Lymphoma

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Lymphoma

Neoplasms of cells of lymphoid origin

Start in lymph nodes but can involve lymphoid tissue of spleen, GI tract, liver or bone marrow

Classified according to degree of cell differentiation & origin of predominant malignant cell

Hodgkin Lymphoma (HL)

Rare, high cure-rate

Two peaks (15-34 & after 60 years)

More common in men than women

Disease occurrence has familial pattern

First degree relatives have ↑­ frequency of disease but the actual incidence of the pattern is ↓

Commonly seen in PTs:

Chronic immunosuppressive therapy

Examples: for renal transplant

Agent Orange

Veterans of military exposed to this herbicide

Questionable viral etiology?

Cause is unknown; viral etiology is suspected

Pathophysiology:

Originates in a single node

Spreads by contiguous extension along the lymphatic system

Reed-Sternberg cells

Malignant cell of HL; gigantic tumor cell that is morphologically unique & thought to be of immature lymphoid origin

L lymphocytes

Clinical Manifestations:

Enlargement of one or more nodes on the side of the neck

Painless, firm but not hard

Common sites of lymphadenopathy are cervical, supraclavicular, & mediastinal nodes

Involvement of iliac or inguinal nodes are less common

Mediastinal mass

May be seen on chest X-RAY

Large enough to compress the trachea & cause dyspnea

Pruritus

Common; can be extremely distressing & cause is unknown

B symptoms:

Fever

Without chills

Drenching sweats

Usually at night

Unintentional weight loss

More than 10% of body weight

Found in 40% of PTs

Herpes zoster infections are common

Easier to treat because it is localized

Assessment & Diagnostic:

Mild anemia

Most common hematologic finding

Elevated ESR & Elevated copper

Assessing disease activity; elevations may reflect increases in disease activity

Lymph node biopsy

Reed Sternberg cells

History

PT is assessed for any B symptoms

Physical

Careful, systemic evaluation of all palpable lymph node chains

CT/PET

X-RAY & CT of chest, abdomen, & pelvis are crucial to identify lymphadenopathy in those regions

PET is the most sensitive test identifying residual disease

CBC, platelet count, liver and renal function studies, & ESR

Bone marrow biopsy is not routinely performed

Medical Management:

Goal: cure

85-90% cure rate for PT with early stage disease & 65-85% for advanced stage

Chemotherapy combinations

Short course (2-4 months) of chemo, followed by radiation therapy to the specific involved area

Chemo is often successful in obtaining remission even when relapse occurs

Radiation

Effective

HSCT used for advanced or refractory disease

Nursing Management:

Support discussion regarding development of secondary cancer with treatment of Lymphoma

However, PTs need to be informed that HL is often curable

Nurses should encourage PT to reduce factors that increase the risk of developing second cancers; such as use of tobacco & alcohol, environmental carcinogens & excessive sunlight

Non-Hodgkin Lymphoma (NHL)

Heterogeneous group of cancers

Neoplastic growth of lymphoid tissue

Similar to CLL, neoplastic cells arise from a single clone of lymphocytes; however, NHL, the cells may vary morphologically

6th most common type of cancer in US

Incidence increases with each decade of life

Median age for DX is 65 years old

­↑ risk of NHL

Immunodeficiency or autoimmune disorders

Prior cancer treatment

Prior organ transplant

Viral infections

Epstein-Barr virus & HIV

Exposure to pesticides, solvents, dyes, defoliating agents (Agent orange)

Pathophysiology:

No common etiologic factor

Morphology & histology varies

Appears as different types of cells

Stage based on site of disease and its spread to other sites

Stage I – highly localized

Respond well to localized therapy (radiation)

Stage IV – at least one extra nodal site detected

Clinical Manifestations:

Lymphadenopathy

Common

In indolent types of lymphomas, lymphadenopathy can wax & wane

With early stage disease à absent or little symptoms

Considered indolent

Symptoms are virtually absent or very minor, & illness not diagnosed until it progresses to a later stage when PT is symptomatic

In stages III or IV, lymphadenopathy is distinctly noticeable

B symptoms: fever, drenching night sweats, unintentional weight loss

1/3 of PTs

Mass effects of tumor

Masses can compromise organ function

Example: mass in the mediastinum can cause respiratory distress; abdominal masses can compromise the uterus, leading to renal dysfunction; & splenomegaly can cause abdominal discomfort, nausea, anorexia, & weight loss

CNS involvement

Assessment & Diagnostic:

Histopathology, immunophenotyping, cytogenetic analysis of malignant cells

Indolent types tend to have small cells distributed circularly or in follicular pattern

Aggressive types tend to have large or immature cells distributed through the nodes in a diffuse pattern

Staging is based on data from CT or PET scans, bone marrow biopsies, & occasionally cerebrospinal fluid analysis

International Prognostic Index (IPI)

Stage of disease is important but often not an accurate predictor of prognosis

IPI prognostic classification in older adult PTs

Follicular Lymphoma International Prognostic index (FLIPI) is also used for follicular lymphomas

Scored to determine risk of failure or death from disease

Age

Performance status

LDH (lactate dehydrogenase) levels

Stage of disease

Extra nodal involvement

Medical Management:

Radiation

Chemotherapy combinations

CNS: cranial radiation or intrathecal chemotherapy

Nursing Management:

Important to know staging of disease and current treatment plan

Risk for infection

Monitor for complication