Medical Oncology Consultation

Identification

Mr. Arthur Pendelton is a 68-year-old male referred for medical oncology consultation regarding a new diagnosis of stage III diffuse large B-cell lymphoma (DLBCL).

History

The patient initially noticed a painless, progressively enlarging right cervical mass in January-2025. Over the subsequent six weeks, he developed drenching night sweats and an unintentional weight loss of 6 kg, prompting presentation to his primary care provider.

An excisional biopsy of the right cervical lymph node performed on February 18, 2025 demonstrated diffuse effacement of the nodal architecture by large atypical lymphoid cells. Immunohistochemistry was positive for CD20, CD10, and BCL6, and negative for MUM1, with a Ki-67 proliferation index of 85 %, consistent with germinal center B-cell-like (GCB) diffuse large B-cell lymphoma; fluorescence in situ hybridization (FISH) was negative for MYC, BCL2, and BCL6 rearrangements.

A staging FDG-PET/CT scan completed on March 02, 2025 revealed hypermetabolic lymphadenopathy above and below the diaphragm, including a right cervical conglomerate measuring 4.2 x 3.1 cm (SUVmax 18.4), bulky mediastinal adenopathy measuring 5.5 x 3.8 cm (SUVmax 21.0), and retroperitoneal nodes measuring up to 3.4 cm (SUVmax 16.2), with no evidence of extranodal or bone marrow involvement.

Baseline laboratory investigations on March 05, 2025 showed hemoglobin 118 g/L, white blood cell count 6.4 x 10^9/L, platelets 210 x 10^9/L, creatinine 88 umol/L, and an elevated lactate dehydrogenase (LDH) at 420 U/L (upper limit of normal 225 U/L). Hepatitis B, Hepatitis C, and HIV serologies were non-reactive.

The case was reviewed with Dr. Elena Rostova in Radiation Oncology on March 10, 2025, who advised that consolidative radiation to the bulky mediastinal mass may be considered depending on the end-of-treatment PET response. The patient reported increased fatigue and mild exertional dyspnea since that consultation.

Past Medical History

• Hypertension, diagnosed in May-2015, well controlled on oral therapy.
• Type 2 diabetes mellitus, diagnosed in November-2018, managed with oral hypoglycemics and routine HbA1c monitoring.
• Osteoarthritis of the bilateral knees, managed conservatively.

Medications

• Ramipril (Altace®) 5 mg PO daily for hypertension
• Metformin (Glucophage®) 500 mg PO BID for type 2 diabetes mellitus
• Paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN for knee pain

Allergies

The patient reports an allergy to penicillin, which causes a generalized maculopapular rash.

Social History

Mr. Pendelton is a retired high school teacher who lives in a single-story home with his wife, who is his primary support. He is a lifelong non-smoker, consumes alcohol rarely, and receives a standard teachers' pension with comprehensive extended health benefits.

Physical Examination

On examination today, the patient is alert, oriented, in no acute distress, with an ECOG performance status of 1, vital signs showing BP 128/76 mmHg, HR 78 bpm, and temp 36.8 °C, a firm, fixed 4 cm right anterior cervical lymph node, clear auscultation of the lungs, normal heart sounds, and no palpable hepatosplenomegaly.

Assessment / Plan

Mr. Pendelton is a 68-year-old male with newly diagnosed Stage IIIB diffuse large B-cell lymphoma, GCB subtype. High-risk characteristics include advanced stage, bulky mediastinal disease, and elevated LDH, yielding an International Prognostic Index (IPI) score of 3 (high-intermediate risk).

We discussed curative-intent chemoimmunotherapy with the R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) administered every 21 days for 6 cycles. Standard dosing will be utilized with no planned upfront omissions, alongside supportive therapy including allopurinol 300 mg PO daily for Cycle 1 tumor lysis syndrome prophylaxis, ondansetron for antiemetic coverage, and primary prophylaxis with pegfilgrastim (Lapelga®) 6 mg SC on Day 2 of each cycle to mitigate febrile neutropenia risk. Close glycemic monitoring will be required while on high-dose prednisone.

Potential adverse effects reviewed in detail included alopecia, nausea, fatigue, peripheral neuropathy, cardiomyopathy, cytopenias, and the risk of life-threatening infection or febrile neutropenia. The patient expressed understanding of these risks and provided informed written consent to proceed; a baseline transthoracic echocardiogram (TTE) is currently pending prior to doxorubicin administration.

Given the symptomatic bulky disease, treatment will commence urgently next week following completion of the TTE, and a referral to the oncology pharmacy team has been placed for education. The patient was instructed to monitor his temperature and present immediately to the nearest emergency department for a fever of 38.0 °C or higher, and an interim restaging PET/CT scan is planned after Cycle 3.

"This document was prepared with AI ambient scribing and speech-recognition software and may contain spelling or transcription errors. The patient or guardian consented to its use."