Debra Norrell



Case Study: Follicular Non-Hodgkin's LymphomaDebra NorrellArgosy UniversityIntroductionI have had the pleasure of meeting a man along with his wife who has so graciously allowed me to follow him through-out his radiation treatments. On December 24th 2004, he received a very unwanted "Christmas present", the diagnosis of follicular lymphoma. I will talk about his struggles with multiple chemotherapy treatments he has gone through along with ultimately how he ended up at the radiation oncologist's doorstep. From his consultation to his follow up appointment; I will discuss his simulation, process of treatment planning, and of course describe how he made it through his daily radiation treatments.To conclude the study, I will discuss research found on Non-Hodgkin's follicular lymphoma along with treatment options that are currently available. ConsultationThe patient is a 77-year-old man that has been on and off chemotherapy for the last ten years during his battle with cancer. He was diagnosed in 2004, when he presented with retroperitoneal adenopathy (swelling of the lymph nodes in the abdomen). A biopsy revealed follicular grade 3A Non-Hodgkin's lymphoma and a lymphoma positive bone marrow biopsy designated him with stage IV. He and his medical oncologist have been working very closely together ever since the diagnosis. His first round of chemotherapy started soon after the diagnosis in January 2005. He received eight cycles of Rituxan/CHOP (cyclophosamide, vincristine, prednisone). Monitored closely by his physician, a negative PET scan in July looked promising however, by the end of August, progressive adenopathy was found in his left axilla. He underwent four; weekly doses of Rituxan in October 2008, April 2009, and again in October 2009. He unfortunately was diagnosed with an auto-immune disorder; temporal arteritis, and had to discontinue his lymphoma treatments in December 2009. Computed tomography scans were conducted in July 2010, December 2011 and again in March 2012. All showed progressive retroperitoneal adenopathy but otherwise stable.December 2012, he had a creatinine of 1.7 which warranted a renal ultrasound resulting in bilateral ureteral obstruction likely due to the increasing size of lymph nodes in his abdomen and pelvis. He then completed six cycles of Rituxan/Treanda. He had three stable CT scans thereafter from August 2013-March 2014. His medical oncologist used Rituxan alone again weekly for 4 doses however his adenopathy remained. He then began using Treanda alone for 3 cycles but in July 2014, adenopathy of his left neck was still persistent. At that point he was referred to a radiation oncologist. The patient has a nephew with lymphoma otherwise no other history of cancer in his family. Heart disease however, is a common ailment in his genetics. His mother died from heart failure at the age of 77. His brother just recently passed from coronary disease. His father is also deceased at age 54 from multiple sclerosis. He has a 12.5 pack year history with no significant alcohol use.CT SimulationHe was positioned supine with his head first on the simulation table. A shim was attached to the S-frame and a clear "B" head holder was positioned under his head and neck while he held a ring low on his abdomen. A sponge was placed under his knees for additional back support. Assuring he was as straight at possible by using the CT lasers, a thermoplastic mold for his face and neck was made. Aligning the lasers about mid-plane and midepth on his neck, lateral and longitudinal marks were placed on the mask with a sharpie marker. BB's were also placed on top of the sharpie marks. After the scan was complete, data obtained was sent to the planning computers in dosimetry.Treatment PlanningThe two field AP/PA plan was designed with dynamic wedges. Radiation therapy was given to the involved field only, meaning that only the enlarged nodal group was included in the treatment field. A total of 15 treatments at 200cGy per fraction were given to the left supraclavicular area to a total dose of 3000cGy using 6x photons. Multileaf collimation made avoiding most of the larynx and esophagus much more attainable. Since the treatment was isolated to the left side of the neck, minimal morbidity was to be expected.Daily Administration of TreatmentsPositioning for daily treatments were specified from his simulation and the lasers were used to align the patient accordingly. Once a week port films were taken to verify anatomical positioning and central axis