Non-Hodgkin’s
Lymphoma
LAUREN BOUTWELL MS, RD, LDN
MING CHEUNG MS, RD, LDN
Agenda
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Lymphoma Overview - L
Nutritional Changes due to Lymphoma - M
Treatment Options - L
Case Study - M
Nutrition Therapy General - L
Nutrition Therapy Case Study - M
Questions
Conclusion - M
Objectives
▪Understand basic information about cancer and lymphoma
▪Learn about the different treatments for cancer
▪Understand the nutritional impact of cancer and cancer treatment
▪Understand the RD’s role in treatment
▪Understand the nutritional needs of cancer patients
Lymphoma
oCancer of the lymph cells (lymphatic system), which is the body’s disease
fighting network
oSystemic
oThe lymphatic system includes blood, spleen, thymus gland, and bone
marrow
oLymphocytes act abnormally by either dividing faster than normal or living
longer than usual
Types of Lymphoma
▪There are several types of lymphomas, classified by origin
▪Two main groups:
◦ Hodgkin’s lymphoma is characterized by the presence of Reed-Sternberg cells2
◦ Non-Hodgkin’s lymphoma is classified by the absence of Reed-Sternberg cells3
▪Non-Hodgkin’s lymphoma more common
◦ Tumor develops from lymphocytes3
◦ The most common sub-type of non-Hodgkin’s lymphoma is diffuse large B-cell lymphoma3
▪Classification of the type of lymphoma is important because it can affect treatment and
prognosis
Symptoms of Lymphoma
Common symptoms include:
▪ Swollen lymph nodes in the neck, armpits or groin
▪ Abdominal pain or swelling
▪ Chest pain, coughing or trouble breathing
▪ Fatigue
▪ Fever
▪ Night sweats
▪ Weight loss (usually unexplained weight loss and as much as 10% or more of their body
weight)
▪ Loss of appetite
Lymphoma Staging
Stage
Definition (N = Non-Hodgkins, H = Hodgkins)
0
• Cancer is confined to site of origin, no spread
I
• Lymphoma in only 1 lymph node area or lymphoid organ
• Or lymphoma found in only 1 area of a single organ outside the lymph system
II
• Lymphoma in 2+ groups of lymph nodes on the same side of diaphragm
• Lymphoma extends from a single group of lymph node(s) into nearby organ
III
• The lymphoma is found in lymph node areas on both sides of (above and below) the diaphragm
• The cancer may also have spread into an area or organ next to the lymph nodes, into the spleen,
or both
IV
• The lymphoma has spread outside lymph system into organ not next to involved node
• The lymphoma has spread to the bone marrow, liver, brain or spinal cord, or the pleura (thin
lining of the lungs).
Nutritional Changes
Due to Lymphoma
General
Fevers
Fatigue
Anorexia
Anemia
Changes in taste
Cancer cachexia
Biological Alterations
Cancer Cachexia
Characterized by:
 Involuntary weight loss
 Tissue wasting
AA are not spared as in simple
starvation
Muscle wasting:
 increased protein breakdown
(hypercatabolism)
 Inability to perform daily
activities
 decreased protein synthesis
 Metabolic alterations
 Occurrence of both results in
intense muscular atrophy
Changes in taste and smell
perception plays an important role in
the severity
Biological Changes in Malignancy
▪Carbohydrate abnormalities
Alterations in lipid metabolism5
▪ Insulin resistance
 Increased lipid metabolism
▪ Increased glucose synthesis
 Decreased lipogenesis
▪ Gluconeogenesis
 Decreased activity of lipoprotein
▪ Increased Cori cycle activity
▪ Decreased glucose tolerance and
turnover
lipase (LPL)
 Lipid-mobilizing factor (LMF)
produced by tumor or host tissue
Lymphoma Treatment
Options
Chemotherapy
oSystemic treatment
oPowerful chemicals to kill fast-growing/rapidly dividing cells
oChemotherapeutic agents travels throughout the body to reach cancer cells
oCannot differentiate between normal reproducing cells and cancer cells
oInterrupts cell DNA, RNA or protein synthesis of the cell cycle
oDifferent chemo agents interrupt cell proliferation at different stages
o Combination therapy is common - enhance the effectiveness & minimize
overall toxicity
oNormal cells are damaged as well as the cancer cells
Radiation Therapy
 Localized treatment used to shrink tumors, kill cancer cells and prevent their
growth
 X-rays, gamma rays, and charged particles most common types
 External-beam radiation therapy - delivered by a machine
 Brachytherapy - radioactive material placed near cancer cells
 Systemic radiation therapy - radioactive substances (i.e. radioactive iodine)
travel in blood
 Often used in conjunction with other therapies
Other Options
 Surgery
 Biological Therapy
 Bone Marrow Transplant
Case Study: Lymphoma
Patient Introduction
▪Denise Mitchell (DM)
▪ DOB: 2/18
▪ 21 yowf
▪ College student
▪ Religion: Methodist
▪Adm for evaluation of viral illness
▪ Experienced night sweats, fevers, and weight loss
▪CXR indicates a possible mass
Physical Exam
▪General appearance: thin, pale, appears tired
▪Vitals
▪ T: 100.5°F, RR: 18 bpm, B/P: 95/70 mm Hg, HR: 85 bpm
▪HEENT:
▪
▪
▪
▪
▪
Head: Normocephalic
Eyes: EOMI; wears glasses for myopia; fundi grossly normal bilaterally
Ears: Tympanic membranes normal
Nose: Dry mucous membranes without lesion
Throat: Slightly dry mucous membranes without exudates or lesions; abnormal
lymph nodes
Physical Exam cont.
