, it has already started to metastasized to other parts of the body (stage 4). One good example of this type of cancer is follicular lymphoma.
The immune system is the body's defense system to thrash out pathogens (bacteria, fungus and viruses) when they come into contact with the body. These pathogens can enter the body in many ways. Dirty contaminated hands and feet, catching someone else's sneezes and coughs, use of contaminated articles of a sick person, etc can cause human to contract pathogens.
There are times when the immune system is good and strong. And there are times when the immune system is a bit weaker and not at its best. When the immune system is weak, changes in the cells, tissues and organs are not cleared or corrected, and cancerous growth go unchecked.
Keywords: B cell, non-Hodgkin lymphoma (NHL), follicular lymphoma, lymphoma. lymph
What is blood cancer?
Huffington Post, UK: Blood cancer
Blood cancer:
- is an umbrella term
- is a group of cancers that affect the blood, bone marrow and lymphatic system
- there are 137 types (eg: leukaemia, lymphoma, multiple myeloma)
- they are often diagnosed late
- late diagnosis affects a patient's survival (life span)
- blood cancer rate: 1 in 25 persons in UK (4%)
- how common is blood cancer? 5th most commonly diagnosed cancer in UK
What is lymph? What is the lymphatic system? What are lymph nodes?
Wikipedia: Lymph
Lymph capillaries in the tissue spaces.
Uploaded: 13 June 2006
The lymphatic system comprises
- lymphatic tissue (found in the stomach, bowel, eye and thyroid gland)
- white blood cells (called lymphocytes)
- lymphatic organs (such as the bone marrow, tonsils, thymus, testicles, spleen and lymph nodes).
What is a lymphocyte? What is a B cell?
Wikipedia: B cell
What is lymphoma? What is Non-Hodgkin Lymphoma (NHL)?
CDC: Lymphoma, Non-Hodgkin Lymphoma, Causes, Symptoms
St Baldrick's Foundation, UK: Non-Hodgkin Lymphoma
Lymphoma is a type of cancer that affects the lymph glands or other organs in the lymphatic system. There are different types of lymphoma. The 2 main types are:
- Hodgkin lymphoma (a cancer of a type of white blood cell called lymphocytes)
- non Hodgkin lymphoma (NHL) (a cancer of the lymphatic system).
What are the causes of lymphoma?
CDC: Lymphoma, Non-Hodgkin Lymphoma, Causes, Symptoms
The cause of lymphoma is unknown. It develops because of changes in the genes of a lymphocyte. These changes affect how the cell grows and divides, or prevent it from dying when it normally should. Thus, the cancer cell lives on without ever dying.
What are the symptoms of lymphoma?
Cancer has symptoms. Symptoms in lymphoma can be apparent or not. Patients may experience some of the following:
- weight changes (rapid weight loss over a short time, losing a lot of weight, eg losing 15 kg in 2 weeks)
- appetite changes (refusing normal meals and usual food)
- heavy sweating (night sweats, profuse sweating at night, pillows and bedsheet are drenched)
- fever (extremely high fever overnight for a week),
- tiredness, fatigue (not much energy to get up except to lie down and continue sleeping)
- restlessness, blank mind, unthinking
- swollen lymph nodes (here and there, off and on, painful or painless, varying sizes, ballotable, at groin, upper arm and neck),
- feeling funny in the groin and armpit due to swollen lymph nodes
- legs affected (walk funny, limping, cannot lift up one leg fully)
- weird looking neck and upper arm (where lymph nodes are swollen and are visible)
- difficulty swallowing (when trying to drink or eat something because the swollen lymph nodes are blocking and pressing on the blood vessels and nerves in the throat and neck)
- more noticeable lymph nodes (feeling the lymph nodes are increasing in number with time)
- more lymph nodes detected (progressing upwards towards the neck and head region)
- large swollen lymph nodes in the neck or encircling the neck
- difficulty breathing, shortness of breath (SOB) or feeling breathless (the swollen lymph nodes have spread to the lungs and neck region and can block the oesophagus and trachea
- infected lymph nodes (bacteria survive in the swollen lymph nodes which are difficult to treat)
- skin changes (worsening itchy skin, will not disappear with calamine lotion, nothing seems to reduce the skin itch)
- irritating dry coughing to clear the throat (when trying to remove smelly pus from the swollen or enlarged tonsils)
- abdominal pain (constant abdominal pain after food intake, lump in the abdomen)
- food cannot go down normally (need to push food down, can only eat minimally)
- bloatedness (constantly feeling bloated but not burping)
- discomfort when seated (due to large abdomen because of enlarged liver or spleen)
- headaches (if lymphoma starts in the brain or cannot fart)
- difficulty thinking
- difficulty moving limbs and body parts (legs, arms, and neck)
- changes in personality and moods (due to dissatisfaction, frustration, unhappiness and depression, inability to do much physical activities as before cancer)
- seizures
What is follicular lymphoma?