placement. Physician approval was needed prior to the first treatment and once weekly thereafter. Patient was very cooperative and seemed to tolerate the mask fairly well. Weekly Assessment of Patient's progressPatient overall tolerated his treatments very well. He complained of some soreness with swallowing and a dull pain in his left neck with mild tenderness upon palpation during his second week. By the third week he was in no pain but he began to have a decreased appetite, a lack of energy, and mild erythema of the skin. Patient was given an aloe ointment to apply to the reddened area on his neck. He reported that the ointment seemed to help temporarily. Follow-upA month after his last treatment was given, he was seen for his follow-up appointment. His skin was healed and he denied any issues with swallowing. Patient reported having some clear to white sinus drainage in the morning that he was able to cough up. He denied any pain and reported that he was happy and doing well. He was offered another appointment in two months but he didn't think that was necessary.Non-Hodgkin's Follicular Lymphoma Non-Hodgkin's Lymphoma is a cancer of the immune system and can originate in the lymph nodes or in extra nodal tissues. There are two main types known as follicular/nodular and diffuse. The follicular type is a more slow growing malignancy while the diffuse type of non-Hodgkin's lymphoma is more aggressive. Follicular non-Hodgkin's lymphoma (FNHL) is not curable however, patients may live a decade or more by controlling its symptoms and minimizing the effects from therapy. Morrison (2007) states that, "although remissions may last for extended periods, a pattern of continuous late relapse after discontinuation of therapy is present, and cure rates are low. The average age of diagnosis is 67 years. It is found to be 60 times more common in patients that have AIDS than in the general population. Incidence has increased 65% since the 1970's. It is more common in men than in women and is also seen in whites more commonly than in African and Asian Americans (Sharkey, Burton, & Goldenberg, 2005).The exact cause of follicular lymphoma is highly unknown however there are a few risk factors that may increase the chance of it developing such as: genetic alterations of the B or T lymphocyte cells, exposure to ionizing radiation, viral- HIV infections, and reduced immune function. Presenting symptoms are often that the patient has swollen lymph nodes and symptoms often depend on the site that is involved. It can arise anywhere in the body and its spread is unpredictable. Unlike Hodgkin’s disease patients rarely present with the classic B symptoms (fever, night sweats, and/or weight loss of greater than 10%). Detection and diagnosis include a complete history and physical examination, along with lab work including; complete blood count (CBC), HIV test, urinalysis, and a bone marrow biopsy. Radiographic studies include a chest x-ray, CT of abdomen, pelvis, chest, and neck. According to Fueger, Yeom, Czernin, Sayre, Phelps, & Allen-Auerbach (2009), CT/PET fusion imaging is being utilized for staging and re-staging patients with FNHL. The majority of patients are diagnosed with grade 1 or 2 disease, and already have the malignancy spread to their bone marrow. According to the Ann Arbor staging system they are most often at stage 3 or 4 at time of diagnosis (Foster et al., 2009). A process known as transformation occurs when the indolent lymphoma changes into a more aggressive one, this happens in about 20-70% of patients. This process can happen at any time and usually does not correlate to timing of treatment. Once this transformation happens, the patient usually only survives on average another 18 months (Foster et al., 2009).Treatment for FNHL is first and foremost immunotherapy combined with chemotherapy. Rituximab (Rituxan) which is a monoclonal antibody that is used to destroy excessive numbers, overactive, or dysfunctional B cells. Cyclophosphamide/doxorubicin/vincristine/prednisone (CHOP) is used in conjunction with Rituximab and studies have shown an overall response rate of 95% and a complete response rate of 55% (Coffey, Hodgson, & Gospodarowicz, 2003). With the goal of inducing remission, FNHL also responds very well to radiation therapy and has been used alone and also in conjunction with chemotherapy. It can produce a very long remission for those patients with local disease and according to Caimi, Barr, Berger & Lazarus (2010), in cases where FNHL is found at an early stage, 40% of these