An-Najah National University

Faculty of Medicine and Health Sciences

(Case report)

In FARM

ONCOLOGY

Prepared by:

Shama Radwan Amoudi 11821071

Submitted to:

Dr. Shatha Foqaha

Nablus, 2024

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  Finding:

:Name B.R Age 52 Gender male Address Nablus

Blood None weight 75kg Height 163 cm BSA m2 1.84

transfusion

.Past medical history: Type 2 DM for 3 years

Past Surgical history: Free

:Social history
 Married with 4 offspring

 EX-smoker.

 Worker as a taxi driver.

Family History:
 Father died with blood cancer (unknown type).

History of presenting illness: present with history of enlarged lymph node (Rt cervical area) 7

months ago , increase in size Associated with : weight loss , night sweating

Biopsy: CLL/SLL after a LN biopsy

 CT-scan: Extensive lymphadenopathy in both sides of the neck, supraclavicular region,

superior and anterior mediastinum, both axilla and abdomen

.Chief compliant: Taking the 5th cycle of FCR regimen chemotherapy regimen

Diagnosis: CLL, Stage A

Sign and symptoms: weight loss and night sweating

.Past Medication History: Metformin, aspirin, paracetamol and Glimepiride

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:Current Medication history

 Metformin 850 BID PO

 Aspirin 100 mg once daily PO

 Glimepiride 4mg once daily PO

 Pre-medications:

 Saline 0.9 1000 cc stat (for good hydration)

 Paracetamol Ig IV 30 min before rituximab (to reduce risk of infusion reaction)

 Dexamethasone 8mg IV 30 min before chemotherapy on day 2 to day 4 (to reduce risk of

infusion reaction)

 Desloratidine 5mg PO before rituximab (to reduce risk of infusion reaction)

 Ondansteron 8mg IV 30 min before chemotherapy on day 2 to day 4 (anti-emetic)

 FCR regimen:

 Day 1:

Rituximab 690 mg IV over 2-3 hrs.

Start slowly with gradual increase the dose.

 Day 2-4:

Cyclophosphamide: 460mg IV over 30 min

Fludarabine: 46 mg IV over 30 min

))) Repeated every 4 weeks (((

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Allergies: NKFDA

Immunization: Fully immunized

Nutritional history: low bacterial diet

:Lab tests

 CBC is stable with Hb 14.88, WBCs 43.2, Plt 165

 Hepatitis profile should be done before starting treatment with rituximab! *

 Assessment:

:Goals of Therapy

 The primary goal is to achieve cure of the disease and prolonging survival.

 Improve the patient's quality of life

 Minimizing Treatment Toxicity and side effects, while still achieving therapeutic

efficacy

 Prevent worsening and metastatic of the disease

 Prevent recurrence of the disease

 Prevent the complication of the disease if untreated.

:DRP

 Rituximab should be given as test dose followed by long infusion time to reduce the

risk of infusion reaction

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  Resolution:

Pharmacology treatment: Continue all the medication

Non pharmacological treatment:

 Nutrition Therapy: A balanced diet can support the body's nutritional needs during

treatment and aid in maintaining strength and energy levels.

 Social Support: Maintaining connections with friends, family and social activities and

hobbies to reduce feelings of isolation and also achieve enjoyment.

 Patient education:

Regarding cyclophosphamide:

 This medication causes infertility, so if the patient in reproductive age, sperm banking

should be done.

Regarding rituximab

 Notify your healthcare provider immediately if you experience any unusual

symptoms or side effects because It can cause more serious side effects such as

severe infusion reactions, liver toxicity, lung problems, and rare but serious

infections.

 Inform your healthcare provider if you have a history of viral infections because

Rituximab may also increase the risk of reactivation of certain viruses, such as

hepatitis B virus.

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Regarding Fludarabine

 Monitoring:

Regarding the disease:

Routine CT SCAN imaging should be done to assess the progression of the disease.

Routine CBC tests to measure the efficacy of the medication.

Regarding cyclophosphamide:

 Hematologic Toxicity:

Risk of myelosuppression leading to neutropenia, anemia, and thrombocytopenia.

Lab test: Regular monitoring of complete blood count (CBC) to assess for signs of

myelosuppression.

 Renal Toxicity:

Risk of nephrotoxicity, especially with high doses or prolonged use.

Lab test: Regular monitoring of blood renal function tests, serum creatinine levels and

urinary output to assess renal function.

 Hemorrhagic Cystitis:

Risk of bladder toxicity, including hemorrhagic cystitis.

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 Monitor for signs and symptoms of hemorrhagic cystitis, such as hematuria or bladder

discomfort.

Hydration: Ensure adequate hydration before and after cyclophosphamide infusion to

reduce the risk of hemorrhagic cystitis.

Mesna: Consider co-administration of mesna to mitigate the risk of hemorrhagic cystitis.

 Nausea and Vomiting:

Common side effects of cyclophosphamide treatment.

Assess the severity and frequency of nausea and vomiting and give antiemetic therapy as

needed.

 Immunosuppression:

Risk of increased susceptibility to infections due to myelosuppression.

 Potential Long-term Effects: Risk of secondary malignancies and infertility

with prolonged use.

Fertility Preservation: sperm banking according to patient needs.

Regarding rituximab:

 Risk of infusion-related reactions and Hypersensitivity such as fever, chills,

hypotension, and respiratory symptoms.

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Lab tests: Monitor vital signs before, during, and after rituximab infusion for signs of

infusion-related reactions

 Infection Risk: Increased susceptibility to infections due to B-cell depletion.

Lab tests: complete blood count (CBC)

 Hepatitis B Reactivation: especially in patients with prior HBV infection.

Lab tests: Monitor complete blood count (CBC), liver function tests (LFTs), and hepatitis B

serology regularly during rituximab treatment and before starting treatment

 Tumor Lysis Syndrome (TLS):

Lab tests: Monitor electrolytes, renal function, and uric acid levels

Prevention: hydration and uric acid-lowering therapy

 Immunosuppression:

Lab tests: complete blood count (CBC)

:Regarding Fludarabine

 Hematologic Parameters: Monitor complete blood count (CBC) regularly to assess

for signs of myelosuppression.

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 Infection Surveillance: Monitor for signs and symptoms of infection and perform

appropriate diagnostic tests if indicated.

 Neurological Assessment: Perform regular neurological assessments to monitor for

signs and symptoms of neuropathy or CNS toxicity.

 Renal Function Tests: Monitor serum creatinine levels and urinary output to assess

renal function.

 Gastrointestinal Symptoms: Monitor for gastrointestinal symptoms such as nausea,

vomiting, diarrhea, and mucositis.

 Liver Function Tests: Monitor liver function tests, including ALT and AST,

periodically during treatment.

 Hypersensitivity Reactions: Monitor for signs and symptoms of hypersensitivity

reactions, such as rash, fever, or respiratory distress.

{ End of the case }

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