Hl & Tls Presentation


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  • LHD – lactate dehydrogenase – 100-250 - In medicine, LDH is often used as a marker of tissue breakdown as LDH is abundant in red blood cells and can function as a marker for hemolysis.USpGr- urine specific gravity – 1.005-1.030UpH- urine pH - 4.8-8.0Uurob- urine uribikirubin -0-8
  • Often spreads from one lymph node to another and can also spread to other organs
  • A No symptomsB Fever (temp higher than 38 C), drenching night sweats, unexplained weight loss of more than 10% in the last 6 monthsX Bulky disease (mediastinal mass exceeding 1/3 the maximum transverse diameter of the chest or the presence of a nodal mass with a maxiumum dimension > 10 cm) E Involvment of a single extranodal site that is contiguous or proximal to a known nodal siteCS Clinical Stage PS Pathologicial Stage (the mediastinum is considered as a single site, whereas hilar lymph nodes are lateralized).  The number of anatomical sites should be indicated by a subscript (i.e., II3)
  • Highlighted is what our pt is exhibiting. Pel-Ebstein fever is a rarely seen condition noted in patients with Hodgkin's lymphoma in which the patient experiences fevers which cyclicly increase then decrease over an average period of one or two weeks.[1] A cyclic fever may also be associated with other conditions, but it is not called "Pel-Ebstein fever" unless the fever is associated with Hodgkin's.
  • Stanford V Mechlorethamine,Doxorubicin,Vinblastine, Vincristine, Bleomycin, Etoposide, PrednisoneAre there any medication issues? RT is optional with ABVD and not best for our young patient because it has potential for long-term toxicity leading to heart disease, pulmonary dysfunction, and secondary malignancies, and sterility. Doxorubicin-MOA: Safety: Efficacy:Bleomycin- MOA: Safety: Efficacy: Vinblastine- MOA: Safety: Efficacy: Dacarbazine-MOA: Safety: Efficacy:
  • Raynaud’s phenomenon is a condition in which cold temperatures or strong emotions cause blood vessel spasms that block blood flow to the fingers, toes, ears, and nose. Low risk <10% for neutropenia.
  • Tumor response with all drugs!Doxorubicin (Anthracycline)- CBC,EF ----Intercalation blocks replication of nucleotide and action of DNA and RNA polymerases.Bleomycin (Antibiotic)- CBC prior to each dose, chest- X ray every 2 weeks, PFTs, renal and hepatic function, idosyncratic reactions ---inhibition of DNA synthesis via single-strand breaks Vinblastine (Mitotic Inhibitor)-Signs and symptoms of extravasation. ---Alkaloidal antineoplastic agent that inhibits microtubule formationDacarbazine (Alkylating Agent)- CBC with differential ----It may inhibit DNA synthesis by acting as a purine analog
  • Because Dacarbazine has high emetogenic potential risk we chose a regimen the mose aggressive regimen.
  • All pregnancy category D except Dacarbazine C.
  • Megestrol acetateCorticosteroids
  • Hl & Tls Presentation

    1. 1. Cory Phillips, Jennifer Corder, Whitney Dulin
    2. 2.  CC: “Two month history of night sweats, fever/chills, and a recent 20 lb weight loss.” HPI: Amy is a 22 yo female who presents to the ER with a 2 month history of night sweats, fever/chills, and unintentional weight loss (20lbs). The patient also reports fatigue. The patient reports an enlarged supraclavicular lymph node which hurt after drinking alcohol. The LN was biopsied, and Amy was diagnosed with Hodgkin’s Lymphoma. She is scheduled to receive ABVD. PMH: tonsillectomy 14 years ago. PSH: Student at Vanderbilt. Stress associated with school. No tobacco. No illicit drugs. Drinks 3-4 nights per week. FH: N/A (adopted) Chemo Regimen: ABVD (Doxorubicin, Bleomycin, Vinblastine, Dacarbazine) MH: Ortho Tri-Cyclen 1 tablet daily as directed NKDA
    3. 3.  General:  Ht 5 ft 8 in Wt 80 kg = 176 lb BMI 26.8 IBW 63.9  CrCl 68.47  BSA 1.96 m2  PE: WNLs  Vitals: BP 115/68 P 65 RR 18 T 99.8 F (fever)  Pertinent Labs: WNL except: 143 105 32 ↑ 10.6 ↓ 6.2 ↑ 20 ↓ 1.3 ↑ 127 ↑ 9.4 180 32 ↓  Phos 5.4 ↑  LDH 562 ↑  UA ↑UColor UChar USpGr UpH UGluc UAlb UrPro UKeto UBili UUrob ULuEst UrLEU NitriteYellow Clear 1.017↑ 6.8 Neg. Neg. Neg. Neg. Neg. < 1.0 Neg. Neg. Neg.