▪Extremities: Normal muscular tone with normal ROM, nontender
▪Skin: warm and dry without lesions
▪Chest/lungs: Respirations are shallow; dullness present to percussion
▪WNL: Genitalia, Heart, Neurological tests, Abdomen, Peripheral
vasculature
▪CC/HPI: “I don’t seem to have ever gotten over the flu that I had
several weeks ago. I still have a fever sometimes, and the cough won’t
go away.”
Patient History
NKA
Previous Hospitalization: Tonsillectomy – age 5
Medication:
 Dimetapp, OTC (2 tsp, occ)
 Tylenol, OTC (400mg, occ)
Cold in past two weeks
Non-smoker
FH: (non-contributory)
Anthropometrics
▪Ht: 5’6”
▪Wt: 120 lbs
▪UBW: 130 lbs
▪%UBW: 92.31%
▪BMI: 19.34 – normal range
▪% unintentional wt loss: 7.69% over the last 2-3 months, significant loss
Nutritional Hx
General
 Appetite decreased
 No N/V, constipation, or diarrhea
 Food
allergies/intolerances/aversions:
NKA
 Previous nutrition therapy: None
 Vitamin/mineral intake: None
 Food purchase/prep: Self, parents,
college cafeteria
Usual dietary intake
 AM: Cold cereal, toast or
doughnut, skim milk, juice
 Lunch: (in college cafeteria)
sandwich or salad, frozen yogurt,
chips or pretzels, soda
 PM: Meat (eats only chicken and
fish), 1-2 vegetables including a
salad, iced tea, or skim milk
 Snack: Popcorn, occasionally pizza,
soda, juice, iced tea
24-Hour Recall


AM: 1 slice dry toast, plain hot tea
 Lunch: ½ c ice cream, ¼ c fruit
cocktail, few bites of other foods
on tray
 PM: Few bites of chicken (1 oz), 2
tbsp mashed potatoes, ½ c Jell-O,
plain hot tea
Diagnosis and Treatment Plan
▪Dx:
▪ Chest CT, MRI, and bone marrow and lymph
node biopsy
▪ Stage II diffuse large B-cell lymphoma w/
mediastinal disease and positive lymph
node involvement
▪ Bone marrow and other organs show no
indication of disease
Tx plan:
 Chemotherapy – cyclophosphamide,
doxorubicin, vincristine, and prednisone
(CHOP)
 Prednisone administered orally on first 5
days of each 21-day cycle
 Other chemotherapeutic meds given
intravenously on first day of cycle
 Radiotherapy planned to begin 3 wks
after third cycle of CHOP
•Discharged for outpatient therapy on hospital day 5
What Symptoms is Denise
Experiencing?
