Case Study Lymphoma Laura Croan Lymphoma Clinical Nurse

Case Study Lymphoma Laura Croan Lymphoma Clinical Nurse Specialist Belfast City Hospital Funded by Friends of the Cancer Centre

AG – 25 yo male Presented June ‘ 16 to ED with 1 -2 week history of: LUQ pain SOBOE Night sweats Reduced appetite and nauseous Weight loss 2/52 Lethargy ++ Poor historian and mother felt he had been unwell longer

Examination Massive hepatosplenomegaly – both 5 fb below costal margin Abdomen distended LN’s palpable – cervical, axilla and groin bilaterally Thin, poor pallor and clammy HS I & II Reduced air entry bilaterally with L upper zone wheeze

Examination Hb 38 Plts 48 WCC 4. 2 ANC 0. 9 Lymph 3. 2 AST 566 ALT 693 Bil 5, ALP 119, GGT 18 CRP 34. 7 LDH 524 Temp 378 BP 109/64 P 111 R 17 Sa. O 2 97% RA ECG sinus tachy CXR NAD

History PMHx Childhood epilepsy Learning difficulties ICU admission for OD of citalopram and diazepam Substance misuse Anxiety DSH Medications Citalopram 40 mg Amitriptyline 10 mg Diazepam 1 -2 mg prn Sensitive to Ibuprofen No other allergies At diagnosis denied elicit drug use

Social History Unemployed Lives with mother/grandmother No siblings Step-father RIP 2 children & 1 on the way No foreign travel Smoker 40/day since 11 No alcohol At diagnosis denied any recent drug misuse

Haematology Advice Transfuse PRCs Oxynorm & paracetamol for analgesia Virology – HIV/Hep B&C/Enterovirus/CMV PCR Negative EBV PCR +ve – CT value 36. 98 Peripheral Blood Film Abnormal lymphocytes – CD 19+, CD 5 -, CD 10 - BMBx – try tap x 2, trephine roll –

Haematology Advice CT CAP – widespread lymphadenopathy, splenomegaly with infart, liver, bilateral pleural effusions LN excision biopsy with platelet cover Transfer to Haematology Inpatients for further management

Admission to Haem A/w diagnosis Absconding off ward for 4 -12 hours Returning drowsy, slurred speech, unsteady, slow thought processes Gambling online and “going to the bookies” Aggressive when confronted Not engaging in conversation “If I die, I die” Took “ 10 blues” of friends diazepam (100 mg!)

Help! Enforced the AWOL policy – informed police every time he absconded Would a court order be needed to act in patients best interest? Psych referral and capacity assessment Addictions service – refused Smoking cessation Negotiation - ‘agreement’ with staff and AG

Diagnosis CT CAP: widespread LNs, splenomegaly with infart, liver, bilateral pleural effusions Peripheral Blood Film Abnormal small cleaved lymphocytes, lymphocytes 75%, MONOCLONAL CD 19+ CD 5 - CD 10 - LAMBDA RESTRICTED B-CELL population BMBx: dry tap x 2, trephine roll – Abnormal cleaved lymphocytes, lymphocytes 80%, severely reduced erythropoiesis – CD 20+ CD 79+, CD 5 -, CD 10 Indicative of B cell NHL Axillary LN Biopsy: IMMUNOPHENOTYPE: Positive: CD 20, CD 10, BCL 6, BCl 2 Negative: CD 3, CD 5, Cyclin D 1, CD 43, CMYC, P 53, MUM-1 Histology : abnormal neoplastic follicles. MIB 1 shows a Ki 67 labeling index of 25% Grade 2 follicular lymphoma No transformation to high grade lymphoma seen

Diagnosis Stage 4 B Follicular Lymphoma With extensive lymphadenopathy, spleen, liver & bone marrow involvement. Plan: 6 cycles RCHOP with Rasburicase ? Radiotherapy on completion Maintenance Rituximab

Complications Further delays: Fall – “cramp in his leg” and fell hitting his head GCS 15/15, PEARL, no apparent injury CTB – clear Wanted to leave hospital to attend the hearing of his step-fathers court case

Treatment 5/7/16 – 1 st CHOP with Rasburicase (no GCSF-splenomegaly) 6 -7/7/16 – split dose rituximab Hypersensitivity reaction, chest discomfort & nausea 8/7/16 – much more comfortable 10/7/16 – spleen 3 fb, abdomen visibly less distended IVABx for PUO 19/7/16 – allowed day leave Day 23 post RCHOP anc 0. 5 – stat GCSF Discharged home

Treatment 4/8 – course 2 RCHOP as an outpatient no problems 25/8 – course 3 RCHOP Mild constipation and nausea – manageable Admitted to previous steroid abuse Interim scan – spleen reduced to 13 cm, 50% reduction in Lymph nodes

Discussion