1. Cory Phillips, Jennifer Corder, Whitney Dulin

2.  CC: “Two month history of night sweats, fever/chills, and a recent 20 lb
weight loss.”
 HPI: Amy is a 22 yo female who presents to the ER with a 2 month
history of night sweats, fever/chills, and unintentional weight loss (20lbs).
The patient also reports fatigue. The patient reports an enlarged
supraclavicular lymph node which hurt after drinking alcohol. The LN was
biopsied, and Amy was diagnosed with Hodgkin’s Lymphoma. She is
scheduled to receive ABVD.
 PMH: tonsillectomy 14 years ago.
 PSH: Student at Vanderbilt. Stress associated with school. No tobacco.
No illicit drugs. Drinks 3-4 nights per week.
 FH: N/A (adopted)
 Chemo Regimen: ABVD
(Doxorubicin, Bleomycin, Vinblastine, Dacarbazine)
 MH: Ortho Tri-Cyclen 1 tablet daily as directed NKDA

3.  General:
 Ht 5 ft 8 in Wt 80 kg = 176 lb BMI 26.8 IBW 63.9
 CrCl 68.47
 BSA 1.96 m2
 PE: WNLs
 Vitals: BP 115/68 P 65 RR 18 T 99.8 F (fever)
 Pertinent Labs: WNL except:
143 105 32 ↑ 10.6 ↓
6.2 ↑ 20 ↓ 1.3 ↑ 127 ↑ 9.4 180
32 ↓
 Phos 5.4 ↑
 LDH 562 ↑
 UA ↑
UColor UChar USpGr UpH UGluc UAlb UrPro UKeto UBili UUrob ULuEst UrLEU Nitrite
Yellow Clear 1.017↑ 6.8 Neg. Neg. Neg. Neg. Neg. < 1.0 Neg. Neg. Neg.

4.  Lymphoma is the most common blood cancer
 Lymphocytes grow abnormally
 B-lymphocytes (B-cells) and T-lymphocytes (T-cells)
 Cancerous lymphocytes can travel to the lymph
nodes, spleen, bone marrow, blood or other
organs, and can accumulate to form tumors
 Hodgkin’s lymphoma is characterized by the
presence of Reed-Sternberg (R-S) cells, although
other abnormal cell types may be present.
 Usually starts in lymph nodes.

5.  Classical Hodgkin Lymphoma
 Nodular Sclerosis (60-80% cases): Most common
subtype
▪ Lymph nodes contain R-S cells mixed with normal WBCs and
prominent scar tissue
▪ More common in women
▪ Affects adolescents and adults < 50 yoa
▪ Majority of patients’ cured with current treatments
 Mixed Cellularity (15-30% cases):
▪ More common in men
▪ Lymph nodes contain many R-S cells and several other cell
types
▪ Affects older adults and may be associated with HIV and EBV
▪ Extensive disease usually present by diagnosis

6.  Classical Hodgkin Lymphoma
 Lymphocyte Depletion (<5% cases):
▪ Few normal lymphocytes, but abundant R-S cells
▪ Lymphocyte depletion aggressive and not diagnosed until
disease is widespread
 Lymphocyte-Rich (<5% cases):
▪ The disease may be diffuse (spread out) or nodular (knot-like)
▪ Numerous normal lymphocytes and few abnormal cells and
classical R-S cells
▪ Usually diagnosed at an early stage in adults and has a low
relapse rate

7.  Lymphocyte Predominant Hodgkin Lymphoma
 Nodular Lymphocyte Predominant (5-10% cases):
▪ More common in men
▪ Diagnosed <35 yoa
▪ Most lymphocytes in the lymph nodes are normal (not cancerous)
▪ Typical R-S cells are usually not found in this subtype
▪ Large, abnormal B-cells and reactive small B-cells, which may be
distributed in a nodular (knot-like) pattern within the tissues
▪ Usually diagnosed at an early stage and not very aggressive
▪ Resembles low-grade (indolent) B-cell non-Hodgkin lymphoma
 Diffuse Lymphocyte Predominant (rare)
▪ Existence questioned
▪ Most cases are nodular lymphocyte predominant Hodgkin
Lymphoma with an ill-defined nodular pattern

8.  Family history of HL
 Higher social class
 Advanced education
 Small family size
 Delayed exposure to common infectious or
environmental agents
 Associated with EBV
 Slight increase in HIV (HIV-associated HL)

9.  Stage Description
I. Involvement of a single lymph node region or
lymphoid structure
II. Involvement of two or more lymph node regions on
the same side of the diaphragm
III. Involvement of lymph node regions or structures on
both sides of the diaphragm
IV. With involvement of splenic hilar, celiac, or portal
nodes
V. With involvement of paraaoartic, iliac, and
mesenteric nodes
VI. Involvement of one or more extranodal sites in
addition to a site for which the designation “E” has
been used

