LYMPHOMA

• The lymphomas are neoplasms of cells of lymphoid origin.
• Lymphomas are malignant disorders of the reticuloendothelial system that result in an accumulation of dysfunctional, immature lymphoid-derived cells.
• These tumors usually start in lymph nodes but can involve lymphoid tissue in the spleen, GI tract (eg, the wall of the stomach), liver, or bone marrow.
• They are classified according to the predominant cell type and by the degree of malignant cell maturity (eg, well differentiated, poorly differentiated, or undifferentiated).
• Lymphomas can be broadly classified into two categories: Hodgkin lymphoma and non-Hodgkin lymphoma (NHL).

HODGKIN'S LYMPHOMA

• Hodgkin's lymphoma originates in the lymphoid system and involves predominantly lymph nodes. Characterized by appearance of "Reed-Sternberg" multinucleated giant cell in tumor.
• Generally spreads via lymphatic channels, involving lymph nodes, spleen, and ultimately extralymphatic sites. May also spread via bloodstream to such sites as GI tract, bone marrow, skin, upper air passages, and other organs.
• Hodgkin lymphoma is a relatively rare malignancy.
• It accounts for about 12% of all lymphomas.
• More common in men than women
• Peaks of incidence: in the early 20s and after 50 years of age.
• Disease occurrence has a familial pattern:
  • First-degree relatives have a higher-than-normal frequency of disease, but the actual incidence of this pattern is low.
• The 4 most common histological subtypes are:
  • Lymphocyte-predominant.
  • Nodular sclerosing.
  • Mixed cellularity.
  • Lymphocyte-depleted.

STAGING

Based on Ann Arbor classification- The principal stage is determined by location of the tumor:

• Stage I - cancer is located in a single region, usually one lymph node and the surrounding area, with not have outward symptoms.
• Stage II - cancer is located in two separate regions, an affected lymph node or lymphatic organ and a second affected area, and that both affected areas are confined to one side of the diaphragm—that is, both are above the diaphragm, or both are below the diaphragm.
• Stage III - cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
• Stage IV - diffuse or disseminated involvement of one or more extralymphatic organs, including involvement of the liver, bone marrow, or nodular involvement of the lungs.

CAUSE

• Exact cause is unknown.
• Risk factors include:
  • Male sex.
  • Infection with Epstein–Barr virus (EBV).
  • Immunosuppression, e.g. HIV patients.
  • Chronic immunosuppressive therapy eg, for renal transplant
  • Exotoxin exposure - in veterans of the military who were exposed to the herbicide Agent Orange.

CLINICAL MANIFESTATION

• Nontender lymphadenopathy.
• Unintentional weight loss.
• Fever (constitutional 'B signs': fever >38°C, night sweats, weight loss).
• Dyspnoea.
• Splenomegaly.
• Hepatomegaly.

DIAGNOSTIC INVESTIGATIONS

• Blood – Peripheral blood Smear, WBC Count, Urea & Electrolyte's, C-Reactive Protein, ESR, lactate dehydrogenase, creatinine,
• Lymph node biopsy—determines type of lymphoma. Histology: Reed–Sternberg cells seen.
• Bilateral bone marrow aspirate and biopsy—determine whether bone marrow is involved.
• Radiographic tests (eg, x-rays, PET scan, CT scan, MRI—detect deep nodal involvement.
• Gallium-67 scan—detects areas of active disease and determine aggressiveness of disease.
• Liver function tests—determine hepatic involvement; liver biopsy - if results abnormal.
• Lymphangiogram—detects size and location of deep nodes involved, including abdominal nodes, which may not be readily seen via CT scan.

COMPLICATIONS

• Increased risk of infection.
• Recurrence and metastasis.
• Increased risk of cardiovascular disease.
• Complications of chemotherapy.
• Neurological complications.

MEDICAL MANAGEMENT

• Conservative: patient education
• Choice of treatment depends on extent of disease, histopathologic findings, and prognostic indicators or depends on Ann Arbor classification
• Radiation therapy.
  • Treatment of choice for localized disease.
  • Areas of body where lymph node chains are located can generally tolerate high radiation doses.
  • Vital organs are protected with lead shielding during radiation treatments.
• Chemotherapy.
  • Initial treatment commonly consists of
  • ABVD regimen of doxorubicin (Adriamycin), bleomycin, vinblastine (Velban), and dacarbazine;
  • MOPP regimen of nitrogen mustard (Mustargen), vincristine (Oncovin), procarbazine, and prednisone.
  • BEACOPP regimen: - bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone.
• Three or four drugs may be given in intermittent or cyclical courses with periods off treatment to allow recovery from toxicities.
• Autologous or allogeneic bone marrow or stem cell transplantation.

NURSING MANAGEMENT

Impaired Tissue Integrity related to high-dose radiation therapy.