Librae: Follicular lymphoma, Causes, Symptoms, Treatment
Micrograph showing a small B-cell lymphoma compatible with follicular lymphoma. H&E stain. Related images FL - very low mag. FL - low mag. FL - intermed. mag. FL - high mag. FL - very high mag. FL - BCL2 - low mag. FL - BCL2 control - low mag. Uploaded: 12 May 2014. Wikipedia image by Nephron - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=32752068
What happens in follicular lymphoma?
Some cells of the immune system can proliferate voraciously and become massive. The patient ends up with a big hard abdomen. Some cancer grows a bit more slowly but given time, it too can become massive, and give a big hard abdomen.
When a cancerous growth becomes massive, it can occupy all available spaces in the abdomen, pushing on nearby organs and blood vessels away from their normal orientation and location.
This means, the major aorta that supplies the legs can be occluded and there is no blood supply to the legs ... walking can become arrested.
The diaphragm is pushed upwards by the massive cancerous growth, and disrupts lymphatic flow ... causing backflow and unequal build up of lymph in the pleural spaces of both lungs.
How is pleural fluid drained?
The lungs can easily get filled with a litre of lymph exudate each pleural space per 8 hours collection. Lymph is drained from the pleural space by a tube. The tube is of 2 types:
- Pigtail tube (8 months) with collection canister, and
- Intraperitoneal catheter (IPC), also called chest tube (7 months) with urine bag for collection of pleural fluid.
What is a pigtail?
Initially because of the large volume of lymph that must be drained daily every 8 hours, a pigtail is installed by the Interventional Radiology (IR) Unit, under local anaesthesia and takes 15-20 minutes. This is a very painful procedure. The initial lymph drained in bloody and then becomes milky, then clear amber with time. The pigtail is left in use for about 8 months. The exit port can hurt extremely painful. Bandage must be replaced daily.
What is IPC?
Once the fluid in the pleural spaces has reduced, another type of tube is used. This is the IPC or chest tube. It is installed in the ward treatment room by the Chest Specialist and her team (about 5 people). The chest tube is left in place for a few months (7 months) till the pleural fluid is reduced to less than 50 ml overnight.
When and how is the chest tube removed?
When the pleural fluid is much reduced (less than 50 ml overnight), the chest tube is then removed surgically in the treatment room. It is removed by pulling it out quickly and strongly ... the patient feels a shocking vacuum. The incision is then stitched with 8 stitches for complicated removal where the tissues have attached to the chest tube. Chest tube removal is 20 minutes in a simple removal. However, a complicated chest tube removal may take up to an hour.
How do you care for the incision site after chest tube/IPC removal?
A light bandage with waterproof cover is applied to protect the stitches. This bandage is replaced daily for a week or two. Then daily cleaning without bandage should suffice.
What is a keloid?
Keloid will develop in some cases. The scar is itchy and painful even at 8 months post-op when sweat accumulates and soak the scar.
Healthcool.com: Keloid
What is pleural effusion? What is the difference between Transudate vs. Exudate?
Wordpress: Pleural effusion
What is chylothorax?
NCBI: Chylothorax
ResearchGate: Chylothorax
Health Jade: Chylothorax
Wikipedia: Chylothorax
Chest X-ray showing bilateral chylothorax.
Created: 1 January 2015
Pleural fluid removed from the chest of a person with a chylothorax.
