Case Study: Lymphoma Treated with Chemotherapy
Introduction:
DM was admitted to University Hospital on March 8, 2011. She was diagnosed with stage II diffuse large B-cell lymphoma-with mediastinal disease and positive lymph nodes. This case study will discuss the pathophysiology of lymphoma and its corresponding chemotherapy treatment. It will review current research on the etiology and treatment of lymphomaand cancer cachexia.
Patient Profile and Social History:
DM was a 21-year-old Caucasian female who was a college student at Midwest University. DM was a Methodist and denied alcohol and tobacco use. The patient had no family history of cancer.
Medical History:
The patient had no significant illness until the past 2-3 months. The patient described herself as having flu-like symptoms, and feeling run down. She complained of excessive sweating at night and frequent fevers. Upon evaluation by her family physician, the patient was referred to the University Hospital for follow-up and evaluation of symptoms.
Upon admission, the patient was diagnosed with stage II diffuse large B-cell lymphoma with medistinal disease and positive lymph nodes. Her bone marrow and other organs showed no indication of disease.
Literature Review:
Cancer
Cancer is the abnormal division and reproduction of cells that do not undergo normal regulation leading to metastasis (1). There are three progressive phases of cancer. The first phase, initiation, is when stimuli cause a transformation to take place in a healthy cell. Initiation factors include chemicals, radiation, or viruses. The transformed cell remains dormant until the second phase, promotion, which is the activation of the abnormal cell. Promotion allows cells to multiply without regulation and escape the protective mechanisms of the body. The abnormal cell is called a neoplasm. The final stage is known as progression, which is characterized by an aggregation of the abnormal cells, which eventually results in a tumor. Tumors have the ability to spread to other tissues and organs through a process known as metastasis (1).
Lymphoma
Lymphoma is a cancer that affects the lymphatic system, and integral part of the immune system (2). The lymphatic system is part of the body’s main immune defense system, which helps fight disease and infection. The lymphatic system is a network of thin tubes that branch into tissues throughout your body carrying lymph, a colorless substance that contains lymphocytes, which are infection-fighting cells. Throughout the lymphatic system, there are small clusters of bean lymph nodes, which are located in the underarm, groin, neck, chest, and abdomen (3). In a healthy immune system, B-cells contained within lymph nodes are a key component of the immune system
A common type of lymphoma is diffuse B-cell lymphoma, which account for approximately 40% of all cases of lymphoma . B-cell lymphoma can become extranodal and metastasize to distal organs (2). As lymphomas progresses, your body is less able to fight infection and many signs and symptoms may occur as a result. For example, painless swelling in the lymph nodes of neck, underarm, and groin can occur. Lymphoma can lead to night sweats, fever, weight loss, itching, reddened patches of skin, lethargy, nausea, vomiting and abdominal pain(3).
Diffuse B-cell lymphoma is considered high-grade which requires immediate treatment (2). However, high-grade lymphomas are generally more curable than low-grade lymphomas (3). In order to determine the proper treatment protocol, a biopsy will be preformed to remove part of the lymph node, which helps to determine the spread of cancer (2). The biopsy will also be able to help differentiate between Hodgkin lymphoma and non Hodgkin lymphoma. Hodgkin lymphoma is characterized by a unique cell called Reed-Sternberg cell. Hodgkin lymphomas usually have a more predictable pattern of spread and the spread is more limited that is generally observed in non-Hodgkin lymphoma. Non-Hodgkin lymphoma is more likely to originate in extranodal sights and spread quickly (3).
Treatments
The primary treatment for diffuse B-cell lymphomas is chemotherapy (2). Chemotherapy consists of cytotoxic drug therapy that targets rapidly dividing cells, including cancer cells. Chemotherapy often causes nausea, vomiting, diarrhea, as well as changes in taste and smell. All such side effects can lead to weight loss, which can compromises the effectiveness of the chemotherapy. Thus it is important for the patient to maintain or possible gain weight throughout the cancer treatment (2).
