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Hilari Holmgren
Stage II B-Cell Lymphoma:
A Case Study
Hilari Holmgren
Introduction
DM was a 21-year-old college student, admitted to the hospital on March 8, 2010
with complaints of flu-like symptoms, fever and excessive sweating for 2-3 months.
Upon evaluation, she was diagnosed with stage II diffuse large B-cell lymphoma with
mediastinal disease and positive lymph nodes. The following case study will discuss the
pathophysiology and progression of cancer as it relates to B-cell lymphoma. It will also
discuss the nutritional implications associated with B-cell lymphoma. It will review the
patient’s medical history, treatment and progression as well as the nutrition care plan.
Patient Profile and Social History
DM was a 21-year-old Caucasian female who resided with her parents and three
younger siblings. Her primary caregivers were her parents. DM was a sophomore at
Midwest University. She was a Methodist. The patient denied smoking or drinking
alcohol.
Medical History
DM’s family history considered noncontributory. DM herself had an
unremarkable past medical and surgical history.
Upon admit, DM was diagnosed with stage II diffuse large B-cell lymphoma with
mediastinal disease and positive lymph nodes. Bone marrow and other organs showed no
indication of disease. The patient was prescribed a 21-day cycle of the chemotherapy
regimen, cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). While
hospitalized, she received her first cycle of chemotherapy. She was scheduled to undergo
radiation after completion of the third chemotherapy cycle. She also received cancer selfmanagement education.
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Stage II B-Cell Lymphoma- Literature Review
Cancer statistics in the USAbout 65,540 people (35,380 males and 30,160 females) of all ages will be
diagnosed with non-Hodgkin lymphoma annually? Of which, about 20,210 people will
die from this type of cancer (10,710 males and 9,500 females) (5 references must go in
sequential order so this should be 1 and not 5). More than 95% of cases occur in adults.
The average American's risk of developing non-Hodgkin lymphoma during his/her
lifetime is about 1 in 50. Since the 1970s, incidence rates for non-Hodgkin lymphoma
have nearly doubled. Some of this increase is due to AIDS-related non-Hodgkin
lymphoma, but for the most part, the reason for the rise is unknown. The risk of
developing non-Hodgkin lymphoma increases as age increases (5).
B-Cell LymphomaPrimary mediastinal B cell lymphoma (PMBL) has been recognized as a subtype
of diffuse large B cell lymphoma (DLBCL) based on its distinctive clinical and
morphological features (2). In many patients, the only site of lymphoma involvement is
the mediastinum, but the lymphoma can extend locally to involve other thoracic
structures and occasionally disseminate to distinctive extranodal sites (3).
Treatment options for lymphomaThe standard treatment for patients with diffuse large-B-cell lymphoma is
cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). Rituximab, a
chimeric monoclonal antibody against the CD20 B-cell antigen, has therapeutic activity
in diffuse large-B-cell lymphoma. The addition of rituximab to the CHOP regimen
increases the complete-response rate and prolongs event-free and overall survival (7).
Hilari Holmgren
Side effects for chemotherapyDrug resistance can occur in individuals who are going through chemotherapy
treatment. Identified mechanisms include overexpression of target genes, drug
inactivation by tumor cells, defective apoptosis in tumor and loss of receptors for
hormonal agents (6).
Diffuse large-B-cell lymphoma, the most common type of lymphoma in adults,
can be cured by anthracycline-based chemotherapy in only 35 to 40 percent of patients
(4).
Transferrin DeficiencyIn the case of a transferrin deficiency, absorbed iron that enters the portal system
as transferrin-bound iron is deposited in the liver. Subsequent transfer to sites of red
blood cell (RBC) production is reduced because of the transferrin deficiency. Lack of
ferroxidase results in defective conversion of Fe2+ to Fe3+, which is necessary for
binding to transferrin; this in return impairs the movement of iron from intracellular
stores to plasma transport, resulting in tissue iron accumulation (6).