Created: 16 November 2013
What are tumour markers? What investigations are done (for chylothorax) for cancer diagnosis?
Orchid: Investigations in penile cancer (men)
Integrated Health Clinic: Cancer-focused laboratory-testing
How does cancer spread? What is metastasis?
Health Jade: Metastasis
What were the difficulties of cancer diagnosis and complications of cancer?
This particular cancer was not detected at first until much later. It presented as a renal problem (hyperkalaemia). Correcting and investigating Hyperkalaemia resulted in an accidental finding of massive growth in ultrasound of the abdomen. A CXR was performed for SOB. A CT guided biopsy was performed and revealed Follicular lymphoma. The accumulated pleural fluid was drained from both lung, major from right lung. Pigtail was installed 4x for 8 months. Then IPC was installed for 7 months. IPC was removed after minimal pleural fluid remained in the right lung. The pleural fluid was less in the left lung and was drained only once using pigtail. CA 19-9 for ovarian cancer was suspected but was negative. Chemotherapy with dual monoclonal antibodies was performed for 6 cycles at 28 days apart. CT-NATP was done after every 3 chemo sessions. Stimulating growth factor was given after 4 days starting each chemo. The abdominal mass was partially reduced after 6 chemo cycles. Maintenance chemo with Rituximab was continued (for an additional 2 years at 2 months apart).
Treatment depends on:
- type and stage of cancer
- health of patient
- patient's will power to survive cancer
- faith in treatment modes
- consent
Treatment modes and drugs will depend on type and stage of cancer, patient's immunity, affordability and consent. There are a few treatment modes available (as of 16 December 2021):
- Chemotherapy (using monoclonal antibodies: 1. Rituximab (Ritu) and 2. Bendamustine (Benda))
- Radiotherapy (using tagged radioisotopes)
- Steroids
- Biological drugs (proteins which affect functions of the cancer cells and control cancerous growth)
- Stem cell (homologous stem cells are obtained by harvesting patient's own blood for stem cells)
- Bone marrow transplant (BMT)
- Microencapsulation (in future; based on research at ISS, NASA)
* * *
Case #1
This is a case of a 62 year-old Malay lady presenting with renal problems at the Urology Clinic, Hospital USM at Kubang Kerian, Kelantan, Malaysia. She had hydroureter, hyperkalaemia, hypertension, and later chylothorax and follicular lymphoma were diagnosed and all were treated.
Early 2019
- 15 January 2019, 3.30 pm, CXR at Radiology (old A&E): CXR clear. No pleural effusion. No focal lesion.
Late 2019
- 1 December 2019, Radiology: U/S Abdomen: Mild hydroureter, AAA
- 5 December 2019, Urology Clinic: Dr Hafizi?
- 15 December 2019, Vascular Clinic: Dr Faisol
- 16 December 2019, 8TD Dahlia: Dr A. Firdaus Lutfi (Vascular) called to admit for urgent CT scan. Take blood for RFT and CA 19-9 by Dr A. Firdaus Lutfi (Vascular). O/N fast (2 am-2 pm) for CT scan at 2 pm. Discharged home at 5.30 pm.
- 17 December 2019, 8TD Anggerik: Cancelled CT scan for today. Paid RM75 for Gribbles CA 19-9 RIA test. To do URS tomorrow - to insert stent tomorrow under GA. Weight = 65 kg.
- 18 December 2019, 8TD Anggerik: Surgery URS @ HUSM. URS stent by Urology, Mr Ashraf & Mr Hafizi. URS biopsies (inside ureters). Inject Tramal for pain relief. Drained first urine bag, bloody 1,300 ml. Collect second urine bag o/n, dark urine. X-ray abdomen @ 10.04 pm to check stent.
- 19 December 2019, 8TD Anggerik: Collect 2nd urine bag o/n at 5.46 am, 1,200 ml dark urine. BP 141/71 @ 5.22 am. Take blood for RFT at 6.20 am by 2 HOs. Urine bag (2nd o/n) @ 7.15 am, 800 ml. Urine bag (3rd o/n) at 7.20 am-zohor, 800 ml. 4th urine bag @ 8.20 pm, 1,200 ml. iv bolus (1 g) Sulperazone (2nd dose). Iv bolus (1 g) Sulperazone (3rd dose). Take blood for FBP at 11 pm by 2 HOs.
