What are the next steps in managing a 23-year-old patient with a past medical history (PMHx) of lymphoma presenting to the emergency department (ED) with sacral back pain and computed tomography (CT) findings of adenopathy in the retroperitoneum and iliac regions?

From the Guidelines

The next step in management for this 23-year-old lymphoma patient with sacral back pain and stable retroperitoneal and iliac adenopathy is to provide appropriate pain management while arranging prompt oncology consultation, as recommended by the Lugano classification 1. Initially, administer NSAIDs such as ibuprofen 400-600mg every 6 hours or naproxen 500mg twice daily, potentially supplemented with acetaminophen 1000mg every 6 hours for pain control. If pain is severe, consider short-term opioid therapy such as oxycodone 5-10mg every 4-6 hours as needed. Some key points to consider in the management of this patient include:

• The importance of hepatitis B testing before initiating anti-CD20 monoclonal antibody-based regimens, as highlighted in the guidelines for non-Hodgkin's lymphomas 1
• The role of bone marrow biopsy in the workup for lymphoma patients, which may be essential for certain types of lymphoma, such as primary cutaneous DLBCL, leg-type (PCDLBCL-LT) 1
• The use of FDG-PET scan for initial staging, restaging, and follow-up of patients with NHL, which has been shown to have high positivity and specificity 1
• The recommendations for follow-up evaluations, including the use of clinical judgment, history, and physical examination, as well as laboratory tests and imaging studies, as outlined in the Lugano classification 1 Concurrently, arrange urgent follow-up with the patient's oncologist within 1-2 days for comprehensive evaluation of disease status. The oncologist will likely order additional imaging (PET/CT) to assess for disease progression and may recommend bone marrow biopsy if there's concern for bone involvement. Laboratory tests including CBC, comprehensive metabolic panel, LDH, and inflammatory markers should be obtained to evaluate disease activity. The stable adenopathy on CT suggests this may represent known disease rather than new progression, but the new back pain warrants thorough investigation as it could indicate bone involvement or nerve compression requiring specific intervention beyond pain management. It is also important to consider the patient's history of lymphoma and the potential for relapse, as well as the need for ongoing monitoring and follow-up, as recommended by the ESMO minimum clinical recommendations for diagnosis, treatment, and follow-up of relapsed large cell non-Hodgkin's lymphoma 1.

From the Research

Management of Sacral Back Pain in a Patient with Lymphoma

• The patient's presentation of sacral back pain with a history of lymphoma and adenopathy in the retroperitoneum and iliac regions requires careful consideration of pain management options.
• According to 2, pharmacologic management of acute pain should be tailored to each patient, and first-line treatment options for mild to moderate pain include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs).
• However, the use of acetaminophen in cancer patients receiving strong opioids for pain management has been shown to have no significant benefit in pain control or reduction of opioid utilization, and may even be associated with a longer length of stay 3.
• Additionally, regular use of acetaminophen has been associated with an elevated risk of non-Hodgkin lymphoma in women 4, which is a concern for this patient given their history of lymphoma.
• In terms of opioid management, 5 suggests that "as-needed" range orders for opioid analgesics can be safely implemented by a registered nurse competent in pain assessment and analgesic administration.
• Furthermore, 6 highlights the potential impact of acetaminophen on the efficacy of immunotherapy in cancer patients, suggesting that its use may suppress antitumor immunity and should be used with caution in patients treated with immune checkpoint blockers.

Considerations for Pain Management

• Given the patient's history of lymphoma and the potential risks associated with acetaminophen, alternative pain management options should be considered.
• NSAIDs may be a viable option for managing the patient's sacral back pain, but their use should be carefully monitored due to potential gastrointestinal and cardiovascular risks 2.
• Opioid analgesics may be necessary for severe or refractory pain, but their use should be carefully titrated and monitored to minimize risks 2, 5.