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Case Review #1: Non-Hodgkin's Lymphoma

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by

Madison Smith

on 11 October 2012

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Transcript of Case Review #1: Non-Hodgkin's Lymphoma

Non-Hodgkin's Lymphoma Case Study #1 Patient History Pathology men > women
60+
Caucasian
developed countries
weakened immune system
exposure to pesticides
estimated that there will be 7800 new cases in Canada in 2012 Non-Hodgkin's Lymphoma Patient Care Concerns planner and R.O. confirmed O.K. to treat as treatment progressed, swelling of the neck significantly decreased, making the mask and therefore bolus no longer flush with the skin 68 year old caucasian male, 2 children
engineer, retired on first week of RT
non-smoker, no known history of cancer in family
no medical issues but suffered from rheumatic fever as a child
during a routine dental exam a palpable lymph node was discovered, base of left neck
increasingly frequent night sweats
referred to Dr. Sharkey for incisional biopsy Incisional biopsy revealed abnormal B-cells and patient was sent for staging.
-cyclin D1 negative: Mantle cell far less likely
-CD20+, CD5+
-no Reed-Sternberg cells
CT scans of neck, chest, abdo, pelvis
Gallium scan
Bone marrow biopsy/aspirate: performed to distinguish B-cell lymphoma or CLL
Bilateral Stage IIA disease: marginal B-cell lymphoma
bilateral disease, but confined so chemo not required
nodes on same side as diaphragm
Referred to Dr. Rachakonda Over 30 different types
80-90% B-cell origin curative
treated with rapidarc VMAT technique
3600 cGy/20fx/4weeks, 6MV, doserate 600
bilateral cervical and supraclavicular nodes
on h&n board with shell and 0.5cm bolus
"C" headrest, bearclaws to lower shoulders
Daily CBCT
15x17.5 field, CW: coll.10, 237mu. CCW: coll.350, 244mu Treatment Plans Possible side effects:
fatigue, radiation dermatitis (erythema, dry/moist desquamation), hyperpigmentation, alopecia, radiation mucositis, xerostomia Structures to avoid:
parotid glands (TD 5/5: 3200)
spinal cord (TD 5/5: 4700 20cm) Patient Experienced... Erythema, hoarseness of voice; informed about using Glaxal as well as magic mouthwash. Rituximab (Rituxan): Chemo drug commonly used to treat lymphoma. Like Herceptin, Rituximab is a drug categorized as monoclonal antibodies. CD-20 is present in more than 90% of B-cell NHL. This drug attaches to CD-20 receptors and causes the tumour cells to lyse, sometimes preventing the production of more tumour cells.

Questioned why this patient would not have been given this drug given the bilateral Stage II disease since it seems very promising.

Study published in American Journal of Clinical Oncology that evaluated treatment with involved-field radiation therapy followed by rituximab and the associated progression-free survival for early-stage indolent non-Hodgkin lymphoma
Patients who received rituximab were given 4 weekly doses after radiation completion
PFS: 46% for rituximab patients
72% for patients who did not receive rituximab Interesting Information Questions?? Chai, M. (2006). Clinical Handbook of Radiation Therapy Side Effects and Interventions. 2nd edition. Toronto: ON

Canadian Cancer Society. (2012). www.cancer.ca

Lukens, J. N. (2012). Outcomes After Involved-field Radiation Therapy (IFRT) With or Without Rituximab in Patients With Early-stage Low-grade Non-Hodgkin Lymphoma (NHL) Staged With CT and PET. American Journal of Clinical Oncology. http://www.ncbi.nlm.nih.gov/pubmed/22992623
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