- 20 December 2019, 8TD Anggerik: 5th urine bag o/n @ 5.46 am, 1,200 ml. Take blood for RFT @ 7.06 am by 2 HOs. Negative water balance. Remove iv port. Remove Foley catheter. 6th urine bag @ 12 pm, 1,000 ml
Early 2020
- 19 January 2020, Vascular Clinic: Dr Faizo R
- February 2020, Urology: SOB. Diagnosis Chylothorax
- 9 February 2020, 8TD: Admit to 8TD. Iv optimal hydration. Weight = 65 kg.
- 10 February 2020: Scan abdomen after stent: Mild hydroureter. Query AAA or growth?
- 27 February 2020, Urology Clinic: Dr Ashraf
- March-July 2020, Urology: Chylothorax
- 5 March 2020, Urology Clinic: Dr Hafizan (lady)
- 23 April 2020, Urology Clinic: Take blood for RFT, LFT (SOPD Clinic). Dr Mohd Zaim Zakaria
- 18 March-28 April 2020: Movement Control Order (MCO). Stayed at home. Need police permit to travel.
- 4 May 2020, 8TD: Admit to 8TD for stent removal. Weight = 64 kg. Stent removal was performed at OT HUSM (30 min). Bloody (red) urine after stent removal (kencing merah). Backpain (sakit belakang).
- 4 June 2020: If no MCO, can do stent removal.
- 4 June 2020, 8TD: Admit to 8TD for stent removal. Dr Mohd Zaim.
- 16 June 2020: Fell on slippery floor
Suggestion: To undergo 6 cycles of chemotherapy using dual antibodies, each chemo at 28 days apart, and with pre-chemo.
Pre-chemo means that blood is taken for lab analysis. The patient is hydrated on saline overnight. When the lab results return, additional meds maybe added to the i.v. line, eg magnesium sulphate for magnesium deficiency. Administration of any salt solution hurts terribly.
Late 2020
- 20 July 2020, Uro SOPD Clinic: Take blood
- 27 July 2020, 3U: Ultrasound abdomen
- 27 July-1August 2020: Chylothorax
- 28 July 2020, 3U: Tapping chylothorax
- 30 July 2020, 3U: CT scan after stent removal. Diagnosis: Peritoneal mass, high CE.
- 31 July 2020, 3U: Admit for Chylothorax. BO first time after CT scan.
- 27 July-2 August 2020, 3U: Admit for Chylothorax.
- 2 August 2020. Discharged home at 5 pm
- 2-5 August 2020, 3U: Diarrhoea
- 13 August 2020, A&E, HUSM Day ward: Overnight at A&E Day Ward. No food given. Have to search for own food. CXR at Trauma unit, A&E.
- 14 August 2020, 8S (HDU): Admit to 8S (HDU). No visitors. No outside food. Stay in bed only. Cannot go to toilet. Pray in bed only. Puncture right lung space second time, insert second pigtail.
- 14-15 August 2020, 8S (HDU)
- 16 August 2020, 8S (HDU): Puncture left lung space to drain pleural fluid by Dr Norasyikin (temporary tube).
- 17 August 2020, 3U: Puncture right lung space to insert pigtail at Interventional Radiology (IR), HUSM. Urology - Dr Thiaga and Dr Ashraf.
- 17-19 August 2020, 3U (O&G ward):
- 20 August 2020, 8S (HDU): Anaemic, Hb 7.7 g/dl. Cancelled blood transfusion, 1 pint.
- 21 August 2020, 8S (HDU): Hb 8.8 g/dl. Hyperkalemia ouc (of unknown cause)
- 22 August 2020, 8S (HDU)
- 23 August 2020, 8S (HDU): Met Dr Abdul Ghani, Dr Shamyl, Dr Liyana. 4th Tapping cancelled. May irritate lungs & get infection. Changed Venti mask, flowrate 55% oxygen with green modifier.CXR left & right lungs. Referred to Dietician.
- 24 August 2020, 8S (HDU): O/N fast (2 am-2 pm) for CT guided biopsy at 2 pm.
