Case Study for MNT, 12/2009


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  • Hodgkin lymphoma less common, aka Hodgkin’s DiseaseReed-Sternberg cells, B cells with more than one nucleusAffect young adults, age gap where Hodgkin’s is not found, again affects elderlyNon-Hodgkin Lymphoma is much more commonAffects adults but can affect childrenAs it metastasizes it can pass over lymph nodes or go directly to an organ
  • See the incidence in perspective
  • Increased risk of getting lymphoma if you’ve have certain virusesEpstein-Barr virus is known to increase risk of Burkitt’s lymphoma in AfricaMono which is actually caused by Epstein-Barr, increases chancesH. Pylori; Disorders that this bacteria causes also pose a problem: Celiac sprue, Inflammatory bowel diseaseConnective tissue disorders: Rheumatoid arthritis, lupus
  • HLB-cells become abnormal and turn into Reed-Sternberg cellsThis proliferates a malignancy, which begins in the lymph nodesGradually spreads from one node to the nextNHLB-cells, can involve T-cellsOriginates in any lymph tissue (nodes or accessory organs)As it spreads, it can skip areas; One lymph node directly to an organ
  • *Weight loss; fever; night sweatsPel-Ebstiein fever; found in HLCyclic on-off fever; recurring every 1-2 weeks; response to lymph node necrosisNHLLymph node enlarges more rapidlyCan show up on the skin as itchy patchesPersistent cough can occur if cancer is in the thoracic region – With fever may mimic fluNHL will cause GI symptoms
  • World Health Organizations staging criteriaNote that the higher the stage number, the worse the prognosis, as the disease has spread moreStage 4 is the worst, often require bone marrow or stem cell transplant
  • Sub-staging: A, B, E – also in your brochureDiagnosisLymph node biopsy only way to actually diagnose that it’s lymphomaThe rest are ways to determine stage and spreadPET scan is used to see if bone marrow or central nervous system are affectedImmunophenotyping – stain a sample of tissue with antigen receptors Determines whether lymph tissue is reactive or malignant Determines what type of lymphomaLiver enzymes tested; LDH levels or Beta-2 microglobulinLaparoscopy is used for stagingGallium scans – positive indicates aggressive lymphoma
  • Note the difference between normal and malignant lymphocyte in Hodgkin Lymphoma
  • Refer in the text on page 974: table 37-4AChemotherapy and hormonalMore than one chemo drug used to produce a greater effectUsually administered in on-off cyclesRadiation therapy often used in conjunction with chemo in more aggressive casesBiologic therapy – MOAB Monoclonal antibody. Used with chemo it’s called Chemo-immunotherapy; Rituximab attacks B-cell antigen, in this case CD20 Another MOAB Herceptin, which is used in aggressive breast cancerWatch and wait; Hold off treatment in indolent cases or ones that show no symptoms, and have no immediate danger to health; Patients sometimes call this Watch and worry
  • Weight 10 pounds less than normalCough medicine for a few weeks, experience night sweats and fever, decreased appetiteLymph node biopsy came back positive for lymphomaDiagnosis as Stage II diffuse large B-cell - aggressiveSymptoms indicate that sub stage is B
  • Mentioned earlier, Rituximab now standard treatment with chemo for aggressive lymphomas
  • Emphasis on fluid intake between meals, if you drink during meal, become full quickerFluid intake important to prevent dehydration with diarrhea, also alleviates constipationMoist of soft food choices, determine based on Denise’s food preferences, will help combat dry mouth or xerostomiaSuggest that the doctor prescribes antiemetic to address nauseaMagic mouthwash, used to treat mucositis
  • Based on her Usual Dietary Intake; meats and Ensure are to provide her with adequate protein; Fluid between mealsDiet analysis and meets her protein needs: assuming in a hypermetabolic state; need twice as much protein or about 80 grams: Box 37-3 on page 973
