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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify and describe the components of the staging workup and the corresponding staging and classification systems for non-Hodgkin lymphoma (NHL).

  • Describe the pharmacotherapeutic treatment of choice and the alternatives available for treating NHL.

  • Identify acute and chronic toxicities associated with the drugs used to treat NHL and the measures used to prevent or treat these toxicities.

  • Identify monitoring parameters for response and toxicity in patients with NHL.

  • Provide detailed patient education for the chemotherapeutic regimen.

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PATIENT PRESENTATION

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Chief Complaint

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“What’s the next step for my lymphoma?”

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HPI

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Homer Bunting is a 58-year-old man who presents to his oncologist’s office for recommendations about treatment of a newly diagnosed diffuse, large B-cell lymphoma. He had been in relatively good health other than his long-standing hypertension and chronic heart failure. He initially presented to the ED 2 weeks ago with new onset of shortness of breath and fevers up to 100.8°F (38.2°C). He was then hospitalized for further evaluation and treatment. At that time, he stated that he had lost weight over the past few months. Physical examination findings were significant for decreased breath sounds (worse on the left side than the right) and enlarged, painless supraclavicular lymph nodes on the left side. The largest palpable lymph node measured approximately 2 cm in diameter. Splenomegaly was also noted. Chest x-ray revealed a large heterogeneous mass at the apex of the left lung also involving the mediastinum. Given the patient’s lengthy smoking history, he was presumed to have lung cancer. CT-guided biopsy of the mass was performed. Pathology revealed cells consistent with lymphoma, but definitive diagnosis could not be made. An excisional biopsy of the enlarged supraclavicular lymph node was performed. Pathology showed diffuse large non-Hodgkin B-cell lymphoma. The oncologist on call was consulted, and it was recommended for him to follow up as an outpatient for further evaluation and treatment recommendations.

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PMH

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  • HTN × 10 years

  • Hypercholesterolemia × 5 years

  • NYHA Class II HF × 8 years

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FH

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The patient is the oldest of seven children (four brothers and two sisters), all alive and well. He has two children, both in good health. Family history of terminal prostate cancer in his father (died at age 63). No other history of malignancy that he is aware of.

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SH

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The patient is employed as an usher at a professional baseball park. He previously smoked 1–2 ppd for 32 years. He quit when he was diagnosed with HF, and he complains about the fans who smoke in the section of the ballpark where he works. He drinks one to two beers nightly when working. Diet is mostly ballpark food, heavy on the hot dogs, and ...

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