- 25 August 2020, 8S (HDU): Fasting 4 am. CT guided biopsy at Radiology, 2-5.30 pm
- 25 August 2020, Radiology at old A&E: CT guided biopsy (under General Anaesthesia, GA). Diagnosis: Follicular lymphoma
- 20-26 August 2020, 8S (HDU)
- 27-30 August 2020, 8TD Anggerik
- 30 August 2020, 8S (HDU): Cardiac embolism (due to viscous blood). Prescribed Apixaban (anticoagulant).
- 30 August 2020, 8TD Anggerik: Drainage of pleural fluid. CXR after drainage at 8TD. Diagnosis: Cardiac embolism, SOB (shortness of breath). Moved to 7U.
- 31 August 2020, 7U: Tummy ache. Right chest drained at 7U. CXR after drainage at 7U.
- 1 September 2020, 7U: Tummy ache
- 2 September 2020, 7U: Off PNO 10mg. Tummy ache
- 7 September 2020, Echo clinic: Echocardiography: LV thickened 1.4. Diagnosis: Follicular lymphoma.
- 8 September 2020, 7U: Counselling on chemotherapy with Dr Abu Dzarr.
- 9 September 2020, 1 TD (Cancer ward): Trial chemotherapy with Rituximab only (used dosage as for children).
- 1-22 September 2020, 7U
- 22 September 2020, 7U: CPAP 4 psi
- 23 September 2020, 7U: CPAP 6 psi. Pleurodesis right lung (unsuccessful). Done by Dr Nor Adnin.
- 24 September 2020, 7U: Lower right lung just collapsed on ultrasound (U/S). Still of CPAP 8 psi.
- 25 September 2020, 7U: CPAP 8 psi. Pigtail blocked, can't flush.
- 26 September 2020, 7U: Removed pigtail
- 27 September 2020, 7U (Medical ward): Hemato & Chest reviews
Chemo cycle #1
- 29 September 2020, 1TD: Admit to 1TD for first chemo. Pre-chemo.
- 30 September 2020, 1TD: Weight = 61 kg. Day 1 #1. Chemotherapy (Rituximab + Bendamustine).
- 1 October 2020, 1TD: Day 2 #1. Chemo (Benda only)
- 7 October 2020, Day Care (3rd floor HUSM): Take blood. Stimulant jab after first chemo.
Intraperitoneal catheter (IPC)
- 14 October 2020, Day Care (3rd floor HUSM): Glucose 6.7 mmol/L
- 14 October 2020: Admit to 1TD after 4 pm
- 16 October 2020, 1TD
- 17 October 2020, 1TD
- 18 October 2020, 1TD treatment room: 1. Intraperitoneal catheter (IPC) was installed by Dr Norasyikin, Chest Specialist, HUSM (1.5 hours; 11.30 am to 12.30 pm), and 2. 4th Pigtail was removed by Dr Norasyikin and chest team (30 min; 12.30 pm to 1 pm). Chest team: Dr Norasyikin, Dr Izzat, Dr Nor Adnin and a girl. Staff nurse: Zulaikha Zei.
- 19 October 2020, 1TD: Discharged home after IPC
Chemo cycle #2
- 26 October 2020, 1TD: Admit 1TD for second chemo. Weight = 55.5 kg (lost 5.5 kg).
- 27 October 2020, 1TD: Day 1 #2. Chemo (Ritu + Benda)
- 28 October 2020, 1TD: Day 2 #2. Chemo (Benda only)
- Paglasta (4 days after chemo), Day Care (3rd floor, HUSM). Weight = 55 kg.
- 1 November 2020: Chest Clinic appointment
- 14 November 2020: Clotted blood at IPC insertion point
- 15 November 2020: Pus at IPC insertion point
- 16 November 2020: Yellow scab at IPC insertion point
- 23 November 2020, Day Care (3rd floor HUSM)
Chemo cycle #3
- 24 November 2020, 1 TD: Admit 1TD for 3rd chemo
- 25 November 2020, 1TD: Day 1 #3. Chemo (Ritu + Benda)
- 26 November 2020, 1TD: Day 2 #3. Chemo (Benda only)
- Paglasta (4 days after chemo), Day Care (3rd floor HUSM). Weight = 57 kg (up 2 kg).