Night sweats
Fevers
Loss of appetite
Unexplained weight loss
Coughing
Fatigue/lack of energy
Abnormal lymph nodes
CHOP & What To Expect
Cyclophosphamide
Doxorubicin
N/V, diarrhea, fatigue, loss of appetite, sores in mouth or on
lips, dry mouth and sore throat
N/V; loss of appetite; sore in mouth or on lips; dry mouth;
sores or ulcerations in the throat, esophagus, or colon
(Hydroxydaunomycin)
Vincristine
(Oncovin)
Prednisone
N/V, diarrhea, constipation, fatigue, loss of appetite, mouth
sores
Increased appetite, upset stomach, weight gain, loss of
calcium from bones, dry mouth and sore throat
Nutritionally Related Labs
Lab Measure
Normal Range
MD
Albumin
3.5 – 5
3.3 L
Total Protein
6–8
5.5 L
WBC
4.8 – 11.8
12.0 H
HGB
12 – 15 (women)
11 L
HCT
37 – 47 (women)
31 L
MCV
80 – 96
70 L
Retic
0.8 – 2.8
2.9 H
Ferritin
20 – 120 (women)
19 L
Nutrition Diagnosis
▪ Malnutrition
▪ Altered nutrition related laboratory values (albumin)
▪ Unintended weight loss (involuntary weight loss)
▪ Inadequate oral food/beverage intake
▪ Increased energy expenditure
▪ Inadequate energy intake
▪ Hypermetabolism (Increased nutrient needs)
Nutrition Therapy
Nutritional Goals for Lymphoma
▪Prevent or reverse poor nutrition
▪Manage symptoms
▪Maintain or improve weight and strength
▪Maximize quality of life
Dietary and Weight Changes after
Treatments for Lymphoma
Russell NC, et al. Nutrition and Cancer. 2007; 57(2): 168–176
oRetrospective/cross-sectional study
oFocused on current BMI
oPost-treatment therapy longer than other cancers
oNo association b/w BMI and recurrence/death
oChallenging to detect diet and BMI associations - many complications
oDietary counseling important - choosing foods that alleviate symptoms
oEncouraging healthy choices can lead to weight gain
Keys to Nutritional Therapy
▪Careful screening & assessment
▪Symptoms/side-effects vary with pt
▪Individualization (Plan & Recommendations)
◦ Severity of malabsorption,
◦ Increase/decrease protein synthesis
◦ Lipid metabolism changes
◦ Appetite changes
▪Some pts do not need additional calories
▪Wt gain during/after treatment associated with worse outcome & higher relapse rates
Nutrition Therapy: General Side Effects
Side Effect
Nutrition Therapy
N/V
small, low-fat meals, avoid fried/greasy foods, electrolytefortified beverages to maintain hydration
Early satiety
small nutrient-dense meal frequently, nutrient beverages b/w
meals, avoid consumption of high-fiber foods
Dehydration
drink adequate fluids throughout day, consume fluidcontaining foods (i.e. soup), limit caffeine products
Xerostomia
artificial saliva or mouth moisturizers/lubricants, sugar-free
gum, sour-flavored sugar-free hard candies
Nutrition Therapy: Chemotherapy Side Effects
Side Effect
Nutrition Therapy
Neutropenia
avoid raw vegetables, fruits, meat, fish, eggs, avoid salad bars & deli
counters, consume only pasteurized dairy, drink tap/well water
Anemia
increase iron consumption w/ Vit C, add iron-rich foods to diet,
supplementation
Diarrhea
drink small amounts clear fluid throughout the day, avoid high-sugar
beverages, simple-sugars, alcohol, caffeine, avoid gas-producing
foods, add foods with soluble fiber
Mucositis
eat soft, non-fibrous non-acidic foods, avoid hot foods, drink plenty
of liquids, high-calorie/high-protein shakes and supplements may
help
Radiation Side Effects
Side Effect
Nutrition Therapy
Radiation
enteritis
-avoid dairy products, raw veggies, fried foods, nuts/seeds,
caffeine, strong spices, fresh fruit
-encourage consumption of cooked/broiled fish, poultry, meat,
applesauce, white bread, mashed potatoes, mild veggies
-ingest foods at room temp
-low residue diet may be recommended
Delayed wound
healing
increase consumption Vit A, E, C, increase zinc and iron
consumption, ensure adequate fluid, protein, and fat intake
Dysgeusia
-avoid metal utensils, drink from glass instead of metal container ensure adequate protein intake if meat not tolerated
-try highly spiced/flavorful food
Radiation Side Effects Cont.
