LYMPHOMAS

LYMPHOMAS – Types, Etiology, Pathophysiology, Stages, Clinical Manifestations, Diagnostic Evaluations and Management

The lymphomas are neoplasms of cells of lymphoid origins. These tumors usually start in lymph nodes but can involve lymphoid tissue in the spleen, the gastrointestinal tract, the liver and the bone marrow.

They are often classified according to the cell differentiation and the origin of the predominant malignant cells. Lymphomas can be broadly classified into two categories:

• Hodgkin’s lymphoma
• Non-Hodgkin’s lymphoma

Hodgkin’s Lymphoma

Hodgkin’s lymphoma is also called Hodgekin’s disease. It is a chronic, progressive, neoplastic disorder of lymphatic tissue tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites such as the spleen, and liver.

ETIOLOGY

• Exact cause of Hodgkin’s lymphoma remains unknown
• Infection with Epstein-Barr virus
• Genetic predisposition
• Exposure to occupational toxins
• The incidence of hodgkin’s lymphoma is increased among HIV infected patients

PATHOPHYSIOLOGY

Normally the lymph nodes are composed of connective tissues that surround a fine mesh of reticular fibers and cells —- in Hodgkin’s lymphoma the normal structure of lymph node is destroyed by hyperplasia of monocyte and macrophages —- in recurrent disease, it may be more diffuse (wide spread) —- it eventual infiltrate other organs, especially the lungs, liver and spleen

STAGES OF HODGKIN’S LYMPHOMA

Stage 1: involvement of a single lymph node region on a lymphoid structure (e.g. spleen, thymus)

Stage 2: involvement of two or more lymph node regions on the same side of the diaphragm

Stage 3: involvement of lymph node regions or structure on both sides of the diaphragm

Stage 3₁: involvement limited to the lymphatic structures in the upper abdomen that is spleen or splenic, celiac or hepatic portal nodes

Stage 3₂: involvement of lower abdominal nodes, that is para-arotic, iliac, inguinal, with or without involvement of the splenic, ciliac or hepatic portal nodes

Stage 4: diffuse or disseminated involvement of one or more extra lymphatic organs or tissues with or without associated lymph node involvement

CLINICAL MANIFESTATION

• Enlargement of cervical, axillary and inguinal lymph nodes
• The enlarged lymph nodes are not painful unless they exert pressure on adjacent nerves
• Pruritus: is the common it can be extremely distressing and the cause is unknown
• The symptoms results from compression of organs by the tumor
• Cough and pulmonary effusion: from pulmonary filtration
• Jaundice: from hepatic involvement or bile duct obstruction
• Abdominal pain: from splenomegaly
• Retroperitoneal adenopathy
• Bone pain: from skeletal involvement
• Fever
• Unintentional weight loss
• Anemia

DIAGNOSTIC EVALUATION

• Physical examination: to assess swollen lymph nodes, including neck, axillary and groin, as well as a swollen spleen or liver
• Blood tests: a sample of blood is examined in a lab to see if anything in blood indicates the possibility of cancer
• Imaging tests: imaging tests used to diagnose Hodgkin’s lymphoma include X-ray, computerized tomography (CT) scan and positron emission tomography (PET)
• Bone marrow biopsy: a bone marrow biopsy may be used to look for signs of cancer in the bone marrow. During this procedure, a small amount of bone marrow, blood and bone are removed through a needle.

MANAGEMENT

Treatment depends on the nature and extent of the disease. Once the stage of Hodgkin lymphoma is established management focuses on selecting a treatment plan.

• The standard for chemotherapy is the ABVD regimen: Doxorubicin, Bleomycin, Vinblastine and Dacarbazine
• Patients with early stage disease will receive two or four cycles of chemotherapy
• Patient with early stage but unfavorable prognostic feature or intermediate stage disease will be treated with four to six cycles of chemotherapy
• Other chemotherapy regimens include MOPP alternating with ABVD. MOPP consist in Mechlorethamine, Vincristine, Procarbazine and Prednisone
• Role of radiation as a supplement to chemotherapy varies to depending on sites of disease and the presence of resistant disease after chemotherapy
• The most distressing and immediate side effect of the chemotherapeutic agents used to treat Hodgkin’s disease is severe nausea and vomiting. Symptoms may severe enough to force a client to discontinue therapy. Pancytopenia a toxic effect of these agents, usually occurs 10 to 14 days after intravenous therapy

Non-Hodgkin Lymphoma

Non-Hodgkin’s lymphomas are a heterogeneous group of malignant neoplasms of primarily B and T-cell origin affecting all ages. B-cell lymphomas constitute about 90% of all non-Hodgkin’s lymphoma. They are classified according to different cellular and lymph node characteristics.