CT-NATP #1 (after 3 cycles of chemo)
- 27 November 2020, Old Radiology (CT Scan room): #1. CT-NTAP (after 3rd chemo, o/n fasting). Weight = 57 kg (no weight gain).
- 1 December 2020: Weight = 57.5 kg (up 500 g).
- 6 December 2020: Pilgrastim
- 14 December 2020, Day Care (3rd floor HUSM): Take blood for FBCDC, RFT.
- 17 December 2020, Day Care (3rd floor HUSM): Take blood for RFT. Weight = 56 kg (down 1.5 kg).
Chemo cycle #4
- 28 December 2020, 1TD: Admit for 4th chemo. Pre-chemo hydration.
- 29 December 2020, 1TD: Day 1 #4. Chemo (Ritu + Benda)
- 30 December 2020, 1TD: Day 2 #4. Chemo (Benda only)
- Paglasta (4 days after chemo), Day Care (3rd floor HUSM)
Early 2021
- 13 January 2021, Day Care (3rd floor HUSM): Take blood.
- 24 January 2021, Day Care (3rd floor HUSM): Check blood results for pre-chemo (RFT, LFT, LDH). Hyperkalemia. Low magnesium. Weight = 55 kg (lost 2 kg). BMI = 23.
Chemo cycle #5
- 25 January 2021, 1TD: Admit for 5th chemo.
- 26 January 2021, 1TD: Treat hyperkalemia with i.v. lactate cocktail. Wrongly set up iv line and wrongly injected lactate into tissues ... got a swollen right arm!
- 27 January 2021, 1TD: Take Kalimate 15g (3 packets) to treat high K+ (hyperkalemia). Off saline drip (3x 500 ml). Mix and consume Sodium bicarbonate 2g to treat Acidosis. Urine dipstick test.
- 28 January 2021, 1TD: Day 1 #5. Chemo (Ritu + Benda)
- 29 January 2021, 1TD: Day 2 #5. Chemo (Benda only)
- 4 February 2021: End of PKP
- 9 February 2021, Day Care (3rd floor HUSM): Take blood. Paglasta (4 days after chemo). Weight = 55 kg (lost 2 kg).
- 23 February 2021: Take blood for pre-chemo (FBCDC, RFT). Weight = 58 kg. BP 111/60. K+ 5.4 mmol/L (high). Refused admission to correct K+.
Chemo cycle #6 (last)
- 24 February 2021, 1TD: Admit for chemo #6 (last chemo). Weight = 58 kg (up 3 kg).
- 25 February 2021: Set i.v. line. To try inline antibiotic using ventilator mask - 1. Salbutamol (antiasthma), 2. Pentamidine (bitter antibiotic). CXR. Start saline drip (pre-hydration before chemo tomorrow).
- 26 February 2021: Take blood for FBCDC, RFT, check K+. Do COVID-19 nasal swab. Temp 37.3 C.
- Day1 #6. Chemo (Ritu + Benda)
- Day 2 #6. Chemo (Benda only)
- 28 February 2021, Day Care (3rd floor HUSM): Take blood for FBCDC post-chemo. Paglasta (4 days after chemo). Weight = 58 kg (up 3 kg).
- 9 March, Day Care (3rd floor HUSM): Take blood
CT-NATP #2 (after 6 cycles of chemo)
- 6 April 2021, 1TD: Pre-hydration for CT-NTAP. Overnight fasting (12 midnight to 12 noon).
- 7 April 2021: Still fasting. Prepare for CT-NATP. Drink 600 ml contrast media in the ward. Then 300 ml. Then 120 ml into anus at CT-scan room in Radiology. Scan 20 min.
- 7 April 2021, Old Radiology (CT-Scan room): #2. CT-NTAP (after 6th chemo, o/n fasting). Weight = 61 kg (up 3 kg).
- 11 April 2021, Day Care (3rd floor HUSM): Check blood after CT-NATP
- 13 April 2021 (1 Ramadan 1442 Hijrah): Puasa Ramadan (Ramadan fasting)
- 21 April 2021 (9 Ramadan), Day Care (3rd floor HUSM: Take blood for FBCDC, RFT and LFT; CXR at Radiology Satellite near Kopitiam.