    4. 4.  Lymphoma is the most common blood cancer  Lymphocytes grow abnormally  B-lymphocytes (B-cells) and T-lymphocytes (T-cells) Cancerous lymphocytes can travel to the lymph nodes, spleen, bone marrow, blood or other organs, and can accumulate to form tumors Hodgkin’s lymphoma is characterized by the presence of Reed-Sternberg (R-S) cells, although other abnormal cell types may be present. Usually starts in lymph nodes.
    5. 5.  Classical Hodgkin Lymphoma  Nodular Sclerosis (60-80% cases): Most common subtype ▪ Lymph nodes contain R-S cells mixed with normal WBCs and prominent scar tissue ▪ More common in women ▪ Affects adolescents and adults < 50 yoa ▪ Majority of patients’ cured with current treatments  Mixed Cellularity (15-30% cases): ▪ More common in men ▪ Lymph nodes contain many R-S cells and several other cell types ▪ Affects older adults and may be associated with HIV and EBV ▪ Extensive disease usually present by diagnosis
    6. 6.  Classical Hodgkin Lymphoma  Lymphocyte Depletion (<5% cases): ▪ Few normal lymphocytes, but abundant R-S cells ▪ Lymphocyte depletion aggressive and not diagnosed until disease is widespread  Lymphocyte-Rich (<5% cases): ▪ The disease may be diffuse (spread out) or nodular (knot-like) ▪ Numerous normal lymphocytes and few abnormal cells and classical R-S cells ▪ Usually diagnosed at an early stage in adults and has a low relapse rate
    7. 7.  Lymphocyte Predominant Hodgkin Lymphoma  Nodular Lymphocyte Predominant (5-10% cases): ▪ More common in men ▪ Diagnosed <35 yoa ▪ Most lymphocytes in the lymph nodes are normal (not cancerous) ▪ Typical R-S cells are usually not found in this subtype ▪ Large, abnormal B-cells and reactive small B-cells, which may be distributed in a nodular (knot-like) pattern within the tissues ▪ Usually diagnosed at an early stage and not very aggressive ▪ Resembles low-grade (indolent) B-cell non-Hodgkin lymphoma  Diffuse Lymphocyte Predominant (rare) ▪ Existence questioned ▪ Most cases are nodular lymphocyte predominant Hodgkin Lymphoma with an ill-defined nodular pattern
    8. 8.  Family history of HL Higher social class Advanced education Small family size Delayed exposure to common infectious or environmental agents Associated with EBV Slight increase in HIV (HIV-associated HL)
    9. 9.  Stage Description I. Involvement of a single lymph node region or lymphoid structure II. Involvement of two or more lymph node regions on the same side of the diaphragm III. Involvement of lymph node regions or structures on both sides of the diaphragm IV. With involvement of splenic hilar, celiac, or portal nodes V. With involvement of paraaoartic, iliac, and mesenteric nodes VI. Involvement of one or more extranodal sites in addition to a site for which the designation “E” has been used
    10. 10.  Staging (most crucial determinant of prognosis) Histopathology of subtype Age > 60 Anemia Elevated ESR Bone marrow involvement Bulk of disease Poor Karnofsky’s scale performance status
    11. 11.  Male sex Age ≥45 years Stage IV disease Serum Alb <4 g/dL Hemoglobin <10.5 g/dL WBC >15,000/mcL Lymphocytes <600/mcL or <8% of WBC
    12. 12.  Painless lymphadenopathy usually CC  Superficial lymph nodes Systemic symptoms:  Fevers  Night sweats  Weight loss Marked fatigue and general weakness  Pruritus (often intense)  Pel-Ebstein fever Pain  Alcohol-induced pain  Abdominal pain  Bone Pain  Neurogenic pain  Back pain
    13. 13.  Stage IB Hodgkin’s Lymphoma Tumor Lysis Syndrome Nausea and Vomiting Infection Prophylaxis Alopecia Fatigue Constipation Stress Weight loss
    14. 14.  Cure cancer Prevent Metastasis Reduce fatigue Control anxiety and stress Control any constipation Prevent  Nausea and vomiting  Neutropenia  Infection Maintain quality of life as much as possible
