BMT CASE STUDY
By Lark Duncan
Patient Overview
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53 YOWM
Relapsed Non-Hodgkins Lymphoma
Diet: Immuno
PMH: Large-cell malignant lymphoma, Hepatitis B &
C, HTN, erosive esophagitis
Ht: 70”
Admit Wt: 84.1kg
Most Current Wt: 85.2kg
Patient Overview
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Patient Received:
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Chemo
 Kills all or most fast growing cells such as bone marrow, hair cells,
some GI cells, etc.
ALLO MUD
 Allogenic transplant from a matched unrelated donor.
 Higher risk of complications
Significant Labs that were altered:
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AST/ALT/Alk Phos
Albumin
WBC/Platelets
What is Non-Hodgkins Lymphoma?
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Non-Hodkins Lymphoma is a cancer that begins in
the cells of the immune system:
 Lymph
vessels
 Lymph
 Lymph
Nodes
 Other parts such as
spleen or tonsils
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Usually it is found in a
lymph node first
What is Non-Hodgkins Lymphoma?
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Risk Factors:
 Weakened
 Inherited,
 Certain
 HIV,
Immune System
Organ transplant
Infections
H. pylori, Hep C
 Age
 Most
people are over 60
What is Non-Hodgkins Lymphoma?
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Symptoms
 Swollen
lymph nodes
 Weight loss
 Fever
 Night Sweats
 Coughing, trouble breathing, chest pain
 Weakness
What is Non-Hodgkins Lymphoma?
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Types of NHL:
Indolent – slow growing
 Aggressive (intermediate or high grade) – fast growing
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Stages of NHL:
Stage I – lymphoma cells are in one lymph node group or in
one organ (not liver or bone marrow)
 Stage II – lymphoma cells are found in at least 2 lymph
nodes on the same side of the diaphragm
 Stage III – lymphoma cells both above and below
diaphragm
 Stage IV – lymphoma in several parts of one or more
organs or tissues or is in the liver, blood, or bone marrow
 Recurrent – the disease returns after treatment
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Treatment
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Side effects of chemotherapy:
 Blood
cells lowers – both red and white cells are
lowered making the patient tired and weak.
 Blood
 Hair
can be given or Rx to help the body make more cells
loss
 Loss of proper GI function –
often poor appetite, nausea,
vomiting, diarrhea,
trouble swallowing, taste
changes, or mouth and
lip sores.
Treatment
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Bone Marrow Transplant
 Autologous
stem cell transplant – uses the patient’s own
stem cells
 Allogenic stem cell transplant – donor cells are used
from a relative or an unrelated donor
 Syngenic stem cell transplant – cells from the patient’s
healthy identical twin
Drug-Nutrient Interactions
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Xanax – caution with grapefruit, decr. appetite,
decr. weight, incr. weight
Magnesium Oxide – may need AL supplement
Phenergan – for Nausea
Acyclovir – Anorexia
Benicar HCT – Caution with K supplement or salt
substitution
Zofran – for Nausea
Zocor – avoid grapefruit/related citrus
Drug-Nutrient Interactions
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Celexa – incr. weight, incr. appetite
Clonazepam – decr. weight, incr appetite, incr.
weight
Lexapro – incr. weight, incr. appetite
Epivir – Anorexia, N/V
Bactrim – Anorexia, N/V
Fludara – Anorexia, stomatitis, N/V
Actigall – N/V/D/C
Drug Nutrient Interactions
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Levofloxacin – N/D, take with water
Cefepime – May need Vit K supplement
Vancomycin – nausea
Tacrolimus – Anorexia, incr. appetite, decr Fe
Oxycodone – Anorexia, N/V/C
Decadron – high BG
Nutritional Implications
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Loss of appetite – encourage protein and kcal
intake and explain importance for strength and
healing
Taste changes – provide food preferences, make
suggestions on the menu from prior experiences
Mouth sores – provide foods that are soft and low
acid
Nausea/Vomiting – provide bland foods, TPN
Nutritional Implications
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Oral Feedings
Enteral Feedings
 GI
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issues are common with chemo and BMT patients
TPN
 Higher
risk of infection
 Low plate count
 Central line in place
 GI issues
Medical Terminology
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Allogenic Stem Cell Transplant – patient receives
bone marrow cells from a genetically similar, but not
identical donor.
