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

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

  • Recommend treatment for NHL with high-risk genetic features.

  • 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 selected to treat NHL.


Chief Complaint

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


Ben Burner 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 longstanding hypertension, hypercholesterolemia, and GERD. He initially presented to the ED 1 week ago with new-onset left lower extremity edema. He was then hospitalized for further evaluation and treatment. At that time, he stated that he had lost weight over the past few months. Vital signs on admission included elevated temperature of 100.8°F (38.2°C). Physical examination findings were significant for a round, protuberant abdomen that was soft on the right side but firm on left and 3+ pitting edema of the left lower extremity from foot to knee. Laboratory findings were significant for serum creatinine 1.9 mg/dL, serum calcium 11.6 mg/dL, and hemoglobin 10.6 g/dL. A renal ultrasound revealed severe hydronephrosis on the left side and displacement of the bladder with compression, possibly from a mass. A CT scan without contrast of the chest, abdomen, and pelvis was performed. Results showed multiple enlarged lymph nodes, including several mediastinal nodes, paraesophageal nodes, and retrocrural nodes. A large, confluent soft tissue mass was found, extending through the retroperitoneum and involving the left pelvis. The mass encased the distal left ureter. The mass in its widest dimension was 16.3 cm. A diagnosis of lymphoma was presumed based on the extent of lymph involvement. Urologists placed a left ureteral stent and performed ultrasound-guided biopsy of the mass. Pathology showed diffuse large non-Hodgkin B-cell lymphoma. Upon confirmation of diagnosis, a bone marrow biopsy was performed. Results were not available during hospitalization. The patient was insistent on discharge to attend his daughter’s wedding, so treatment was deferred after initial consultation with an oncologist in the hospital. His creatinine and calcium values were normalizing at the time of discharge.


HTN × 10 years

Hypercholesterolemia × 5 years

GERD × 15 years


The patient is the oldest of ...

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