(Maintaining Tissue Integrity)

• Encourage patient to keep treated area clean and dry.
• Bathing area gently with tepid water and mild soap.
• Avoid rubbing or application of powders, deodorants, lotions, or ointments on treated area.
• Application of heat and cold to treated area.
• Encourage wearing loose-fitting clothes.
• Advise patient to protect skin from exposure to sun, chlorine, and temperature extremes.

Impaired Oral Mucous Membrane related to high-dose radiation therapy.

(Preserving Oral and GI Tract Mucous Membranes)

• Encourage frequent small meals
• Using bland and soft diet at mild temperatures. Avoid extreme food temperatures.
• Advice patient to avoid irritants, such as alcohol, tobacco etc.
• Encourage mouth care at least twice per day
• After meals using gentle flossing, soft toothbrush, and mild mouth rinse.
• Administer or teach self-administration of pain medication or anti-emetic before eating or drinking, if needed.
• Assess for ulcers, plaques, or discharge that may be indicative of superimposed infection.
• For diarrhoea, switch to low-residue diet and administer antidiarrheal, as prescribed.

NON-HODGKIN'S LYMPHOMA

• This is a group of malignancies that are either B cell or T cell in origin.
• Non-Hodgkin's lymphomas are a group of malignancies of lymphoid tissue arising from T or B-lymphocytes or their precursors. It includes both indolent and aggressive forms.
• In the United States B-cell lymphomas represent about 80% of all cases.
• Types of Non-Hodgkin's lymphomas include
• B cell neoplasms
  • Small lymphocytic lymphoma SLL
  • Burkitt's lymphoma: Associated with Epstein–Barr virus (EBV)
  • Diffuse large B cell lymphoma
  • primary cutaneous B-cell lymphoma.
  • Mantle cell lymphoma
  • Follicular lymphoma
• T cell neoplasms
  • Adult T cell lymphoma; caused by human T-lymphotrophic virus-1 (HTLV-1)
  • Sézary syndrome - cutaneous T-cell lymphoma

ETIOLOGY

• Exact cause is unknown.
• Risk factors include:
  • Male sex.
  • Viral Infection, e.g. HTLV-1, EBV, human herpes virus (HHV)-8, hepatitis C.
  • Helicobacter pylori - Helicobacter gastritis (for gastric B-cell lymphoma),
  • Association with defective or altered immune system
    • Immunosuppression, e.g. HIV patients.
    • Patients receiving immunosuppression for organ transplant
  • Family history,
  • White ethnicity,
  • Autoimmune diseases such as rheumatoid arthritis,
  • History of hodgkin's lymphoma,
  • History of radiation therapy,
  • Diet high in meats and fat,
  • Exposure to certain pesticides.

CLINICAL MANIFESTATIONS

• Nontender lymphadenopathy (generally unilateral)
• Unintentional weight loss
• Fever, chills
• Night sweats
• Unexplained pain in chest, abdomen, or bones
• Dyspnoea
• Splenomegaly and Hepatomegaly

DIAGNOSTIC EVALUATION

• Blood – Peripheral blood Smear, WBC Count, Urea & Electrolyte's, C-Reactive Protein, ESR, lactate dehydrogenase, creatinine, alkaline phosphatase, serum cytokine levels, soluble CD25 level.
• Incisional or excisional lymph node biopsy to detect type.
• Bone marrow aspirate and biopsy to detect bone marrow involvement.
• CT scan of the chest, abdomen, and pelvis with oral and intravenous contrast or
• PET with CT scan to detect deep nodal involvement.
• Liver function tests, liver scan to detect liver involvement.
• Hepatitis B testing is recommended due to risk of reactivation.
• Lumbar puncture to detect CNS involvement (for some lymphoma types).
• Surgical staging (laparotomy with splenectomy, liver biopsy, multiple lymph node biopsies).

COMPLICATIONS

• Increased risk of infection.
• Recurrence and metastasis.
• Increased risk of cardiovascular disease.
• Complications of chemotherapy.
• Neurological complications.

MEDICAL MANAGEMENT

• Radiation therapy is generally palliative, not curative.
• Chemotherapy: various regimens including
  • CHOP - cyclophosphamide, doxorubicin (Adriamycin), vincristine (Oncovin), and prednisone
  • BACOP - bleomycin, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), and prednisone.
  • CD20 positive lymphomas - Monoclonal antibody therapy: rituximab alone or with chemotherapy to.
• Autologous or allogeneic bone marrow or stem cell transplantation.

NURSING MANAGEMENT

Risk for Infection related to altered immune response because of lymphoma and leukopenia caused by chemotherapy or radiation therapy.

(Minimizing Risk of Infection)

• Care for patient in protected environment with strict handwashing observed.
• Avoid invasive procedures, such as urinary catheterization, if possible.
• Assess temperature and vital signs, breath sounds, LOC, and skin and mucous membranes frequently for signs of infection.
• Notify health care provider of fever greater than 101° F (38.3° C) or change in condition.
• Obtain cultures of suspected infected sites or body fluids.