ETIOLOGY

The cause of non-Hodgkin’s lymphoma is usually unknown

RISK FACTORS

• Immunosuppressive medicines: used to prevent rejection following an organ transplant or to treat autoimmune disease.
• Infection with certain viruses and bacteria: certain viral and bacterial infections appear to increase the risk of non-Hodgkin’s lymphoma. Viruses linked to increased non-Hodgkin’s lymphoma risk include HIV and Epstein-Barr virus. Bacteria linked to an increased risk of non-Hodgkin’s lymphoma include the ulcer-causing Helicobacter pylori
• Chemicals: certain chemicals, such as those used to kill insects and weeds, may increase risk of developing non-Hodgkin’s lymphoma. More research is needed to understand the possible link between pesticides and the development of non-Hodgkin’s lymphoma.

CLINICAL MANIFESTATION

• Painless, swollen lymph nodes in your neck, axilla or groin
• Abdominal pain or swelling
• Chest pain, coughing or trouble breathing
• Fatigue
• Fever
• Night sweats
• Weight loss

DIAGNOSTIC EVALUATION

• Physical examination: to determine the size and condition of lymph nodes and to find out whether liver and spleen are enlarged
• Blood and urine tests: blood and urine tests may help rule out an infection or other disease
• Imaging tests: imaging tests to look for tumors in body. Imaging tests may include X-ray, computerized tomography (CT) scan, magnetic resonance imaging (MRI) or positron emission tomography (PET)
• Biopsy: a biopsy procedure to sample or remove a lymph node for testing. Analyzing lymph node tissue in a lab may reveal the cause
• Bone marrow biopsy: to find out whether the disease affects bone marrow

MANAGEMENT

• Chemotherapy: chemotherapy is drug treatment-given orally or by injection-that kills cancer cells. Chemotherapy drugs can be given alone, in combination with other chemotherapy drugs or combined with other treatments
• Radiation therapy: radiation therapy uses high-powered energy beams, such as X-rays, to kill cancerous cells and shrink tumors. Radiation therapy can be used alone or in combination with other cancer treatments
• Stem cell transplant: a stem cell transplant is a procedure that involves very high doses of chemotherapy or radiation with the goal of killing the lymphoma cells that may not be killed with standard doses. Later, healthy stem cells-own or from a donor-are injected into body, where they can form new healthy blood cells.
• Medications that enhance immune system’s ability to fight cancer: biological therapy drugs help the body’s immune system to fight cancer. For example, one biological therapy called rituximab is a type of monoclonal antibody that attaches to B-cells and makes them more visible to the immune system, which can then attack. Rituximab lowers the number of B-cells, including healthy B-cells, but body produces new healthy B-cells to replace these. The cancerous B-cells are less likely to recur
• Medication that delivers radiation directly to cancer cells: radioimmunotherapy drugs are made of monoclonal antibodies that carry radioactive isotopes. This allows the antibody to attach to cancer cells and deliver radiation directly to the cells. One radioimmunotherapy drug, ibritumomab tiuxetan is used to treat lymphomas

NURSING MANAGEMENT

Nursing Diagnosis

• Activity intolerance related to fatigue and anemia as evidence by inability to carry out activities of daily living
• Impaired tissue integrity related to high dose radiation therapy
• Risk of infection related to altered immune response because of lymphoma and leucopenia caused by chemotherapy or radiation therapy

1. Activity intolerance related to fatigue and anemia as evidence by in ability to carry out activities of daily living

Interventions

• Assess amount of activity that cause fatigue or dyspnea
• Assessed patient with activities as needed
• Provide oxygen therapy as ordered
• Instruct pt to space rest with activities

• Impaired tissue integrity related to high dose radiation therapy

Interventions

• Avoid rubbing, powder, deodorant, lotion or ointment (unless prescribed) or application of heat and cold to treated area
• Encourage pt to keep treated area clean and dry, bathing area gently with tepid water and mild soap
• Encourage wearing loose-fitting cloths
• Advise patient to protect skin from exposure to sun, chlorine, and temperature extremities

• Risk of infection related to altered immune response because of lymphoma and leucopenia caused by chemotherapy or radiation therapy

Interventions

• Assess patient for risk factor for infection
• Monitor patient for sign and symptoms of infection, such as cough, fever, malaise, erythema, pain or discharge and report immediately
• Teach patient and significant other sign and symptoms of infection to watch for and report
• Teach the pt to avoid exposure to other with influenza or other infection
• Teach patient with proper hand washing and good oral and personal hygiene
• Teach hand hygiene and infection risk education to family member.