"Subcutaneous inflammation mimicking metastatic malignancy induced by injection of mistletoe extract"
"At the risk of upsetting many proponents of alternative medicine, I also contend that intuition is no substitute for evidence."
-Edzard Ernst, professor of complementary medicine, Department of Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter
Holy Nostrums, Batman! Someone is actually criticizing one of the most popular anti-cancer treatments on the shelf of the corner store with the sign Natural Cures Only hanging above it. Professor Edzard Ernst's polite but firm quotation about the use of emotional hallelujahs as definitive evidence of an alternative product's activity against cancer is part of an editorial he wrote in response to a strange case report in the current issue of the BMJ. This incident could be called "The Case of the Mistletoe Mishap":
A 61 year old woman attending a follow-up appointment two months after excision of tubular carcinoma of the breast complained of an abdominal wall mass. The lesion was subcutaneous, mildly tender, and had a nodular consistency. The patient was worried that the soft tissue mass might be a recurrence of follicular lymphoma, which had been diagnosed in April 2001.
This seems to be a reasonable concern, and I suspect her doctors were just as upset about the appearance of this unusual lesion. Did they remove the mass? Why, soitenly!
Microscopically, we identified a widespread infiltrate of plasma cells, lymphocytes, and eosinophils within the subcutaneous adipose tissue, in a septal and lobular distribution, indicating inflammation or panniculitis. In summary, we found no evidence of malignancy after the tissue was examined microscopically on multiple levels.
The doctors found out from the patient that she was injecting her abdomen thrice weekly with an extract of mistletoe, which she thought would keep her lymphoma from recurring. That's obviously a worthy goal, but what the patient likely didn't know is what we might call the rest of the story:
1. The published studies on the use of mistletoe against cancer are not large nor scrupulous in design and lack the statistical power needed to convince academia that they are not riddled with bias.
2. The use of mistletoe by humans has led to many adverse health events, to wit: "local reactions at the site of injection, anaphylaxis, dyspnoea, haemorrhagic colitis, herpes simplex, herpes zoster, joint pain, kidney failure, lymphangiitis, parasthesias, sarcoidosis, ulceration, and vertigo." [Ernst editorial].
3. Patients living with cancer who take alternative or complementary treatments often hide this information, which can confound their physicians if the patients develop toxicity from such roots, shoots and leaves.
As the BMJ authors conclude, until rigorous controlled clinical trials are conducted no one should consider mistletoe to be a useful treatment against cancer. I agree completely, no matter what the mistletoe experts say.
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But what about infectious mononucleosis?
..and a Merry Christmas to you too! ;)
My clinical colleagues reported on a similar issue in JCO a couple of years ago. However, the title lists the brand of the product, Iscador, and not the word "mistletoe," so it rarely gets picked up in literature searches or in the bibliography of reports like this one.
David - thanks for reminding us of your case report. With your permission I would like to reprint an important quote from your letter:
"This case highlights the need for greater understanding of complementary medicines and their potential adverse or beneficial interactions with cytotoxic chemotherapy."
For Pete's sake folks, let your doctor know if you're taking mandrake roots, periwinkle tea, wolfbane or any other out-of-the-ordinary cancer treatments. Danke schoen.