Chemotherapy can be combined with radiation therapy and/or monoclonal antibody therapy. Radiation therapy consists of high-energy waves that induce apoptosis of the target tissue (3) Monoclonal antibody therapy consists of drugs that recognize, target and bind with specific proteins located on the cancerous cells. This leads to the recognition of the bound cells by the immune system causing eradication of the cells (2). Recent studies have suggested molecular profiling can also be used in conjunction with chemotherapy (3). Molecular profiling is based on the molecular feature of individuals tumors, and can be used to predict the survival rate of patients after chemotherapy. Deosyribonucleic acid (DNA) microarrays can also be used to formulate a survival rate predictor. This new technology may influence patients’ choice of treatment method in the future(3).
Cancer Cachexia
Cancer cachexia is characterized by progressive weight loss and catabolism of muscle and adipose tissue. It is critical to understand cancer cachexia because it greatly increases mortality, reduces the effects of chemotherapy treatment and increases chemotherapy toxicity (5). About half of all cancer patients suffer from cancer cachexia. Cancer cachexia is most common among children and elderly patients. Cancer cachexia is characterized by a greater than 5% weight loss in a sixth month period (6). In patients receiving chemotherapy, nausea, vomiting, diarrhea and stomatitis all contribute to the weight loss.If patients lose over 30% of weight, death is likely (5). The best treatment for cancer cachexia is to cure the cancer; however, this is not always possible.The next best treatment is pharmaceutical agents. Antiserotnergic drugs enhance appetite and inhibit tumor derived catabolic factors that antagonize tissue. Prednisone is another pharmaceutical agent that enhance appetite (6). The role of nutrition in cachexia is complex. Many clinical trials have researched the effect of total parenteral nutrition (TPN) on cachexia outsomes. However,the results have failed to show a correlation between TPN and weight gain in such patents. In fact, it may be that TPN may result in a lower survival rate (5).
Treatment and Progression:
The patient was admitted to University Hospital on March 8, 2011 and was released five days later on March 12, 2011. She was prescribed a chemotherapy regimen of cyclophospahamide, doxorubicin, vincristine, and prednisone (CHOP). Prednisone was to be administered orally on the first five days of each 21-day cycle, and the other agents were be given intravenously on the first day of each cycle. Radiotherapy was schedule to start three weeks after the third cycle of CHOP. She was discharged for outpatient therapy on hospital day five.
Anthropometry:
The patient was a 21-year-old female. Her admit weight was 54 kilograms. Her usual body weight was 59 kilograms. Her ideal body weight was also 130 pounds. She was 92% of her ideal body weight. She had experienced an 8% body weight loss in the past two months, which was considered significant weight loss. Her body mass index was 19, which was classified as borderline underweight.
Laboratory Data:
The following table represents DM’s nutritionally pertinent laboratory values:
Test
Normal
Admit 3/18
Alb
3.5-5 g/dL
3.3 L
Total protein
6-8 g/dL
5.5 L
WBC
4.8-11.8 x10^3/mm^3
12.0 H
Hgb
12-15 g/dL(women)
11 L
Hct
37-47 % (women)
31 L
MCV
80-96 um^3
70 L
MCHC
31.5-36 g/dL
27 L
Ferritin
20-120 mg/mL
19 L
The patient had a low albumin and total protein, which indicated diminished visceral protein stores. The patienthadan elevated high white blood cell count, which indicated stress. DM had a low hemoglobin (Hgb), hematocrit(Hct), mean cell volume(MCV),mean cell hemoglobin concentration (MCHC) and ferritin. All of these low values indicatediron deficiency.
Medications:
She was prescribed a chemotherapy regimen of cyclophospahamide, doxorubicin, vincristine, and prednisone (CHOP. Prednisone was to be administered orally on the first five days of each 21-day cycle, and the other agents were to be given intravenously on the first day of each cycle. Prednisone has been shown to increase appetite, which could possibly help with weight maintenance (2).