10.  Staging (most crucial determinant of prognosis)
 Histopathology of subtype
 Age > 60
 Anemia
 Elevated ESR
 Bone marrow involvement
 Bulk of disease
 Poor Karnofsky’s scale performance status

11.  Male sex
 Age ≥45 years
 Stage IV disease
 Serum Alb <4 g/dL
 Hemoglobin <10.5 g/dL
 WBC >15,000/mcL
 Lymphocytes <600/mcL or <8% of WBC

12.  Painless lymphadenopathy usually CC
 Superficial lymph nodes
 Systemic symptoms:
 Fevers
 Night sweats
 Weight loss
 Marked fatigue and general weakness
 Pruritus (often intense)
 Pel-Ebstein fever
 Pain
 Alcohol-induced pain
 Abdominal pain
 Bone Pain
 Neurogenic pain
 Back pain

14.  Stage IB Hodgkin’s Lymphoma
 Tumor Lysis Syndrome
 Nausea and Vomiting
 Infection Prophylaxis
 Alopecia
 Fatigue
 Constipation
 Stress
 Weight loss

15.  Cure cancer
 Prevent Metastasis
 Reduce fatigue
 Control anxiety and stress
 Control any constipation
 Prevent
 Nausea and vomiting
 Neutropenia
 Infection
 Maintain quality of life as much as possible

16.  ABVD x 2-4 cycles
 Doxorubicin 25 mg/m(2) IV on days 1 and 15
▪ Doxorubicin 49 mg IV on days 1 and 15
 Bleomycin 10 units/m(2) IV on days 1 and 15
▪ Bleomycin 19.6 units IV on days 1 and 15
 Vinblastine 6 mg/m(2) IV on days 1 and 15
▪ Vinblastine 31.4 mg IV on days 1 and 15
 Dacarbazine 350 to 375 mg/m(2) IV on days 1 and 15
▪ Dacarbazine 686 mg IV on days 1 and 15
 Repeat cycle every 28 days
 Restage after chemotherapy with PET-CT

17.  Doxorubicin
 alopecia, nausea, vomiting, heart failure, extravasation
 Bleomycin
 hyperpigmentation of skin, stomatitis, pneumonia,
Raynaurd’s phenomenon, hemorrhagic cystitis,
hepatotoxic, nephrotoxic
 Vinblastine
 alopecia, constipation, bone pain, malaise,
hypertension, leukopenia, myelosuppression
 Dacarbazine
 hypotension, alopecia, loss of appetite, nausea,
vomiting, headache, polyneuropathy, influenza-like
illness, myelosuppression, hepatotoxic

18.  Monitor
 Tumor response
 Chem 7
 CBC with differential
 Ejection fraction (EF)
 Pulmonary function tests (PFTs)
▪ Diffusion capacity of the lungs for carbon monoxide (DLCO)
 Renal and hepatic function
 Urinalysis
 S/Sx of Extravasation

19.  Doxorubicin – moderate (30-90 %)
 Bleomycin – minimal (<10%)
 Vinblastine – minimal (<10%)
 Dacarbazine – high (>90%)
 Emetogenic Regimen
 Aprepitant
▪ 125 mg PO day 1 (day of chemo), then 80 mg PO day 2
 Dexamethasone
▪ 8 mg PO BID day prior to chemo, 12 mg IV day of chemo, and 12 mg
PO day after chemo
 Palonsetron
▪ 0.5 mg PO day 1 (day of chemo)
 Lorazepam
▪ 0.5 mg PO Q4-6H PRN to decrease anxiety from stress
▪ May also help prevent nausea and vomiting

20.  Group of metabolic complications that can
occur spontaneously or after treatment of a
neoplastic disorder
 Tumor-burden and chemotherapy induced
 Caused by the rapid destruction of cancer
cells
 Leads to release of intracellular components
 Most commonly seen after aggressive
therapy for hematologic malignancies
 If not treated it can lead to muti-organ failure
and death

21.  More common in leukemias and lymphomas
 Direct releationship between mass doubling
time and risk of TLS
 The more sensitive the tumor is to treatment
the greater the risk for TLS
 Patients with baseline compromised renal
function are at increased risk for TLS due to
inability to excrete electrolytes effectively
 Elevated baseline UA levels 
 less purine catabolism  increased risk of
hyperuricemia

22.  Laboratory TLS
 2 or more of the following criteria occuring within 3 days before or 7
days after initiation of chemotherapy in a well-hydrated patient who
is receiving a hypouricemic agent:
▪ Uric Acid ≥ 8 mg/dL
▪ Phosphate ≥ 4.5 mg/dL
▪ Potassium ≥ 6 mEq/L
▪ Calcium ≤ 7 mg/dL
 Clinical TLS
 Includes the diagnosis of laboratory TLS plus 1 or more of the
following:
▪ Increased SCr (1.5 times the upper limit of normal)
▪ Cardiac arrhythmia or sudden death
▪ New-onset seizures
 Patient is hyperkalemic (potassium >6.0 mmol/L),
hyperphosphatemic (goal 3.3-4.9 mEq/L) , and hyperuricemic (goal
3-7 mg/dL)
 Patient is considered laboratory TLS but not clinical TLS

