Case 31 Lymphoma Treated with Chemotherapy

Understanding the Disease and Pathophysiology1. (2-points- 1 paragraph) What type of cancer is lymphoma?
The tumors are named based on the tissues they arise from and the suffix oma is used. For
example, Lymphoma is the cancer of the cells found in the lymphatic system. The lymph
nodes are affected and can be spread via the lymphatic system to other lymph nodes. The
tumors are first classified and then given a stage depending on the following: cell type, tissue
origin, benign or malignant, degree of differentiation, anatomic site and function. The TNM
(Tumor Node Metastases Staging System) is used for diagnosis and treatment for the patient.
2. (2-points) Radiation and chemotherapy may also affect healthy tissues.
a. What other cells in the body may be affected by either or both of these treatments?
In radiation, electromagnetic rays and charged particles are delivered to the cells
that are continually proliferating, like cancer cells do. The goal of treatment
planning is to uniformly irradiate a specified target while minimizing the does to
surrounding normal tissues. Normal cells as well as the targeted cancer cells are
susceptible to the toxicity of radiation so custom-made lead blocks are developed
for each patient to protect vital organs.
Because chemotherapy is given systemically, all cells of the body are exposed to
the toxic effects of the drug and almost all body systems will be affected. The
medications of chemo interrupt different stages of cell cycle replication.
b. What symptoms may the patient experience as a result of the destruction of these
cells?
Depending on how much and where the radiation is being administered, some
adverse effects include fatigue, mucositis, dysgeusia, dysphagia, severe
esophagitis, high risk of dehydration, radiation enteritis, bowel injuries, severe
diarrhea and malabsorption.
In chemotherapy, rapidly dividing GI cells promote nausea and vomiting and rapidly
hair follicle cells promote hair loss. Chemos most common side effects are due to
the toxicity to the cells and include neutropenia, thrombocytopenia, anemia,
diarrhea, mucositis, cardiotoxicity, neurotoxicity and nephrotoxicity.
Understanding the Nutrition Therapy
3. (2-points-one paragraph) Describe the major factors that may impact the nutritional
status of the cancer patient.
The major factors that can impact the nutritional status of the cancer patient is nausea,
vomiting, xerostomia, constipation, weight loss and anemia. They can all place the
individual at nutritional risk and can lead to malnutrition. Reversing malnutrition in the
cancer patient can be very difficult. The effects above can cause severe anorexia and
cachexia. These patients must be carefully screened and assessment is vital to the
patients health. Malnutrition reduces responsiveness in the patient that is having
chemotherapy and radiation and increases perioperative morbidity, worsens the quality of
life and diminishes the likelihood of survival.

4. (2-points) Describe the nutrition therapy recommendations that would be appropriate to

assist in treatment of the following symptoms:
a. Stomatitis/mucositits: Try to maintain good oral hygiene to prevent infection,
chew gum, candy, drink water during meals to prevent dehydration, eat only soft,
non-fibrous, non-acidic, moist foods (Ex. Gravy on foods), avoid hot and dry foods, ,
non-acidic juices may be helpful, high-calorie, high-protein milkshakes or nutritional
supplements may be beneficial at this time. Can use rinses with numbing gels for
mucositits but let patient know tongue can become numb and taste of food may be
affected.
b. Diarrhea: encourage patient to drink small amounts of fluid frequently throughout
the day, avoid large amounts of fruit juices, drink fluids that have electrolytes, if
patient can tolerate eating, encourage foods high in soluble fiber to help with
diarrhea. Recommend a bread diet, bland, and non-spicy foods. Ex. Applesauce
and Probiotics
Nutrition Assessment
5. (1 point) Which is the most appropriate to use in determining nutritional risk for this
patient, BMI or percent usual body weight? Explain why.
BMI is used to assess the patients weight classification using her current height and
weight. The most appropriate tool to determine nutritional risk in this patient is to use
percent usual body weight because cancer patients can have significant weight loss or
gain because of wasting, dehydration and can edema. Usual body weight is used to
compare the patients current weight to her usual body weight to assess the nutritional
risk and health complications.
6. (1-point) Using kcal/kg, calculate Denises energy requirements.
30-35 kcal
54.5 x 30 = 1635
54.5 x 35 = 1908
1635-1908 kcal
7. (2-points)
a. Calculate Denises protein requirements.
Increased protein needs because of extreme wasting 1.5-2.5g
54.5 x 1.5 = 82
54.5 x 2.5 = 136
82-136g
b.

What lab would be most appropriate to monitor to determine if she is receiving the
appropriate level of protein?
Visceral protein is assessed by serum proteins, albumin, transferrin, prealbumin,
retinol binding protein and fibronectin. Acute changes in protein status are reflected
by prealbumin, transferrin, retinol binding protein and fibronectin levels. These
have a shorter half-life than albumin and are more sensitive to acute changes.