Clinical:
The patient was a thin, pale young woman who appeared tired. The patient appeared to be slightly malnourished.
Diet Evaluation:
First section should be her energy, protein, and fluid needs. Tell us what equation you used to obtain these and why.
A diet history was obtained from DM. DM admitted to a decrease appetite but no nausea, vomiting, diarrhea, or constipation DM’s 24-hour recall was especially low in kilocalories and protein as she consumed. Only 475 kilocalories and 14 grams of protein, which was not adequate to meet her needs and was reflective of her current weight loss. Need to have a paragraph about her intake while in the hospital.
The patient was educated on power packing to help promote weight gain. She was also educated on iron-rich foods due to her deficiency as well as nutrition and cancer. The patient verbalized understanding, was receptive, and was likely to comply.
Summary and Conclusions:
DM was placed at moderate nutrition risk due to her weight loss, cancer, and cancer therapy. DM was discharged from University Hospital with a clear understanding of power packing and the importance of weight maintenance.DM’s prognosis was considered good with a full recovery expected.
Nutrition Note:
Subjective:
Pt complains of cough, fever, flu-like symptoms and excessive sweating at night. MD states decrease appetite over last 3 months and pt UBW is 130 lbs.
Objective:
21 yof dx with Stage II Lymphoma. She has a BMI of 19. Her weight is 120lbs and her ht is 5 “6”. She is 92% of UBW and IBW. 8 % wt loss in last 2 months.Her temperature in high at 100.5 F. She has shallow respirations, decreased Alb of 3.3, increased WBC count of 12, decreased Hct of 31, Hgb of 11, Ferritin of 19, MCV of 70. PO Regular. Obtained diet recall. Radiation and begin 3rd cycle.
Assessment:
Moderate Nutrition Risk because of decrease alb, wt loss fever, cough. Fever indicated fever factor so increased energy needs. Excessive sweating indicates dehydration. Decreased appetite and wt loss due to Stage 11 Lymphoma and flu-like symptoms. BMI, IBW% and UBW% indicated significant weight loss. Decreased Alb indicates malnourished. Increase WBC, decreased Hct, Hgb, Ferritin, MCV all indicate iron deficiencyanemia. High temp indicates fever factor and increased energy needs. Shallow respiration due to illness. PO Regular is inadequate because of increased energy needs.
Malnourished r/t loss of appetite, flu-symptoms, cancer, AEB % UBW, %IBW, BMI, dietary recall, decreased Alb.
Increased energy/ pro needs r/t healing AEB increased temp, new dx.
Increased nutrient needs-iron r/t decreased appetite, wt. loss, diet recall AEB decreased Hct, Hgb, Ferritin, MCV.
Plan:
Purpose of nutrition education is to help learn how to Power Pack and increase fluids, and eat foods with iron. Take an iron supplement.
Nutrition Prescription is 2400kcals, 65-80g protein, At least 2000 ml of fluid. Revaluate understanding of power packing and importance of wt. maintenance. Monitor wt, alb, Hct, Hgb, Ferritin, MCV, and dietary intake. Reassess in 3-5 days.
References:
1) Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th edition. St. Lewis, Missouri. Saunders Elsevier; 2008.
2) Cancer Treatment of America. B-cell Lymphoma. Available at: http://www.cancercenter.com/b_cell_lymphoma.cfm. Accessed: February 8, 2011.
3) Your Life Health. Lymphoma. Available at: http://www.healthscout.com/ency/68/304/main.html. Accessed: February 9, 2011.
4) Rosenwald A, Wright G, Chan WC et al. The Use of Molecular Profiling to Predict Survival After Chemotherapy for diffuse Large B-cell Lymphoma. New England Journal of Medicine. 2002;346:1937-1947.
5) Tisdale MJ. Cancer Cachexia. 1991;63:337-342.
6) Inui A. Cancer Anorexia-Cachexia Syndrome: Current Issues in Research and Management. A Cancer Journal for Clinicians. 2008;52(2):72-91.