Side Effect
Nutrition Therapy
Dysphagia
-specific food consistencies using thickening agents (depending on
ability to swallow
-enteral nutrition may be needed
Odynophagia
-avoid hot, rough, acidic, and/or spicy foods
-suck on ice or consume cold beverages
-try soft or pureed diet
Esophagitis
-sit upright when eating
-eat slowly
-eat small frequent meals
-avoid spicy, acidic foods
-avoid alcohol and tobacco
DM’s Nutritional Needs
Energy Requirement
▪Formula for patients who need to gain weight, are anabolic, or slightly
hypermetabolic:
▪30 – 35 kcal/kg5
▪Her energy needs is between 1,637 kcal and 1,909 kcal
▪Since she has unintentional weight loss, her energy requirement to be
closer to 1,909 kcal
Protein
oDM does not appear to be very stressed
oProtein guidelines:
•
•
Non-stressed cancer patient: 1.0 – 1.5 g/kg5
Her protein needs would be between 54.55g and 81.83g
oExperiencing some unintentional weight loss
oPE indicates that she looks thin
oHer protein needs would be closer to 1.5 g/kg to help her increase her energy intake
and prevent protein losses due to cancer
oHer protein need is approximately 76 – 82g (1.4g/kg and 1.5g/kg).
Fluid Needs
35 mL/kg (night sweats & diarrhea)
35mL/kg x 54.5 kg = 1,907 mL
Approximately 1.9 - 2 Liters of fluids per day
DM’s Nutrition Plan
Calculated Goal/Recs
1,900 Kcal/d
82 gms Protein/d
2 L fluids/d
Recommendations
Symptoms
 Diarrhea
 Early satiety
 Esophagitis
oconsume mild/non-acidic foods
oeat small, frequent meals
throughout the day
oconsume nutrient-dense
beverages/shakes
otry to consume balanced diet, but
primarily whatever is tolerated to
meet needs
Supplements
No definitive data
No regulation of herbal supplements
 Contaminants - harmful with depressed immune status
 High doses of antioxidants can actually work against the action of
chemo thereby decreasing efficacy
Individual basis
Questions and Concerns from Family
Family has been asking questions about different diets...
 Family support is great
 Encourage questions
 Don’t judge!
Reputable Sources for Information
o Lots of recommendations for alternative treatments for lymphoma
o Not all researched based
Good Sources of Information
 Dana Farber’s (www.danafarber.org/nutrition)
 National Cancer Institute (www.cancer.gov)
 American Cancer Society (www.cancer.org)
 National Institute of Health (www.nih.gov)
 Massachusetts General Hospital Cancer Center
(www.massgeneral.org/cancer/)
 The Leukemia and Lymphoma Society (www.lls.org)
Follow-Up/Evaluation
Food journal (what, where, when, and how much; also mood and
symptoms she was experiencing)
Weight measured and recorded every day (preferably at the same time
everyday), assess compliance and identify any necessary modifications to
plan
This may be too much while she is not feeling well and undergoing chemo
I/O, prealbumin, CRP, hospital generated calorie count if she's not feeling
well enough to manage it
Nutrition Education
Proper record keeping (food journal)
Soluble fiber for diarrhea
Symptoms
Common food and drug interactions
Importance of obtaining adequate energy
and nutrient intake during the treatment
List of foods and recommendations for
common symptoms
Meal replacements
Mouth care
All the instructional material should be
given before the symptoms occur21.
Low microbial diet
Review safe food handling & clean
technique (Dining In/Out)
Sensitivity
o
Understand this is a stressful
time
o
Education is important
o
Be careful to not overwhelm
o
Be sensitive to patient needs
Questions
oIs it recommended that all cancer patients consume more calories?
oIs too much weight gain bad?
oWhat if the pt refuses to eat?
oWhat about conflicting advice?
Conclusion
Nutritional care is important in conjunction medical treatment
Good nutrition can lead to better outcome & tolerance of cancer treatment
There are metabolic changes that can occur with lymphoma
Goal is to prevent malnutrition, treat symptoms, and improve QOL
RDs can make a big difference
How is DM doing Today?
▪Chemotherapy went well
▪Complete remission
▪Feeling a lot better and gained some weight back
▪Finishing up undergraduate degree
▪Impressed and inspired by the difference RDs make in medical treatment, she
plans to pursue a degree in Nutrition (MS/DPD + DI)
References
1.
Lymphoma facts, 2013. Mayo Clinic website. http://www.mayoclinic.org/lymphoma/. Updated July 13, 2013. Accessed September 20, 2013.
2.
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2013.
3.
Non-Hodgkin’s Lymphoma facts, 2013. Mayo Clinic website. http://www.mayoclinic.com/health/non-hodgkins-lymphoma/DS00350. Updated July 26, 2013. Accessed
September 20, 2013.
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Updated July 26, 2013. Accessed September 20, 2013.
5.
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20.
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