Recurrent lymphoma of the left tonsil; diffuse large B cell type.

HISTORY OF PRESENT ILLNESS:

The patient is a 69-year-old female who was initially diagnosed with anaplastic large B cell lymphoma in 1994. At that time, it was stage IIA with multiple left neck masses. Her course of treatment was as follows: She underwent six cycles of CHOP chemotherapy and following that underwent involved‑field irradiation in 1994. She received 36 Gy to the bilateral neck. Since that time, her followup was uneventful until approximately November of last year when a followup PET scan was positive in the left tonsillar region. She underwent bilateral tonsillectomy and pathology revealed recurrent lymphoma in the left tonsil. Since that time, she has undergone approximately four cycles of Rituxan. She presents today for consideration for further radiotherapy for her recurrent lymphoma of the neck.

PAST MEDICAL HISTORY:

Significant for atrial fibrillation, gallstones, ovarian cyst, and hiatal hernia. She also has a history of lymphoma as well.

CURRENT MEDICATIONS:

She is on Multivitamins, Synthroid, Fosamax, and Rituxan.

ALLERGIES:

No known drug allergies.

FAMILY HISTORY:

She reports a history of her sister having a low-grade lymphoma in the past. She denies any other significant family history.

SOCIAL HISTORY:

She is a nonsmoker and nondrinker.

REVIEW OF SYSTEMS:

A 10-point review of systems was performed and is negative except that mentioned above in the history of present illness. Specifically, she denies any significant fever, night sweats, chills, mouth pain, itching, difficulty swallowing, shortness of breath, any nausea or vomiting, diarrhea or constipation or bleeding in her urine, stools or vagina. She has not experienced any chest pain, abdominal pain, headaches, or seizure activity.

PHYSICAL EXAMINATION:

VITAL SIGNS: Weight today is 161 pounds. Blood pressure is 145/61. Pulse is 56. Respiratory rate is 18.  GENERAL EXAM: She is a middle-aged female who is in no apparent distress.  HEENT: Head is normocephalic and atraumatic. The extraocular movements are intact. The pupils are equal, round and reactive to light. Examination of the intraoral cavity reveals no suspicious masses or lesions. She does have approximately grade 1 xerostomia. NECK: No cervical, supraclavicular or infraclavicular adenopathy.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation bilaterally.  ABDOMEN: Soft and benign.  NEUROLOGIC EXAM: Neurologically, the patient is alert and oriented x4. Cranial nerves II through XII are grossly intact. Motor strength is 5/5 in all extremities. DTRs are 2+ and symmetric bilaterally.  EXTREMITIES: The extremities are warm and well perfused with no clubbing, cyanosis or edema. 

IMPRESSION:

Recurrent lymphoma of the left tonsil, status post surgical removal as well as Rituxan chemotherapy.

PLAN:

The above information was discussed with the patient. I went on to discuss the role of further radiotherapy in decreasing the risk of local recurrence of her lymphoma. She is very hesitant to undergo radiotherapy treatment again. We discussed the role of radiotherapy and its impact on overall survival. She will consider my recommendations and was given an appointment to return to clinic in one month’s time. In the interim, a PET CT will be obtained to restage her since her surgery.