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”
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)
61.
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
Editor's Notes
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