Introduction:
DM was admitted to University Hospital on March 8, 2011. She was diagnosed with stage II diffuse large B-cell lymphoma-with mediastinal disease and positive lymph nodes. This case study will discuss the pathophysiology of lymphoma and its corresponding chemotherapy treatment. It will review current research on the etiology and treatment of lymphomaand cancer cachexia.
Patient Profile and Social History:
DM was a 21-year-old Caucasian female who was a college student at Midwest University. DM was a Methodist and denied alcohol and tobacco use. The patient had no family history of cancer.
Medical History:
The patient had no significant illness until the past 2-3 months. The patient described herself as having flu-like symptoms, and feeling run down. She complained of excessive sweating at night and frequent fevers. Upon evaluation by her family physician, the patient was referred to the University Hospital for follow-up and evaluation of symptoms.
Upon admission, the patient was diagnosed with stage II diffuse large B-cell lymphoma with medistinal disease and positive lymph nodes. Her bone marrow and other organs showed no indication of disease.
Literature Review:
Cancer
Cancer is the abnormal division and reproduction of cells that do not undergo normal regulation leading to metastasis (1). There are three progressive phases of cancer. The first phase, initiation, is when stimuli cause a transformation to take place in a healthy cell. Initiation factors include chemicals, radiation, or viruses. The transformed cell remains dormant until the second phase, promotion, which is the activation of the abnormal cell. Promotion allows cells to multiply without regulation and escape the protective mechanisms of the body. The abnormal cell is called a neoplasm. The final stage is known as progression, which is characterized by an aggregation of the abnormal cells, which eventually results in a tumor. Tumors have the ability to spread to other tissues and organs through a process known as metastasis (1).
Lymphoma
Lymphoma is a cancer that affects the lymphatic system, and integral part of the immune system (2). The lymphatic system is part of the body’s main immune defense system, which helps fight disease and infection. The lymphatic system is a network of thin tubes that branch into tissues throughout your body carrying lymph, a colorless substance that contains lymphocytes, which are infection-fighting cells. Throughout the lymphatic system, there are small clusters of bean lymph nodes, which are located in the underarm, groin, neck, chest, and abdomen (3). In a healthy immune system, B-cells contained within lymph nodes are a key component of the immune system
A common type of lymphoma is diffuse B-cell lymphoma, which account for approximately 40% of all cases of lymphoma . B-cell lymphoma can become extranodal and metastasize to distal organs (2). As lymphomas progresses, your body is less able to fight infection and many signs and symptoms may occur as a result. For example, painless swelling in the lymph nodes of neck, underarm, and groin can occur. Lymphoma can lead to night sweats, fever, weight loss, itching, reddened patches of skin, lethargy, nausea, vomiting and abdominal pain(3).
Diffuse B-cell lymphoma is considered high-grade which requires immediate treatment (2). However, high-grade lymphomas are generally more curable than low-grade lymphomas (3). In order to determine the proper treatment protocol, a biopsy will be preformed to remove part of the lymph node, which helps to determine the spread of cancer (2). The biopsy will also be able to help differentiate between Hodgkin lymphoma and non Hodgkin lymphoma. Hodgkin lymphoma is characterized by a unique cell called Reed-Sternberg cell. Hodgkin lymphomas usually have a more predictable pattern of spread and the spread is more limited that is generally observed in non-Hodgkin lymphoma. Non-Hodgkin lymphoma is more likely to originate in extranodal sights and spread quickly (3).
Treatments
The primary treatment for diffuse B-cell lymphomas is chemotherapy (2). Chemotherapy consists of cytotoxic drug therapy that targets rapidly dividing cells, including cancer cells. Chemotherapy often causes nausea, vomiting, diarrhea, as well as changes in taste and smell. All such side effects can lead to weight loss, which can compromises the effectiveness of the chemotherapy. Thus it is important for the patient to maintain or possible gain weight throughout the cancer treatment (2).
