Monday, July 21, 2014

Good, bad and ugly

I'm pretty sure I've used that reference before here.  In fact now that I think about it, I remember feeling sorry for Eli Wallach.  I can picture his agent calling him.  "Eli, baby, have I got a part for you!  There's this movie, see, called The Good, The Bag and The Ugly.  The parts of The Good and The Bad have already been cast…"

The Good



What a handsome devil, eh?

So the good news is that my tests last week came back negative for MRD (clean bone marrow) and my numbers look really, really good.

The Bad


A tough customer indeed, is Mr. Van Cleef.   As another "Van", by the way, I have no idea what a "Cleef" is.  A Dutch pronunciation of Cliff?  Hmm.

The bad news is that the MRI is unchanged.  Stable, faint, sub 1cm focal lesions (not currently active for cancer) are still seen at T2, T3, T4, T10 and T12.  I like the faint part, I suppose.  I sure wish they would go away, though, for reasons which will shortly become apparent to readers that see this post through to its conclusion.  As was published by Arkansas just last week (more on this below) these lesions can be issues because "MRD…only evaluates a random marrow aspirate and does not assess any dormant consecratory myelomatous cells, which can be present in focal lesions on magnetic resonance imaging (MRI), and can provide a disease reservoir for relapse."

In other words, as I have reported from time to time in this blog, I want those bloody things gone.

The Ugly



Yes…well…forgive me if I feel more sorry for myself than Eli after all.   Get a load of these graphs, from this article just published by UAMS about how stem cell transplants are curing people.:



Recall I was in the "TT4 Lite" arm of the study.  This can be most readily identified as the lines as the bottom were people are relapsing left and right without any indication of a plateau.

Specifically, TT4 patients with deletion 13 and hypo diploid disease (that's too few chromosomes versus too many -- and it's odd because too many chromosomes is generally a better prognosis) have done well and reached a plateau after two years.  However the other cohorts in TT4 Lite have no fared well at all.  For this with no cytogenetic abnormalities, if this graph is right (and there may be an error in it since there appears to be a cliff at the 5.5 year mark and it suggests something's wrong with the graph selection) there's no plateau and the relapse rate is high with only 30% of people still in CR at the 5.5 year point.  Looking at it objectively, I think there must be a mistake in the graph…so maybe I feel a *little* better if that's the case (I've asked my friends at UAMS to clarify) but still, it looks like the Lite arm isn't faring nearly as well as the Standard arm.   Did I sell my therapy short?  Should I have gone through something more rigorous?  Should I go through something more rigorous right now?

We'll see what they have to say.

I do feel like the goalposts keep being moved farther and farther back.  Can I make it another five years in complete remission and breathe easy?  That's a lot of waiting…

It's ugly.

3 comments:

  1. Well Nick, I have to believe that there is something wrong with those graphs. It appears as all members of TT4-L hit the wall after the same length of time. That can't be right. It would at least be a staggered drop-off

    If you get an explanation, please share it with us. I'm interested to hear what they have to say.

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  2. I may be wrong, but I seem to remember Tricot and Zangari both telling me those focal lesions remain focal because of the healing/rebuilding process. Zangari told me he no longer conducts fine needle biops of those lesions because they more times than not are simply filling with fatty blood. I know there are studies from Barlogie mentioning how focal lesion must be resolved, but I thought he was referencing those with residual myeloma cells. I know I'm not telling you anything new. Just curious what your concern is as related to the MRI results.

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  3. Ugh don't like seeing those Lite arm differences. Hoping it's a glitch.

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