23.  Initiate 1/4NS + D5W 4.0 L per day
 Maintain urine specific gravity ≤ 1.010
 Maintain UOP 80-100 mg/m2/hr
 Allopurinol
 600-800 mg/day PO Q8-12 hours
 OR 200-400 mg/m2/day IV
 Initiate Allopurinol 400 mg/day IV
 Initiate 3 days prior to chemotherapy
 Monitor: UA, I/Os, renal function
 Monitor (Q6hours during treatment)
 CBC, SCr, UA, K, P, Ca

24.  Monitor for normalization of lab values
 After hydration reevaluate and initiate
 Diuretic if UOP not 80-100 ml/m2/hr and patient
is euvolemic
 Rasburicase if UA still high
 Phosphate binder if still hyperphosphatemia
 Alkalinization with sodium bicarbonate NOT
recommended

25.  Lymphoma considered intermediate in
overall infection risk
 Consider antibacterial prophylaxis
▪ Fluoroquinolone
▪ Levofloxacin 500mg PO daily
 Consider fluconazole (anti-fungal) and anti-viral
prophylaxis during neutropenic episodes

26.  Hemolysis evident by very elevated LDH
 ABVD risk of febrile neutropenia <10%
 G-CSF not routinely used but some data exists that it
might be useful
 Could prevent bone pain
 Assess and monitor ANC (data N/A in case)
 Initiate G-CSF if needed after chemotherapy
 G-CSF Filgrastem 5 mcg/kg SQ daily
 Begin 24 hours after completion of chemotherapy
 Continue until ANC >1000 for 3 days
 Or >5000 for 1 day
 Give Filgrastim 3 weeks before the next cycle of
chemotherapy

27.  Patient is already fatigued which may worsen
with chemotherapy
 Life-style modifications
 Exercise, no overexertion, healthy nutrition
 Methylphenidate 2.5 mg twice daily
 Titrate up every 2 days as needed

28.  Non-pharmacological treatment options
 Increased fluids, fiber, and physical activity
 Recommend osmotic laxative
 Sorbitol 45mL PO Qdaily
 Diarrhea should not be an issue with ABVD

29.  Recommendations
 Control anxiety (nonpharmacological
interventions and/or lorazepam)
 Screen for depression regularly
▪ This patient’s whole life will change and she may not be
able to continue her schooling
 Oocyte cryopreservation prior to chemotherapy
 Avoidance of alcohol
 Vaccinations
▪ H. influenzae, pneumonococcal, and meningococcal
vaccines
▪ Especially if radiation therapy (RT) in the future

30.  Patient is in college- Low income
 Probably lives alone and not near family
 Likely she has no insurance
 Patient Background
 Adopted with no known family history
 Manifesting as fatigue, weight loss, and stress
 Likely lose more weight with chemotherapy
 Impacts on Patient
 Postpone school or take online classes
 Move closer to her family for support
 No ETOH - quit drinking
 Will lose her hair from the chemotherapy which may make
social interaction and school difficult
 Cannot consider or get pregnant on ABVD

31.  Fatigue
 Rest when you needed and do not push body too far
 Low impact exercise (walking) to release endorphins
 High nutrient diet
 Methylphenidate initial 2.5 mg twice daily
▪ Titrate up every 1-2 days
 Weight loss
 Eat small, frequent meals
 Use a smaller plate
 Choosing healthy foods with high nutrition (fruits/vegetables)
 Eat food at room temperature
 Dietary consult before starting chemotherapy
 Consider megestrol acetate/CSs if needed
 Nausea/Vomiting – avoid triggers like odors and eat
several small meals a day

32.  Stress Management
 Nonpharmacological stress reducing activities that
the patient enjoys (yoga, painting, etc…)
 And/or an anxiolytic
 Hair loss
 Donate hair prior to chemotherapy if desired
 Good wigs and wraps
 School
 Online classes or reduced load if she is adament
about continuing
 Counseling and Support Groups
 Obtain insurance
 May be able to get through school if continuing

33. 1. Caciato DA, Territo MC. Manual of Clinical Oncology.
6th ed. Philidelphia, PA: Lippinncott/Wolters Kluwer;
2008: chapter 21.
2. Lymphoma Research Foundation.
http://www.lymphoma.org/site/pp.asp?c=bkLTKaO
QLmK8E&b=6300137 . Accessed March 25, 2012.
3. Micromedex® Healthcare Series [database online].
Greenwood Village, CO. Thomson Reuters
(Healthcare) Inc. Updated periodically. Accessed
March 25, 2012.
4. NCCN GuidelinesTM. Hodgkin Lympohma. Version
3.2011. NCCN. www.nccn.org. Updated July 2011.
Accessed March 25, 2012.
5. Caring for Cancer Patients Lectures.