B-cell – a white blood cell that comes from bone
marrow. It makes antibodies and fights infection.
Blood transfusion – administration of blood or
blood products into a blood vessel.
Large-cell lymphoma – type of B-cell NHL that is
usually aggressive.
Nutrition Intervention
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Diet Rx: Immunosuppressive Diet
 Helps
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prevent infection
Education: Immuno Diet, Importance of Protein/Kcal
 Diet
well accepted, followed
 Willing to try new foods to increase Pro/Kcal
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Supplements: Ensure Plus TID
 Tried
to drink at least two a day
Significant Events
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7/8: Admission Date
7/9: Start Chemo
7/12: Minimal toxicity – nausea
7/14: Fever, rigors, chills, headache
7/16: Transplant today, transfuse platelets, acute
onset of abdominal pain from thickening/edema of
the ileum, NPO for the night
7/18: Rash from serum sickness
Significant Events
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7/19: Platelet transfusion
7/21: Liver labs elevated, grade 2 toxicity
7/22: Liver labs more elevated (very high), noted
depression
7/24: Liver labs still very high, continued toxicity
7/26: Liver labs begin to normalize
8/3: Liver labs normal
Significant Events
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Patient had no signs of GVHD
 Can
effect:
 Liver
 Skin
 Mucosa
 GI
Review of Literature
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TNFAIP3/A20 functions as a novel tumor suppressor
gene in several subtypes of non-Hodgkins lymphoma.
The deletion of chromosome 6q is associated with
tumorigenesis of lympoid malignancies.
 The NK-kB pathway is the primary target for 6q deletion in
B-cell
 TNFAIP3/A20 is a negative regulator of the NF-kB
pathway.
 Findings: By increasing the activation of TNFAIP3/A20 there
was an association with resistance to apoptosis
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Review of Literature
Distinctive natural history in hepatitis C virus postive
diffuse large B-cell lymphoma: analysis of 156 patients
from northern Italy.
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Hepatitis C virus (HCV) infection has been associated with
increased risk of developing B-cell lymphoproliferative
disorders.
 Findings: HCV patients had a more frequently elevated LDH
and were older at diagnosis.
 They had favorable outcomes.
 There was a high occurrence of spleen involvement.
 In comparison to patients without HCV, these patients had a
distinctive presentation and natural history.
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Review of Literature
High-Dose Celecoxib and Metronomic “Low-dose”
Cyclophosphamide Is an Effective and Safe Therapy in
Patients with Relapsed and Refractory Aggressive
Histology Non-Hodgkin’s Lymphoma.
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Angiogenesis is increased in aggressive histology nonHodgkin’s lymphoma and may be a target with selective
cyclooxygenase-2 inhibition and metronomic chemotherapy.
 Most common toxicity was skin rash
 Gastrointestinal side effects were uncommon
 Survival rate is comparable to other chemo regiments
 Findings: This regiment is a safe way to treat relapsed NonHodgkins, especially due to the minor side effects.
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Review of Literature
Upfront high-dose sequential therapy (HDS) versus
VACOP-B with or without HDS in aggressive nonHodgkin’s lymphoma: long-term results by the NHLCSG.
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Because there is not univocal concordance for using highdose sequential therapy (HDS) for NHL, this study evaluates
the usefullness of HDS followed by high-dose therapy (HDT).
 Arm A – 12 weeks usual treatment and then HDS/HDT if
disease was persistant
 Arm B – 8 weeks usual treatment plus HDS/HDT
 Findings: Complete response rate for Arm A was 75% and
72.6% for Arm B. Aggressive NHL patients do not benefit
from upfront HDS/HDT.