8. (2-points) Identify each of the drugs that the patient is prescribed, and note the possible
nutritional side effects of each.
Drug
Cyclophosphamide
Doxorubicin
Vincristine
Prednisone (CHOP)

Possible Nutritional Side Effect(s)

Nausea, vomiting, stomatitis, diarrhea
Nausea, vomiting, anorexia, stomatitis, diarrhea
Stomatitis, nausea, vomiting and changes in how food tastes
Increased appetite, weight gain, upset stomach, sodium retention,
fluid retention, hyperglycemia, lean body mass wasting,
hyperglycemia

9. (6 points) During a follow-up visit, Denises mother asks about an anti-cancer diet that
Denises aunt has suggested. This diet recommends a cleansing protocol with frequent
coffee enemas with a diet that focuses primarily on a liquid mixture made from fruits,
vegetables, and raw calfs liver. Mrs. Mitchell is concerned that Denise cannot even
tolerate drinking the mixture and refuses to even consider enemas.
a. How would you advise this patient and her parents regarding adherence to this
anti-cancer diet and WHY?
In times of need, people look everywhere for easy fixes to help battle diseases
such as cancer, especially in someone so young. In this case, what Denise and her
parents need to focus on is obtaining the proper nutrition, proper calories and living
the healthiest lifestyle possible while batting her disease. The diet seems as if its
not credible and eating any raw meats at this point would not be smart because of
her suppressed immune system. For proper research, they should look to credible
sources such as the American Cancer Society or ask her doctor/RD for further
information.
b. What steps would you suggest for them as they research and make appropriate
decisions for care?
For proper research, they should look to credible sources such as the American
Cancer Society or ask her doctor/RD for further information. In order for Denise to
have the strength to combat lymphoma, she will need to eat very healthy and
optimal nutrition is imperative.
c. Why may cancer patients be especially vulnerable to nutrition and medical
quackery?
Cancer patients may be especially vulnerable because there is no magic pill that
can be taken to cure cancer, people will be willing to try anything to try to extend
their life, no matter how silly it may sound. Many times when people hear the word
cancer, it immediately seems it to be a death sentence and unfortunately,
companies out there will take advantage of the vulnerable to make a cheap profit at
the expense of the ill.
Write your Nutrition Care Form from the standpoint of an initial nutrition consult upon admission
to the hospital with diagnosis of lymphoma. (10 points)

Nutrition Care Form

Age: __21___ Gender: ___F____ Height: __56___ Weight: _120# or 54.5 kg

Medical Diagnosis: Stage II diffuse large B-cell lymphoma with mediastinal disease and positive
lymph nodes. Bone marrow and other organs show no indication of disease. Consult: Initial
Nutrition Consult Requested upon admission
ASESSMENT
Weight History: __UBW 130#__ Ideal Weight: __92_____%

Ideal Weight: ___130#___

Activity Level: _Sedentary__Medications: _ Cyclophosphamide, Doxorubicin, Prednisone (CHOP)

first 5 days of each 21-day cycle and radiotherapy planned to start 3 weeks after the third cycle
of CHOP._____
Past History: __Tonsillectomy _______________
Lab Values: _3/18 ALB 3.3, Total Protein 5.5, Bili 0.8, WBC 12.0, Hgb 11, HCT 31, MCV 70, Retic
2.9, MCHC 27, Ferritin 19__
Energy Needs: __1635-1908 kcal___ Protein Needs: __82-136g __ Fluid Needs: _2L___
Energy Intake: __360 kcal___ Protein Intake: _14.7g___ Fluid Intake: __1L____
Current Diet Order: _N/A_____ Education Needs: Increase Kcals and PRO; maintain general
healthful diet.
NUTRITION DIAGNOSIS:
Problem: Inadequate oral intake (NI-2.1), Unintended Weight Loss (NC-3.2), Inability or lack of
desire to manage self-care (NB-2.3)
Related To: Decreased appetite and fatigue ____________________________
As Evidence by: Patient 24-hour recall of currently taking in 360kcal/day, involuntary weight loss,
UBW is 10# less than normal, patient 92% IBW.
NUTRITION INTERVENTION:
Modify distribution type, or amount of food and nutrients within meals or at specified times (ND1.2), Commercial Beverage (ND-3.1.1), Nutrition relationship to health/disease (E1.4)_______________________________
Goal: Patient to eat high kcal, high protein to prevent further weight loss. Eat small freq. meals
that are nutrient dense to intervene with decrease in appetite. Suggest and provide high protein
supplements if patient is unable to eat enough PO. High kcal beverages should be consumed
with nutrients between meals. Limit fluids during meals to avoid fullness and maximize intake
when appetite is normal. Try to increase fruits and vegetables as studies show these help with
reduction of cancer cells. Discuss the importance of maintenance of nutrient stores in disease
outcome.
NUTRITION MONITORING
Total Energy Intake (FH-1.1.1.1), Total protein (FH-1.5.2.1), Amount of food (FH-1.2.2.1), Weight
(AD-1.1.1) Albumin (BD-1.11.1), Glucose (BD-1.5.2), Ca (BD-1.13.9), Medical Treatment Therapy
(CH-2.2.1)_______________________
Goal: Obtain adequate kcals, protein, fluids, vitamins and minerals. Prevent weight loss and
improve quality of life. Follow up and assess patients tolerance to chemotherapy, address any

side effects impacting nutritional status and modify type of diet as need be. Keep a close
vigilance on glucose and Ca levels due to use of prednisone. Monitor weight, intervening if
further decline is observed. __________
RD Signature: Christina Talla, RD Date: 04/23/2013