    15. 15.  ABVD x 2-4 cycles  Doxorubicin 25 mg/m(2) IV on days 1 and 15 ▪ Doxorubicin 49 mg IV on days 1 and 15  Bleomycin 10 units/m(2) IV on days 1 and 15 ▪ Bleomycin 19.6 units IV on days 1 and 15  Vinblastine 6 mg/m(2) IV on days 1 and 15 ▪ Vinblastine 31.4 mg IV on days 1 and 15  Dacarbazine 350 to 375 mg/m(2) IV on days 1 and 15 ▪ Dacarbazine 686 mg IV on days 1 and 15  Repeat cycle every 28 days  Restage after chemotherapy with PET-CT
    16. 16.  Doxorubicin  alopecia, nausea, vomiting, heart failure, extravasation Bleomycin  hyperpigmentation of skin, stomatitis, pneumonia, Raynaurd’s phenomenon, hemorrhagic cystitis, hepatotoxic, nephrotoxic Vinblastine  alopecia, constipation, bone pain, malaise, hypertension, leukopenia, myelosuppression Dacarbazine  hypotension, alopecia, loss of appetite, nausea, vomiting, headache, polyneuropathy, influenza-like illness, myelosuppression, hepatotoxic
    17. 17.  Monitor  Tumor response  Chem 7  CBC with differential  Ejection fraction (EF)  Pulmonary function tests (PFTs) ▪ Diffusion capacity of the lungs for carbon monoxide (DLCO)  Renal and hepatic function  Urinalysis  S/Sx of Extravasation
    18. 18.  Doxorubicin – moderate (30-90 %)  Bleomycin – minimal (<10%)  Vinblastine – minimal (<10%)  Dacarbazine – high (>90%) Emetogenic Regimen  Aprepitant ▪ 125 mg PO day 1 (day of chemo), then 80 mg PO day 2  Dexamethasone ▪ 8 mg PO BID day prior to chemo, 12 mg IV day of chemo, and 12 mg PO day after chemo  Palonsetron ▪ 0.5 mg PO day 1 (day of chemo)  Lorazepam ▪ 0.5 mg PO Q4-6H PRN to decrease anxiety from stress ▪ May also help prevent nausea and vomiting
    19. 19.  Group of metabolic complications that can occur spontaneously or after treatment of a neoplastic disorder Tumor-burden and chemotherapy induced Caused by the rapid destruction of cancer cells  Leads to release of intracellular components Most commonly seen after aggressive therapy for hematologic malignancies If not treated it can lead to muti-organ failure and death
    20. 20.  More common in leukemias and lymphomas Direct releationship between mass doubling time and risk of TLS The more sensitive the tumor is to treatment the greater the risk for TLS Patients with baseline compromised renal function are at increased risk for TLS due to inability to excrete electrolytes effectively Elevated baseline UA levels   less purine catabolism  increased risk of hyperuricemia
    21. 21.  Laboratory TLS  2 or more of the following criteria occuring within 3 days before or 7 days after initiation of chemotherapy in a well-hydrated patient who is receiving a hypouricemic agent: ▪ Uric Acid ≥ 8 mg/dL ▪ Phosphate ≥ 4.5 mg/dL ▪ Potassium ≥ 6 mEq/L ▪ Calcium ≤ 7 mg/dL Clinical TLS  Includes the diagnosis of laboratory TLS plus 1 or more of the following: ▪ Increased SCr (1.5 times the upper limit of normal) ▪ Cardiac arrhythmia or sudden death ▪ New-onset seizures Patient is hyperkalemic (potassium >6.0 mmol/L), hyperphosphatemic (goal 3.3-4.9 mEq/L) , and hyperuricemic (goal 3-7 mg/dL)  Patient is considered laboratory TLS but not clinical TLS
    22. 22.  Initiate 1/4NS + D5W 4.0 L per day  Maintain urine specific gravity ≤ 1.010  Maintain UOP 80-100 mg/m2/hr Allopurinol  600-800 mg/day PO Q8-12 hours  OR 200-400 mg/m2/day IV Initiate Allopurinol 400 mg/day IV  Initiate 3 days prior to chemotherapy Monitor: UA, I/Os, renal function Monitor (Q6hours during treatment)  CBC, SCr, UA, K, P, Ca
    23. 23.  Monitor for normalization of lab values After hydration reevaluate and initiate  Diuretic if UOP not 80-100 ml/m2/hr and patient is euvolemic  Rasburicase if UA still high  Phosphate binder if still hyperphosphatemia  Alkalinization with sodium bicarbonate NOT recommended