  • Assess hydration statusMake sure patient is not losing weight, specifically FFM which is Fat Free mass; loss of ffm in cancer patients is common and can lead to malnutritionCMP – hydration status, not losing protein, CBC – anemia, chemo side effect is decrease in blood cellsStay updated on her medical treatment with the doctor
  • Reed-sternberg cells2. NHL more common with a ratio of 9:13. Two areas, one side, symptoms are not present4. Rituxan or Rituximab5. Dry mouth, nausea, vomiting, diarrhea, constipation, change is taste or smell, weight loss
  • Case Study for MNT, 12/2009

    1. 1. Blood Cancers:<br />Lymphoma<br />Presented by Eileen Barash<br />
    2. 2. Non-Hodgkin Lymphoma (NHL)<br />Incidence: 4% cancers, 89% lymphomas<br />All other Lymphoma types included<br />Most often affects adults, average age 60<br />Spreads in a disorderly fashion<br />Abnormal B-cells (most common) or T-cells<br />Types<br />Over 60 different types<br />Indolent<br />Follicular lymphoma<br />MALT lymphoma<br />Aggressive<br />Diffuse large B-cell lymphoma<br />AIDS-associated lymphoma<br />Burkitt’s lymphoma<br />Diffuse large B-cell lymphoma<br />Classifications<br />Hodgkin Lymphoma (HL)<br />Incidence: 1% cancers, 11% lymphomas<br />Characterized by Reed-Sternberg cells<br />Bimodal incidence: Young adults/elderly<br />Spreads in an ‘orderly’ fashion throughout lymphatic system<br />Involves abnormal B-cells<br />Types<br />Classical HL<br />Nodular sclerosis (60-75%)<br />Mixed cellularity (5-15%)<br />Lymphocyte rich (5%)<br />Lymphocyte depletion (5%)<br />Nodular lymphocyte predominant HL<br />
    3. 3. Cancer Site Statistics<br />#7<br />Top 10 Cancer Sites: 2005, Male and Female, United States – All Races. Source:<br />
    4. 4. Risk Factors<br />NHL<br /><ul><li>Toxic compounds in atmosphere
    5. 5. Epstein-Barr Virus after organ transplant
    6. 6. Helicobacter pylori can cause mucosa-associated lymphoid tissue lymphoma
    7. 7. Other viruses such as Hepatitis C
    8. 8. Genetic predisposition</li></ul>HL<br /><ul><li>Diagnostic history of mononucleosis increases risk of young-adult HL
    9. 9. Sibling diagnosed with HL</li></ul>HL/NHL<br /><ul><li>Human immunodeficiency virus (HIV)
    10. 10. Autoimmune deficiency syndrome (AIDS)
    11. 11. Human T-cell lymphotropic virus (HTLV)</li></ul>- S. Japan, Caribbean, S. America, Africa<br /><ul><li>Suppressed immune function</li></li></ul><li>Physiology<br />HL<br /><ul><li>Development of abnormal B-cells
    12. 12. B-cells that become binucleated or multinucleated are characterized as malignant Reed-Sternberg cells
    13. 13. These cells tend to attract normal lymphocytes, enlarging lymph nodes
    14. 14. Tumor growth usually begins in the lymph nodes of the upper body
    15. 15. Cancer spreads from one lymph node to another, in an ‘orderly’ fashion</li></ul>NHL<br /><ul><li>Can involve abnormal development or B-cells (most common) or T-cells
    16. 16. Originates in the lymph nodes, lymphatic organs, or lymph tissue in organs (such as the spleen, bone marrow, thymus or tonsils)
    17. 17. Cancer can spread around all parts of the body and may skip over lymph regions</li></li></ul><li>NHL<br /><ul><li>Rapid, painless enlargement of lymph nodes
    18. 18. Progressive swelling of legs, swelling of face
    19. 19. Pale skin or dark, itchy patches of skin
    20. 20. Difficulty breathing, chest pain
    21. 21. Pleural effusion, causing persistent cough
    22. 22. Bloating, cramping, diarrhea, flatulence
    23. 23. Abdominal pain or distention, constipation
    24. 24. Unexplained appetite loss, weight loss
    25. 25. Fever, causing excessive night sweating
    26. 26. Increased susceptibility to infections</li></ul>Symptoms<br />HL<br /><ul><li>Painless enlargement of lymph nodes, usually in the neck, armpits, or groin
    27. 27. Swelling from edema in legs or feet
