The diagnostic marker characteristic of Hodgkin lymphoma is the Reed-Sternberg cell. Non-Hodgkin lymphoma is more common than Hodgkin lymphoma. A patient diagnosed with Stage IIA Burkitt's lymphoma has involvement of one or more lymph node regions on the same side of the diaphragm, with no systemic symptoms present. The monoclonal antibody rituximab is now administered along with the CHOP chemotherapy regimen. Common gastrointestinal side effects of chemotherapy include nausea, vomiting, and diarrhea/constipation.

1. Blood Cancers: Lymphoma Presented by Eileen Barash

2. Non-Hodgkin Lymphoma (NHL) Incidence: 4% cancers, 89% lymphomas All other Lymphoma types included Most often affects adults, average age 60 Spreads in a disorderly fashion Abnormal B-cells (most common) or T-cells Types Over 60 different types Indolent Follicular lymphoma MALT lymphoma Aggressive Diffuse large B-cell lymphoma AIDS-associated lymphoma Burkitt’s lymphoma Diffuse large B-cell lymphoma Classifications Hodgkin Lymphoma (HL) Incidence: 1% cancers, 11% lymphomas Characterized by Reed-Sternberg cells Bimodal incidence: Young adults/elderly Spreads in an ‘orderly’ fashion throughout lymphatic system Involves abnormal B-cells Types Classical HL Nodular sclerosis (60-75%) Mixed cellularity (5-15%) Lymphocyte rich (5%) Lymphocyte depletion (5%) Nodular lymphocyte predominant HL

3. Cancer Site Statistics #7 Top 10 Cancer Sites: 2005, Male and Female, United States – All Races. Source: http://apps.nccd.cdc.gov/uscs

5. Epstein-Barr Virus after organ transplant

6. Helicobacter pylori can cause mucosa-associated lymphoid tissue lymphoma

7. Other viruses such as Hepatitis C

10. Autoimmune deficiency syndrome (AIDS)

12. B-cells that become binucleated or multinucleated are characterized as malignant Reed-Sternberg cells

13. These cells tend to attract normal lymphocytes, enlarging lymph nodes

14. Tumor growth usually begins in the lymph nodes of the upper body

16. Originates in the lymph nodes, lymphatic organs, or lymph tissue in organs (such as the spleen, bone marrow, thymus or tonsils)

18. Progressive swelling of legs, swelling of face

19. Pale skin or dark, itchy patches of skin

20. Difficulty breathing, chest pain

21. Pleural effusion, causing persistent cough

22. Bloating, cramping, diarrhea, flatulence

23. Abdominal pain or distention, constipation

24. Unexplained appetite loss, weight loss

25. Fever, causing excessive night sweating

27. Swelling from edema in legs or feet

28. Shortness of breath, fatigue

29. Weight loss, muscle weakness

30. Pel-Ebstein fever, night sweats

31. Increased susceptibility to infections

32. Rapid

33. Pale skin or dark, itchy patches of skin

34. Pleural effusion, causing persistent cough

35. Bloating, cramping, diarrhea, flatulence

38. Fine needle aspiration cytology

39. CBC with differentials

40. X-ray (Pictures using radiation)

41. CT (Computerized tomography)

42. MRI (Magnetic resonance imaging)

43. PET (Positron emission tomography)

44. DNA tests

45. Immunophenotyping

46. Blood proteins

47. Liver enzymes

48. Bone marrow/spleen/liver biopsy

49. CSF examination

52. Chemotherapy is given in about 3 to 12 cycles of treatment/non-treatment

53. Forms of administration: orally, by injection, intravenously

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 drugsOther treatments include: Surgery to remove affected tissue Bone marrow and stem cell transplantation Biologic therapy (such as Rituximab) Radiation therapy “Watch and wait”