    24. 24.  Lymphoma considered intermediate in overall infection risk  Consider antibacterial prophylaxis ▪ Fluoroquinolone ▪ Levofloxacin 500mg PO daily  Consider fluconazole (anti-fungal) and anti-viral prophylaxis during neutropenic episodes
    25. 25.  Hemolysis evident by very elevated LDH ABVD risk of febrile neutropenia <10% G-CSF not routinely used but some data exists that it might be useful  Could prevent bone pain Assess and monitor ANC (data N/A in case) Initiate G-CSF if needed after chemotherapy G-CSF Filgrastem 5 mcg/kg SQ daily  Begin 24 hours after completion of chemotherapy  Continue until ANC >1000 for 3 days  Or >5000 for 1 day Give Filgrastim 3 weeks before the next cycle of chemotherapy
    26. 26.  Patient is already fatigued which may worsen with chemotherapy Life-style modifications  Exercise, no overexertion, healthy nutrition Methylphenidate 2.5 mg twice daily  Titrate up every 2 days as needed
    27. 27.  Non-pharmacological treatment options  Increased fluids, fiber, and physical activity Recommend osmotic laxative  Sorbitol 45mL PO Qdaily Diarrhea should not be an issue with ABVD
    28. 28.  Recommendations  Control anxiety (nonpharmacological interventions and/or lorazepam)  Screen for depression regularly ▪ This patient’s whole life will change and she may not be able to continue her schooling  Oocyte cryopreservation prior to chemotherapy  Avoidance of alcohol  Vaccinations ▪ H. influenzae, pneumonococcal, and meningococcal vaccines ▪ Especially if radiation therapy (RT) in the future
    29. 29.  Patient is in college- Low income Probably lives alone and not near family Likely she has no insurance Patient Background  Adopted with no known family history Manifesting as fatigue, weight loss, and stress  Likely lose more weight with chemotherapy Impacts on Patient  Postpone school or take online classes  Move closer to her family for support  No ETOH - quit drinking  Will lose her hair from the chemotherapy which may make social interaction and school difficult  Cannot consider or get pregnant on ABVD
    30. 30.  Fatigue  Rest when you needed and do not push body too far  Low impact exercise (walking) to release endorphins  High nutrient diet  Methylphenidate initial 2.5 mg twice daily ▪ Titrate up every 1-2 days Weight loss  Eat small, frequent meals  Use a smaller plate  Choosing healthy foods with high nutrition (fruits/vegetables)  Eat food at room temperature  Dietary consult before starting chemotherapy  Consider megestrol acetate/CSs if needed Nausea/Vomiting – avoid triggers like odors and eat several small meals a day
    31. 31.  Stress Management  Nonpharmacological stress reducing activities that the patient enjoys (yoga, painting, etc…)  And/or an anxiolytic Hair loss  Donate hair prior to chemotherapy if desired  Good wigs and wraps School  Online classes or reduced load if she is adament about continuing Counseling and Support Groups Obtain insurance  May be able to get through school if continuing
    32. 32. 1. Caciato DA, Territo MC. Manual of Clinical Oncology. 6th ed. Philidelphia, PA: Lippinncott/Wolters Kluwer; 2008: chapter 21.2. Lymphoma Research Foundation. http://www.lymphoma.org/site/pp.asp?c=bkLTKaO QLmK8E&b=6300137 . Accessed March 25, 2012.3. Micromedex® Healthcare Series [database online]. Greenwood Village, CO. Thomson Reuters (Healthcare) Inc. Updated periodically. Accessed March 25, 2012.4. NCCN GuidelinesTM. Hodgkin Lympohma. Version 3.2011. NCCN. www.nccn.org. Updated July 2011. Accessed March 25, 2012.5. Caring for Cancer Patients Lectures.