    28. 28. Shortness of breath, fatigue
    29. 29. Weight loss, muscle weakness
    30. 30. Pel-Ebstein fever, night sweats
    31. 31. Increased susceptibility to infections
    32. 32. Rapid
    33. 33. Pale skin or dark, itchy patches of skin
    34. 34. Pleural effusion, causing persistent cough
    35. 35. Bloating, cramping, diarrhea, flatulence
    36. 36. Abdominal pain or distention, constipation</li></li></ul><li>Staging<br />Diagnostic staging criteria for Hodgkin and Non-Hodgkin lymphomas.Source:<br />
    37. 37. Sub-Staging<br />A: No systemic symptoms present at diagnosis<br />B: Symptoms present (i.e. fever, night sweats, weight loss)<br />E: Noted when lymphoma spreads from lymph directly to organ<br />Diagnosis<br /><ul><li>Lymph node biopsy
    38. 38. Fine needle aspiration cytology
    39. 39. CBC with differentials
    40. 40. X-ray (Pictures using radiation)
    41. 41. CT (Computerized tomography)
    42. 42. MRI (Magnetic resonance imaging)
    43. 43. PET (Positron emission tomography)
    44. 44. DNA tests
    45. 45. Immunophenotyping
    46. 46. Blood proteins
    47. 47. Liver enzymes
    48. 48. Bone marrow/spleen/liver biopsy
    49. 49. CSF examination
    50. 50. Laparoscopy (</li></li></ul><li>HL: Reed-Sternberg Cell<br />Reed-Sternberg cell<br />Normal lymphocyte<br />Normal lymphocyte versus malignant binucleated or multinucleated R-S cell. Source:<br />
    51. 51. Common Drugs<br />Alkylating agents<br />Antitumor antibiotics<br />Antimetabolites<br />Antimitotic agents<br />Glucocorticoids<br />Treatment<br />Example (Brand)<br />Cyclophosphamide(Cytoxan)<br />Doxorubicin (Rubex)<br />Methotrexate (Rheumatrex)<br />Vincristine (Oncovin)<br />Prednisone (Decadron)<br />Chemotherapy<br />Hormone<br /><ul><li>Multiple drugs administered simultaneously for a synergistic effect (CHOP)
    52. 52. Chemotherapy is given in about 3 to 12 cycles of treatment/non-treatment
    53. 53. Forms of administration: orally, by injection, intravenously
    54. 54. Things to consider: Type, stage, and location(s) of lymphoma; age and initial health status of individual; dose intensity and duration; side effects of drugs</li></ul>Other treatments include: <br />Surgery to remove affected tissue<br />Bone marrow and stem cell transplantation<br />Biologic therapy (such as Rituximab)<br />Radiation therapy<br />“Watch and wait”<br />
    55. 55. Case Study:<br />Denise Mitchell<br />
    56. 56. Assessment<br />Complaint: “I have continued to feel run down since I had the flu.<br />I still have a fever and the cough won’t go away.”<br />Age: 21 years Height: 5’6” UBW: 130<br />Sex: Female Weight: 120 lbs BMI: 19.4 (Normal)<br />PMH: Tonsillectomy at age 5 Family Hx: Noncontributory<br />Meds: OTC cough medicine Allergies: NKA<br />Chest X-ray: Possible mass<br />Biopsy of suspect lymph nodes: Positive<br />Physical exam concerns:<br />Symptoms: Decreased appetite, fever, night sweats, persistent cough<br />Medical Dx: Stage II diffuse large B-cell lymphoma with mediastinal disease<br />100.5°F, slightly high<br />Thin, pale; appears tired<br />Slightly dry mucous membranes<br />Shallow respirations; dullness present to percussion<br />Temperature<br />Appearance<br />Throat<br />Chest/Lungs<br />
    57. 57. Treatment<br />CHOP Regimen<br />C – Cyclophosphamide (Alkylating)<br />H – Hydroxydoxorubicin (Antibiotic)<br />O – Oncovin (Antimitotic)<br />P – Prednisone (Glucocorticoid)<br />Localized Radiotherapy<br />Treatment begins after third cycle of CHOP<br />Recent findings: Rituxan (Rituximab), a monoclonal antibody, is now a standard treatment in conjunction with CHOP (abbreviated R-CHOP).<br />Source: Review by<br />
    58. 58. Nutrition Diagnosis<br /> Inadequate oral food/beverage intake (NI-2.1) RT side effects of chemotherapy (nausea, emesis, diarrhea/constipation, mucositis, xerostomia, dysgeusia, dysosmia) AEB decreased nutrient intake and weight loss following treatment.<br />P: Inadequate oral food/beverage intake<br />E: Side effects of chemotherapy<br />S: Decreased nutrient intake and weight loss<br />