Weight lossWeight loss is an important prognostic indicator for patients suffering with
cancer. Up to one-half of untreated cancer patients experience weight loss and about onethird lose more than 5% of their original body weight (1). The survival rate for cancer
patients is directly related to the weight lost and also the rate in which the weight was is
lost. Even small amounts of weight loss (less than 5% of body weight) can worsen
prognosis. Patients who have experienced weight loss will also have a decreased response
to chemotherapy (1).
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Cancer CachexiaCancer cachexia is a complex complication of cancer with a high mortality rate
accounting for 20% of all cancer deaths (reference). The etiology of cancer cachexia is
largely unknown. Cachexia is different than starvation, starved individuals lose adipose
tissue while lean body mass is preserved whereas in individuals with cachexia, patients
lose both adipose and lean mass. A loss of lean tissue can result in a reduced functional
capacity for organ systems, but initially, this may be difficult to detect because in the at
early stages, there may be an accumulation of water masking early changes in mass. The
loss of skeletal muscle results in weakness, which could lead to immobility and
eventually death because of a loss of respiratory function. Patients with greater than 15%
weight loss are likely to have impaired physiological function Death normally occurs
when weight lost is about 30% of total body weight.
Individuals who suffer with cachexia have an increase in liver mass; this is
because of metabolic recycling activity and synthesis of acute phase protein (APP) (1).
Treatment and Progress:
DM was admitted to the hospital on March 8, 2010 with complaints of flu-like
symptoms, a fever, and cough for the past 2-3 months. Upon evaluation, she was
diagnosed with stage II diffuse B-cell lymphoma with mediastinal disease and positive
lymph nodes. Her bone marrow and other organs showed no indication of disease.
She was prescribed the chemotherapy regimen CHOP. Prednisone was to be
administered orally on the first five days of each 21-day cycle, and the other
chemotherapeutic medications were to be given intravenously on the first day of the
Hilari Holmgren
cycle. Radiotherapy was planned to start three weeks after completion of the third cycle
of CHOP. She received B-cell lymphoma self-management education.
Medications:
Prior to admit, DM took over-the-counter (OTC) cough medicine and Tylenol.
There were no nutritional concerns with these medications.
Upon admit, she was prescribed the chemotherapy regimen CHOP Discuss
possible nutrition-related side effects of these chemo agents.
Anthropometrics:
DM weighed 55 kg at the time of admission and was 168 cm tall. Her body mass
index (BMI) was 19, which indicated she was underweight. Her ideal body weight (IBW)
was 59 kg and she was 92% of her IBW. Discuss weight history in this section also
Laboratory Data:
The following laboratory values were nutritionally pertinent:
Test
Admit
Normal
Gluc
105 H
70-110 mg/dL
Alb
3.3 L
3.5-5 g/dL
Hct
31 L
36-46%
Hgb
11 L
14-18 g/dL
RBC
4.2
4.2-5.4 x10³/mm³
Chol
171
120-199 mg/dL
MCV
70 L
80-96
Ferritin
19 L
20-120 mg/mL
Bilirubin
.8 H
≤ .3 mg/dL
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Total Protein
5.5 L
6-8 g/dL
WBC
12 H
4.8-11.8 x10³/mm³
DM’s elevated white blood cell (WBC) count was due to stress and her diagnosis
of B-cell Lymphoma. DM’s decreased mean corpuscular volume (MCV), albumin (Alb),
hematocrit (Hct), hemoglobin (Hgb), and ferritin indicated microcytic anemia and iron
deficiency.
Clinical Evaluation:
The patient was thin, pale, and lethargic. She did not demonstrate any overt signs
or symptoms of nutrition deficiency. She was able to perform all activities of living.
Diet Evaluation:
Her energy needs were 2,900 kcal/day using the standard estimate of 2,000 kcals
Her protein needs were 83 g/kg using the standard estimate of .8 kcals/kg to promote
healing and repletion of protein stores. Her fluid needs were 1925 mL using the standard
estimate of 25 ml/kg
Upon admittance, the patient was prescribed a regular diet order. Her per os (PO)
was poor at less than 25% of meals, which was not adequate to meet her needs. She
encouraged to improve her PO and high protein supplements were ordered to promote
intake.