55. Case Study: Denise Mitchell

56. Assessment Complaint: “I have continued to feel run down since I had the flu. I still have a fever and the cough won’t go away.” Age: 21 years Height: 5’6” UBW: 130 Sex: Female Weight: 120 lbs BMI: 19.4 (Normal) PMH: Tonsillectomy at age 5 Family Hx: Noncontributory Meds: OTC cough medicine Allergies: NKA Chest X-ray: Possible mass Biopsy of suspect lymph nodes: Positive Physical exam concerns: Symptoms: Decreased appetite, fever, night sweats, persistent cough Medical Dx: Stage II diffuse large B-cell lymphoma with mediastinal disease 100.5°F, slightly high Thin, pale; appears tired Slightly dry mucous membranes Shallow respirations; dullness present to percussion Temperature Appearance Throat Chest/Lungs

57. Treatment CHOP Regimen C – Cyclophosphamide (Alkylating) H – Hydroxydoxorubicin (Antibiotic) O – Oncovin (Antimitotic) P – Prednisone (Glucocorticoid) Localized Radiotherapy Treatment begins after third cycle of CHOP Recent findings: Rituxan (Rituximab), a monoclonal antibody, is now a standard treatment in conjunction with CHOP (abbreviated R-CHOP). Source: Review by http://www.cochrane.org

58. Nutrition Diagnosis 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. P: Inadequate oral food/beverage intake E: Side effects of chemotherapy S: Decreased nutrient intake and weight loss

59. Food and/or Nutrient Delivery Pt receives 8-oz. cans of Ensure Plus or similar supplement to drink BID Nutrition Education 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 Emphasis on consumption of Ensure or other supplemental drinks to help maintain weight, and sufficient fluids to prevent dehydration Verbal instruction on how to achieve a high-calorie, high-protein diet; Recommendations for moist or soft food choices are discussed Nutrition Counseling Pt instructed to eat small, frequent meals throughout the day and consume liquids between meals Collaborative effort to create individualized meal plan including food choices preferred by pt Coordination of Nutrition Care Consult with MD re: administering antiemetic and Magic Mouthwash moist or soft food choices Magic Mouthwash antiemetic Intervention

60. Sample Meal Breakfast 1 c. oatmeal, or cold cereal if tolerated 2 slices bread, 1 T butter *After breakfast, drink 1 c. Ensure Plus Lunch 2 slices bread,1 T. mayonnaise 1 oz. canned or grilled tuna ½ c. frozen yogurt, any flavor Dinner 2 oz. chicken breast ½ c. mashed potatoes, 2 T. gravy 4 oz. Jell-O gelatin, any flavor Snack 2 oz. breadsticks, soft 4 oz. fruit cup 2 oz. dried figs Snack 1 medium banana ½ c. applesauce ½ c. lettuce, 1 T. dressing Fluids Drink or sip through a straw throughout the day, preferably between meals: At least 6 8-oz. cups of water AND 2 c. of Ensure Plus formula, any flavor* If desired, patient may also consume: 2 c. of juice (apple, cranberry; no citrus)

62. References (Visual) Cancer Site Statistics, 2005. http://apps.nccd.cdc.gov/uscs (Visual) Staging for Lymphoma: http://www.labtestsonline.org/understanding/conditions/lymphoma.html (Visual) Reed-Sternberg Cell. http://visualsonline.cancer.gov The Cochrane Library: Rituximab as maintenance therapy for patients with follicular lymphoma. http://www.cochrane.org/reviews/en/ab006552.html American Institute for Cancer Research: Nutrition of the Cancer Patient. Dealing with Side Effects. http://www.aicr.org Lymphoma Research Foundation: Getting the Facts: Diffuse Large B-cell Lmphoma. http://www.lymphoma.org The Merck Manual, 15th Ed.: Hematology and Oncology: Lymphoma. Krause’s Food and Nutrition Therapy, 12th Ed. American Dietetic Association Evidence Library: Nutrition Care Process. http://www.adaevidencelibrary.com National Guideline Clearinghouse:Staging Laparoscopy for Lymphoma. http://guideline.gov/summary/summary.aspx