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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. Hilari Holmgren 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). Hilari Holmgren 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 Hilari Holmgren 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 Hilari Holmgren 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.