A 24-hour diet recall was obtained. She reported a loss of appetite and a weight
loss of 10 lbs over the past 2-3 months. Her diet recall was low in all macro- and
micronutrients.
Hilari Holmgren
The patient was educated on power packing, cancer and nutrition education, and
sources of iron rich foods. The patient verbalized understanding of the education, was
receptive, and was likely to comply.
Nutrition Note: Make sure to make changes to your note based on Meagan Latimer’s
feedback
Subjective:
c/o poor appetite/ 10# wt. loss x 2-3 mos
Objective:
21 yof dx c stage II lymphoma. CHOP prescribed. Radiation to begin s/p 3rd
cycle.
Ht. 5’6”. Wt. 120#. UBW 130 #. BMI: 19. Alb. 3.3. Gluc 105. Hgb 11. Hct 31.
MCV 70. Ferritin 19. Diet order: regular. Po less than 25%. Obtained diet hx.
Assessment:
Pt at moderate nutrition risk. 7-8% wt loss x 2-3 months. decreased albumin, po,
and Fe. New dx of lymphoma chemo/ radiation planned.
Nutrition Dx:
Malnutrition r/t poor po at cancer AEB 8% wt loss x 2-3months. decreased
albumin. AEB Diet hx.
Increased energy pro needs r/t healing AEB increased temperature, new dx.
Nutrition Intervention:
1. Purpose of nutrition education: power packing, cancer, increase Fe foods
education.
2. Modify distribution, increase protein snacks TID
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3. Commercial beverage: boost c meals
Will reassess in 3 days. Will monitor wt. po.
Patient Follow Up:
DM was assessed moderate nutrition risk and was released five days after initial
hospitalization.
Summary and Conclusions:
DM’s overall prognosis was considered good based on her age and type of cancer.
Although her intake had been poor and she had lost weight prior to admission, if DM
adhered to the education she received, she would likely experience fewer complications
and side effects from B-cell lymphoma and its treatment.
Hilari Holmgren
References:
(1) Tisdale MJ, Nature Publishing. Cachexia in Cancer Patients. Research institute, Aston
University, Birmingham UK. 2002; 2. 862-871.
(2) Barth, T, Leithauser F, Joos S, Bentz M, and Moller P. 2002. Mediastinal (thymic)
Large B-Cell Lymphoma: Where Do We Stand? Lancet Oncol. 3:229–234.
(3) Bishop, PC, Wilson WH, Pearson D, Janik J, Jaffe ES, Elwood PC. CNS Involvement
in Primary Mediastinal Large B-Cell Lymphoma. J Clin Oncol. 1999;17:2479–2485.
(4) Coffier B, Lepage E, Briere J, Herbrecht R, Tilly H, Bouabfallah R, Morel P, Van
Den Neste E, Salles G, Gaulard P, Reyes F, Gisselbrecht C. Chop Chemotherapy Plus
Rituximab Compared with Chop Alone in Elderly Patients with Diffuse Large B Cell
Lymphoma. The New England Journal of Medicine. 2002;4(346)235-242.
(5) Key Statistics About Non-Hodgkin Lymphoma. American Cancer Society 2010.
Available at: http://www.cancer.org/Cancer/NonHodgkinLymphoma/DetailedGuide/non-hodgkin-lymphoma-key-statistics. Accessed:
February 9, 2011.
(6) Beers MH, Porter RS, Jones TV, Kaplan JL, Berkwits M. 2006. The Merck Manual of
Diagnosis and Therapy. Eighteenth Edition.
(7) Rosenwald A, Wright G, Chan WC, Connors JM, Campo E, Fisher RI, Gascoyne RD,
Muller-Hermelink K, Smeland EB, Staudt LM. The Use of Molecular Profiling to Predict
Survival After Chemotherapy for Diffuse Large B-Cell Lymphoma. New England
Journal of Medicine. 2002;25(346):1937-1947.