patients may be considered cured by radiation therapy. The current standard radiation treatment dose is given to a total dose of 30-35Gy usually in 200cGy fractions once daily. Another treatment option is radioimmunotherapy. "Radioimmunotherapy combines the efficacy and targeting ability of monoclonal antibodies and the benefits of total body irradiation" (Foster et al., 2009). This has become a very seriously studied treatment option for lymphoma. Stem cell transplants have been used in the treatment arsenal at the various stages of the disease progression however, it is hard on the patients. Watchful waiting is also a treatment option for those patients who are asymptomatic or don't seem to need therapy immediately. "The indolent nature often allows for postponement of treatment until symptoms arise which often occur years after the diagnosis (Foster, Miller, Boye, & Russell, 2009). Caime et al. (2010) reported that according to the studies out there, survival rates are not increased due to treating asymptomatic patients AnalysisThe patient chose to use immunotherapy along with chemotherapy in the form of Rituxan/CHOP. Unfortunately after about 10 years of off and on again cycles of this therapy, adenopathy in his left neck was persistent. His medical oncologist referred him to a radiation oncologist where it was recommended that he have radiation to the “involved field”. He decided to use radiation therapy due to the localized mass size and the minimal side effects that he might experience related to radiation therapy. Surgery was not an option for this type of cancer due to its unpredictable spread and its ability to go anywhere in the body. While discussing this case with the physician, he explained the patient has stopped responding to the treatment that he has been on for many years. This is typical of his disease progression and radiation therapy is an excellent option especially for the area that is needing treatment. There are little side effects that the patient might encounter due to the location and lower radiation doses. I also discussed this patient’s case with another therapist and they agreed with the need for radiation therapy. Non-Hodgkin’s Follicular Lymphoma is sensitive to radiation and responds quickly to treatments, however relapse is likely to occur. "Despite the advances in classification, staging and treatment of the various forms of NHFL, almost all patients succumb to their disease. Therefore, additional approaches to therapy warrant further study" (Sharkey et al., 2005). The role of the radiation therapist in Non-Hodgkin’s Lymphoma is no different from other cancers in that they must recognize the importance of accuracy. There is need for detail when blocking critical structures and also being able to keep precise records of daily treatments. Communication with patients is very important and due to the average age of a NHL patient; overall health assessment should be taken into account with proper staff being informed of any changes seen. The therapist may need to offer additional support to the family members and to communicate instructions very clearly. Radiation side effects will likely occur and require management from not only the staff but also the patient and their family or support system. ReferencesCaimi, P. F., Barr, P. M., Berger, N. A., & Lazarus, H. M. (2010). Non-Hodgkin's lymphoma in the elderly. Drugs & Aging, 27(3), 211-38. doi:, J., Hodgson, D. C., & Gospodarowicz, M. K. (2003). Therapy of non-Hodgkin's lymphoma. European Journal of Nuclear Medicine and Molecular Imaging, 30, S28-36. doi:, T., Miller, J. D., Boye, M. E., & Russell, M. W. (2009). Economic burden of follicular non-Hodgkin's lymphoma. PharmacoEconomics, 27(8), 657-79. doi:, B. J., Yeom, K., Czernin, J., Sayre, J. W., Phelps, M. E., & Allen-auerbach, M. (2009). Comparison of CT, PET, and PET/CT for staging of patients with indolent non-Hodgkin's lymphoma. Molecular Imaging and Biology: MIB, 11(4), 269-74. doi:, V. A. (2007). Non-Hodgkin's lymphoma in the elderly -- part 1: Overview and treatment of follicular lymphoma. Oncology, 21(9), 1104-10. Retrieved from , V. A. (2007). Non-Hodgkin's lymphoma in the elderly -- part 2: Treatment of diffuse aggressive lymphomas. Oncology, 21(10), 1191-8; discussion 1198-1208, 1210. Retrieved from , R. M., Burton, J., & Goldenberg, D. M. (2005). Radioimmunotherapy of non-Hodgkin's lymphoma: A critical appraisal. Expert Review of Clinical Immunology, 1(1), 47-62. doi: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download