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Oncology (General Cancer)/Hemochromitosis/Lymph Nodes/Cancer

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QUESTION: I am a male age 50.

I have enlarged lymph nodes under both of my armpits.  I had a Chet and abdominal CT that showed no other enlarged lymph nodes and confirmed the large nodes under my arms.

An ultraound confirmed thst each node is greater than 1cm, some are over 2cm.  A core biopsy was performed on the largest node.  The results were negative for cancer and lymphoma.  The pathologist stated in the report that the biopsy could not rule out the posibility of neoplasm. They are still enlarged and have been since at least Dec 2012.  I have no known infections and did not take any antibiotics in over 5 years.  

I have a 4 year history of elevated ferritin.  I recently had a DNA test that revealed I have two copies of the H63D mutation for the HFE gene so I was diagnosed with hereditary hemochromitosis.  I recently had my first phlebotimy of 500cc of whole blood.  It took 3.5 days for me to feel good again since I had fatigue and breathlessness the day after the phleb.  As of today, I feel pretty good.

My blood tests just prior to the first phlebotimy were mostly normal.  I did have an MCH value of 32.0 pcg.  An MCV of 96fl. A ferritin level of 589 ng/ml. A CO2 value of 33mmol/l.  An AST of 56U/L and an ALT of 85U/L.

I also have a high frequency tinnitus in both ears on a regular basis.  It started out gradually and it would come and go since last year, but since my phlebotimy last week it has been constant at a relatively low volume but very prevalent.

Based on the above, I have the following questions:

1) Even though my biopsy came back negative for lymphoma and cancer, is it likely thast I have cancer somewhere else and my lymph nodes are reacting?

2) Based on my MCH and MCV values, I am concerned that I might have a bone marrow disease.  I am also concerned that it took me 3.5 days to recover from the phlebotimy which also points to a bone marrow issue.  I take a non-iron containing vitamin each day that includes B12 and folic acid.  Do you think I should have a bone biopsy to rule out some sort of bone disease/cancer?

3) Are there any other tests I should ask my doctor to give me?

I would really appreciate your advice.  I jut have a gut feeling something other than the hemochromitosis is going on. I suspect hidden cancer of some sort.

Thanks,
David

ANSWER: Lymph nodes:  If a core biopsy has been done, and the nodes are not changing in size, you probably don't have a lymphoma -- and if you did, it would be one of those low grade ones that we don't treat unless they become cosmetic nuisances.  I would not do anything else about these unless they get substantially bigger.  Unlike other cancers it doesn't seem to make much of a difference when you start treating a lymphoma, (within reason)  Obviously there are exceptions but those would be the ones which grow very rapidly.  
Bone marrow: That's more complicated.  Your AST and ALT by my laboratory standard are both a little elevated, suggesting some mild liver dysfunction, which is not uncommon in hemochromatosis.  That in turn can give rise to a slight increase in MCV.
Finally, to feel dizzy and have increased tinnitus after phlebotomy is pretty normal.  Next time you have a phebotomy ask your doc to give you some saline afterwards, or drink a lot of fluid during the 12 hours leading up to the procedure.  
I don't think anything you've told me indicates you have cancer.  Doesn't mean you don't but at this point I wouldn't recommend any more tests.  Hope this helps.  

---------- FOLLOW-UP ----------

QUESTION: Thanks Doc for the quick answer.  I have follow up questions please.

What is it about blood draws that causes tinnitus to increase?  

Is there anything I can do to decrease or eliminate the tinnitus?

Also, can hemochromatosis be the cause of the enlarged lymph nodes in any way?  I am just concerned because some of the articles I read stated that there is an increased risk of cancer for hemochromatosis patients and this all just seems so coincidental.  I thought the core biopsy is conclusive but it sounds like it may not be.


Thanks,
David

Answer
When you give a blood transfusion, you get slightly anemic temporarily, and usually your blood pressure goes down a bit.  Both of these can aggravate tinnitus, because there is a decrease in oxygen availability to that part of the brain.  I don't know how to get rid of tinnitus, and I don't think anyone else does; I have it myself and you just have to learn to ignore it.  As for hemochromatosis, I believe it can only cause cancer if it causes cirrhosis of the liver, which is a pre-cancerous condition.  Most liver cancer occurs in patients with cirrhosis.  If you are being treated with phlebotomy on the basis of the discovery of a mutated gene, then you may not even have any cirrhosis.  As for the lymphadenopathy, I"ve again looked up my sources and don't see that there is a relationship.  As for the biopsy, a biopsy only shows the tissue which was biopsied, nothing else.  Cores are usually very accurate, and I wouldn't worry about that right now unless the nodes get seriously bigger.  Hope this helps.  

Oncology (General Cancer)

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Donald Higby, M.D.

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I can answer almost all questions related to the treatment and natural course of most kinds of cancer, especially cancers of prostate, colon, lung and breast.

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I have been a practicing medical oncologist for 36 years, and have been chief of service at a major medical center for 25 years. I've also done research in cancer treatments.

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New England Journal of Medicine American Journal of Medicine Journal of the American Society of Clinical Oncology Hematology Transfusion Medicine

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MD, Stanford University Internal Medicine residency, St. Louis University School of Medicine, St. Louis, MO Medical Oncology Fellowship, Roswell Park Cancer Institute, Buffalo, NY

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