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Review of Literature
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Sequential high dose chemotherapy as initial treatment
for aggressive types of Non-Hodgkin Lymphoma: results
of international randomized phase III trial (MISTRAL).
Sequential high dose (SHD) chemotherapy with stem cell
support has been shown to prolong the event-free survival in
patients with diffuse large B-cell lymphoma.
 Patients were randomized to receive either CHOP of SHD.
 Overall survival rate after 3 years was 46% for SHD and
53% for CHOP.
 Findings: SHD did not confer any survival benefit in these
patients.
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Review of Literature
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Overweight and Obesity at Different Times in Life as Risk
Factors for Non-Hodgkin’s Lymphoma: The Multiethnic
Cohort.
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Obesity may increase the risk for non-Hodgkin’s lymphoma
through an inflammatory pathway.
Body weight and BMI at age 21 were stronger predictors of NHL
risk than anthropometric characteristics at baseline.
At 21, men and women at the highest quartile were at
substantially higher risk than others, whereas there was no
association at baseline.
Findings: weight at age 21 may represent lifetime adiposity
better than body weight at cohort entry.
Weight may at age 21 may be more relevant for the etiology of
NHL.
References
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U.S. Department of Health and Human Services. What You Need to Know about Non-Hodgkin Lymphoma. September 2007.
Honma K, Tsuzuki S, Nakagawa M, Tagawa H, Nakamura S, Morishima Y, Seto M. TNFAIP3/A20 functions as a novel tumor
suppressor gene in several subtypes of non Hodgkin lymphomas. Blood. Published online July 16, 2009.
Visco C, Arcaini L, Brusamolino E, Burcheri S, Ambrosetti A, Merli M, Bonoldi E, Chilosi M, Viglio A, Lazzarino M, Pizzolo G,
Rodeghiero F. Distinctive natural history in hepatitis C virus positive diffuse large B-cell lymphoma: analysis of 156 patients
from northern Italy. Annals of Oncology. 2006;17:1434-1440.
Buckstein R, Kerbel R, Shaked Y, Nayar R, Foden C, Turner R, Lee C, Taylor D, Zhang L, Man S, Baruchel S, Stempak D, Bertolini
F, Crump M. High-Dose Celecoxib and Metronomic “Low-dose” Cyclophosphamide Is an Effective and Safe Therapy in
Patients with Relapsed and Refractory Aggressive Histology Non-Hodgkin’s Lymphoma. Clinical Cancer Research.
2006;12(17): 5190-5198.
Olivieri A, Santini G, Patti C, Chisesi T, De Souza C, Rubagotti, Aversa S, Billio A, Porcellini A, Candela M, Centurioni R, Congiu
A, Brunori M, Nati S, Spriano M, Vimercati R, Marino G, Contu A, Tedeschi L, Majolino I, Crugnola M, Sertoli M. Upfront highdose sequential therapy (HDS) versus VACOP-B with or without HDS in aggressive non Hodgkin’s lymphoma: long-term results
by the NHLCSG. Annals of Oncology. 2005; 16: 1941-1948.
Betticher D, Martinelli G, Radford J, Kaufmann M, Dyer M, Kaiser U, Aulitzky W, Beck J, von Rohr A, Kovascovics T, Cogliatti S,
Cina S, Malbach R, Cerny T, Linch D. Sequential high dose chemo therapy as initial treatment for aggressive sub-types of
Non-Hodgkin Lymphoma: results of the international randomized phase III trials (MISTRAL). Annals of Oncology. 2006; 17:
1546-1552.
Maskarinec G, Erber E, Gill J, Cozen W, Kolonel N. Overweight and Obesity at Different Times in Life as Risk Factors for NonHodgkin’s Lymphoma: The Multiethnic Cohort. Cancer Epidemiol Biomarkers. 2008; 17: 196-203.