Chemotherapy can be combined with radiation therapy and/or monoclonal antibody therapy. Radiation therapy consists of high-energy waves that induce apoptosis of the target tissue (3) Monoclonal antibody therapy consists of drugs that recognize, target and bind with specific proteins located on the cancerous cells. This leads to the recognition of the bound cells by the immune system causing eradication of the cells (2). Recent studies have suggested molecular profiling can also be used in conjunction with chemotherapy (3). Molecular profiling is based on the molecular feature of individuals tumors, and can be used to predict the survival rate of patients after chemotherapy. Deosyribonucleic acid (DNA) microarrays can also be used to formulate a survival rate predictor. This new technology may influence patients’ choice of treatment method in the future(3).
Cancer Cachexia
Cancer cachexia is characterized by progressive weight loss and catabolism of muscle and adipose tissue. It is critical to understand cancer cachexia because it greatly increases mortality, reduces the effects of chemotherapy treatment and increases chemotherapy toxicity (5). About half of all cancer patients suffer from cancer cachexia. Cancer cachexia is most common among children and elderly patients. Cancer cachexia is characterized by a greater than 5% weight loss in a sixth month period (6). In patients receiving chemotherapy, nausea, vomiting, diarrhea and stomatitis all contribute to the weight loss.If patients lose over 30% of weight, death is likely (5). The best treatment for cancer cachexia is to cure the cancer; however, this is not always possible.The next best treatment is pharmaceutical agents. Antiserotnergic drugs enhance appetite and inhibit tumor derived catabolic factors that antagonize tissue. Prednisone is another pharmaceutical agent that enhance appetite (6). The role of nutrition in cachexia is complex. Many clinical trials have researched the effect of total parenteral nutrition (TPN) on cachexia outsomes. However,the results have failed to show a correlation between TPN and weight gain in such patents. In fact, it may be that TPN may result in a lower survival rate (5).
Treatment and Progression:
The patient was admitted to University Hospital on March 8, 2011 and was released five days later on March 12, 2011. She was prescribed a chemotherapy regimen of cyclophospahamide, doxorubicin, vincristine, and prednisone (CHOP). Prednisone was to be administered orally on the first five days of each 21-day cycle, and the other agents were be given intravenously on the first day of each cycle. Radiotherapy was schedule to start three weeks after the third cycle of CHOP. She was discharged for outpatient therapy on hospital day five.
Anthropometry:
The patient was a 21-year-old female. Her admit weight was 54 kilograms. Her usual body weight was 59 kilograms. Her ideal body weight was also 130 pounds. She was 92% of her ideal body weight. She had experienced an 8% body weight loss in the past two months, which was considered significant weight loss. Her body mass index was 19, which was classified as borderline underweight.
Laboratory Data:
The following table represents DM’s nutritionally pertinent laboratory values:
Test
Normal
Admit 3/18
Alb
3.5-5 g/dL
3.3 L
Total protein
6-8 g/dL
5.5 L
WBC
4.8-11.8 x10^3/mm^3
12.0 H
Hgb
12-15 g/dL(women)
11 L
Hct
37-47 % (women)
31 L
MCV
80-96 um^3
70 L
MCHC
31.5-36 g/dL
27 L
Ferritin
20-120 mg/mL
19 L
The patient had a low albumin and total protein, which indicated diminished visceral protein stores. The patienthadan elevated high white blood cell count, which indicated stress. DM had a low hemoglobin (Hgb), hematocrit(Hct), mean cell volume(MCV),mean cell hemoglobin concentration (MCHC) and ferritin. All of these low values indicatediron deficiency.
Medications:
She was prescribed a chemotherapy regimen of cyclophospahamide, doxorubicin, vincristine, and prednisone (CHOP. Prednisone was to be administered orally on the first five days of each 21-day cycle, and the other agents were to be given intravenously on the first day of each cycle. Prednisone has been shown to increase appetite, which could possibly help with weight maintenance (2).