    59. 59. Food and/or Nutrient Delivery<br />Pt receives 8-oz. cans of Ensure Plus or similar supplement to drink BID<br />Nutrition Education<br />Pt educated about tracking dietary intake and the importance of consuming adequate calories and protein to meet nutritional needs, and adequate potassium and calcium to prevent mineral wasting<br />Emphasis on consumption of Ensure or other supplemental drinks to help maintain weight, and sufficient fluids to prevent dehydration<br />Verbal instruction on how to achieve a high-calorie, high-protein diet; Recommendations for moist or soft food choices are discussed<br />Nutrition Counseling<br />Pt instructed to eat small, frequent meals throughout the day and consume liquids between meals<br />Collaborative effort to create individualized meal plan including food choices preferred by pt<br />Coordination of Nutrition Care<br />Consult with MD re: administering antiemetic and Magic Mouthwash<br />moist or soft food choices<br />Magic Mouthwash<br />antiemetic<br />Intervention<br />
    60. 60. Sample Meal<br />Breakfast<br />1 c. oatmeal, or cold cereal if tolerated<br />2 slices bread, 1 T butter<br />*After breakfast, drink 1 c. Ensure Plus<br />Lunch<br />2 slices bread,1 T. mayonnaise<br />1 oz. canned or grilled tuna<br />½ c. frozen yogurt, any flavor<br />Dinner<br />2 oz. chicken breast<br />½ c. mashed potatoes, 2 T. gravy<br />4 oz. Jell-O gelatin, any flavor<br />Snack<br />2 oz. breadsticks, soft<br />4 oz. fruit cup<br />2 oz. dried figs<br />Snack<br />1 medium banana<br />½ c. applesauce<br />½ c. lettuce, 1 T. dressing<br />Fluids<br />Drink or sip through a straw throughout the day, preferably between meals:<br />At least 6 8-oz. cups of water AND 2 c. of Ensure Plus formula, any flavor*<br />If desired, patient may also consume: 2 c. of juice (apple, cranberry; no citrus)<br />
    61. 61. Monitoring & Evaluation<br />Monitor weekly<br />Physical Examination<br />Assess for hydration status<br />Assess for muscle wasting<br />Anthropometric<br />Measure weight and note any changes<br />Determine FFM and note any changes<br />Biochemical<br />CMP (hydration status, protein stores, electrolytes)<br />CBC with differential (anemia)<br />Dietary History<br />Daily food record<br />Ask pt about any problems eating, such as from side effects of chemo<br /><ul><li>Collaborate with MD; If medical Tx changes or pt nutrition status is not responding to nutrition intervention, modify plan accordingly.</li></li></ul><li>Questions<br />1<br />2<br />3<br />4<br />5<br /> What diagnostic marker is characteristic in Hodgkin lymphoma?<br /> Which is more common, Hodgkin or Non-Hodgkin lymphoma?<br /> A patient is diagnosed with Stage IIA Burkitt’s lymphoma. How many lymphoid areas are involved, and is the cancer found on one side or both sides of the body? Are there any symptoms present at diagnosis?<br /> What is the name of the monoclonal antibody currently administered in conjunction with the CHOP regimen?<br /> What are 3 GI-related side effects of chemotherapy?<br />
    62. 62. References<br />(Visual) Cancer Site Statistics, 2005. <br />(Visual) Staging for Lymphoma:<br />(Visual) Reed-Sternberg Cell.<br />The Cochrane Library: Rituximab as maintenance therapy for patients with follicular lymphoma.<br />American Institute for Cancer Research: Nutrition of the Cancer Patient. Dealing with Side Effects.<br />Lymphoma Research Foundation: Getting the Facts: Diffuse Large B-cell Lmphoma.<br />The Merck Manual, 15th Ed.: Hematology and Oncology: Lymphoma.<br />Krause’s Food and Nutrition Therapy, 12th Ed.<br />American Dietetic Association Evidence Library: Nutrition Care Process.<br />National Guideline Clearinghouse:Staging Laparoscopy for Lymphoma.<br />