Check & IPC removal
- 22 April 2021, Chest Clinic, HUSM: Check IPC condition
- 24 April 2021: Stop taking Apixaban. Don't take Apixaban (anticoagulant).
- 25-26 April: Admitted to 1U, HUSM (Ramadan fasting): To remove IPC
- 26 April 2021, 1U treatment room, HUSM: IPC removal (Dr Norasyikin)
- 26 April 2021, Radiology at old A&E: CXR after IPC removal
- 10 May 2021 (KPP Clinic): Removed sutures by nurse. Bandage loosely. Change bandage daily. Wash wound with saline (0.9% w/v), Chlorhexidine (4% Chlorhexidine) aqueous solution (red), or SteriPrep Antiseptic Solution (70% isopropyl alcohol, 2% Chlorhexidine gluconate). Remove pus and clean as normal, dry with hair-dryer, and apply bandage loosely.
COVID-19 vaccinations (for lymphoma patient)
COVID-19 vaccination (first dose) was scheduled a month after the last chemo cycle, so as not to interfere with reduced antibody levels immediately following the last chemo and after the CF Stimulating factor was administered (4 days after last chemo).
COVID-19 vaccinations were arranged by Day Care with the nearest vaccination centre (at USM Health Campus). Details were entered onto MySejahtera app, which was prepared by MoH (KKM). Patient's details were entered by doctors handling pre- and post-vaccination procedures at the vaccination centre.
- First dose: Pfizer (Cominarty), 28 June 2021
- Second dose: Pfizer (Cominarty), 19 July 2021
- Booster: To be announced (6 months wait after second Pfizer vaccination)
Advice on Scheduling Maintenance Therapy and COVID Vaccinations (2021 guide for elderly lymphoma patient)
- After the second dose of Pfizer, chemotherapy was continued with single antibody (Rituximab) at 2 months apart beginning a month after the second dose of Pfizer vaccine.
- Maintenance therapy is planned for 2 years (August 2021-August 2023).
- To do COVID-19 vaccinations first before proceeding with maintenance chemotherapy for follicular lymphoma.
- See COVID-19 vaccinations above.
How to order Rituximab for cancer maintenance therapy
- Prescription: 1 vial of Rituximab for subcutaneous injection (cucuk bawah kulit); s/c Rituximab 1400 mg x1
- Rituximab must be pre-ordered months ahead by the Day Care on behalf of the patient. Patient must sign all necessary papers
- Rituximab is obtained from the Non-Formulary Counter at Farmasi HUSM.
- The LPO must be signed by cancer specialist, USM Registrar and HUSM Director
- The signed LPO must reached Farmasi well ahead of date of intended use of Rituximab
Rituximab Maintenance Therapy
(single monoclonal antibody)
(for lymphoma patient after completing 6 cycles of chemo)
- Administration of Rituximab is done at Day Care
- Blood is taken for pre-chemo on the first visit
- COVID-19 saliva test is done at the second visit on the following day
- If COVID-19 test is Negative (1 line), proceed to do chemo with Rituximab only
- Pre-chemo involves taking 2 Panadol tablets. Wait 30 minutes.
- Lying down on couch
- Hydrocortisone and Piriton are injected into i.v. line. Wait 30 minutes
- Then Rituximab is injected at the side of the navel (1-2 syringes) over 10 minutes (timed)
- Rituximab is viscous and must be administered carefully and slowly
2021
- 24 May 2021 s/c Rituximab 1400 mg x1. Maintenance therapy was withheld. To do COVID-19 vaccinations first.
- #1: 19 August 2021
- #2: 18 Oct 2021
- #3: 20 Dec 2021
2022
CT-NATP #1
CT-NATP #2
2023
CT-NATP #3
CT-NATP #4
Patient is currently on maintenance chemotherapy (Rituximab) for two years (2021-2023), Amlodipine (5 mg) maintenance therapy for hypertension, and Apixaban (2.5 mg) for life. Patient also receives multi-vitamins (vit. B complex, folic acid, and vit. C)