Clinical:
The patient was a thin, pale young woman who appeared tired. The patient appeared to be slightly malnourished.
Diet Evaluation:
First section should be her energy, protein, and fluid needs. Tell us what equation you used to obtain these and why.
A diet history was obtained from DM. DM admitted to a decrease appetite but no nausea, vomiting, diarrhea, or constipation DM’s 24-hour recall was especially low in kilocalories and protein as she consumed. Only 475 kilocalories and 14 grams of protein, which was not adequate to meet her needs and was reflective of her current weight loss. Need to have a paragraph about her intake while in the hospital.
The patient was educated on power packing to help promote weight gain. She was also educated on iron-rich foods due to her deficiency as well as nutrition and cancer. The patient verbalized understanding, was receptive, and was likely to comply.
Summary and Conclusions:
DM was placed at moderate nutrition risk due to her weight loss, cancer, and cancer therapy. DM was discharged from University Hospital with a clear understanding of power packing and the importance of weight maintenance.DM’s prognosis was considered good with a full recovery expected.
Nutrition Note:
Subjective:
Pt complains of cough, fever, flu-like symptoms and excessive sweating at night. MD states decrease appetite over last 3 months and pt UBW is 130 lbs.
Objective:
21 yof dx with Stage II Lymphoma. She has a BMI of 19. Her weight is 120lbs and her ht is 5 “6”. She is 92% of UBW and IBW. 8 % wt loss in last 2 months.Her temperature in high at 100.5 F. She has shallow respirations, decreased Alb of 3.3, increased WBC count of 12, decreased Hct of 31, Hgb of 11, Ferritin of 19, MCV of 70. PO Regular. Obtained diet recall. Radiation and begin 3rd cycle.
Assessment:
Moderate Nutrition Risk because of decrease alb, wt loss fever, cough. Fever indicated fever factor so increased energy needs. Excessive sweating indicates dehydration. Decreased appetite and wt loss due to Stage 11 Lymphoma and flu-like symptoms. BMI, IBW% and UBW% indicated significant weight loss. Decreased Alb indicates malnourished. Increase WBC, decreased Hct, Hgb, Ferritin, MCV all indicate iron deficiencyanemia. High temp indicates fever factor and increased energy needs. Shallow respiration due to illness. PO Regular is inadequate because of increased energy needs.
Malnourished r/t loss of appetite, flu-symptoms, cancer, AEB % UBW, %IBW, BMI, dietary recall, decreased Alb.
Increased energy/ pro needs r/t healing AEB increased temp, new dx.
Increased nutrient needs-iron r/t decreased appetite, wt. loss, diet recall AEB decreased Hct, Hgb, Ferritin, MCV.
Plan:
Purpose of nutrition education is to help learn how to Power Pack and increase fluids, and eat foods with iron. Take an iron supplement.
Nutrition Prescription is 2400kcals, 65-80g protein, At least 2000 ml of fluid. Revaluate understanding of power packing and importance of wt. maintenance. Monitor wt, alb, Hct, Hgb, Ferritin, MCV, and dietary intake. Reassess in 3-5 days.
References:
1) Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th edition. St. Lewis, Missouri. Saunders Elsevier; 2008.
2) Cancer Treatment of America. B-cell Lymphoma. Available at: http://www.cancercenter.com/b_cell_lymphoma.cfm. Accessed: February 8, 2011.
3) Your Life Health. Lymphoma. Available at: http://www.healthscout.com/ency/68/304/main.html. Accessed: February 9, 2011.
4) Rosenwald A, Wright G, Chan WC et al. The Use of Molecular Profiling to Predict Survival After Chemotherapy for diffuse Large B-cell Lymphoma. New England Journal of Medicine. 2002;346:1937-1947.
5) Tisdale MJ. Cancer Cachexia. 1991;63:337-342.
6) Inui A. Cancer Anorexia-Cachexia Syndrome: Current Issues in Research and Management. A Cancer Journal for Clinicians. 2008;52(2):72-91.