20-Sep-16

Lymphoma overview

Lymphatic disorders
NUR3014

Lymphoma overview

8/10 in the cancer list in HK

New cases 300 yearly

Neoplastic cells of lymphoid origin

Usually start in lymph nodes but can involve the spleen, GI tract, liver
or bone marrow
Two types:

Hodgkin's lymphoma (hl)

Non-Hodgkin's lymphoma (NHL) (more common)

Hodgkins lymphoma

Hodgkins lymphoma is a rare cancer of unknown
cause that spreads along the lymphatic system.

more common in men and tends to peak in the early 20s and after
50s

familial pattern

More commonly seen in patients receiving chronic
immunosuppressive therapy (e.g. for renal transplant)

20-Sep-16

Pathophysiology

Pathophysiology

The malignant cell of Hodgkin lymphoma is ReedSternberg cell

It is the pathologic hallmark and essential diagnostic criterion

Causes is unknown

May due to viral etiology Epstein-Barr virus

As the disease progresses, it spreads to other lymph nodes in the

same lymphatic chain, and sometimes to the spleen and bone
marrow.

HL may also affect other organs such as the liver, lungs or the central
nervous system.

Pathophysiology

Clinical Manifestations

HL is often curable with chemotherapy and/or

radiation therapy if diagnosed and treated early.

Prognosis depends on clinical staging at diagnosis.

The presence of constitutional symptoms, advanced
age, and advanced disease at initial presentation
worsens the prognosis.

Refractory and relapsed HL requires chemotherapy
and autologous stem cell transplant.

Firm and painless enlargement of the lymph nodes on one side of

the neck.

Common sites are the cervical, supraclavicular, and mediastinal
nodes.

Mediastinal lymph nodes may be visible on x-ray films and large
enough to compress the trachea and cause dyspnea.

Pruritus is common and can be distressing; the cause is unknown.
Herpes zoster infection is common.

Some patients experience brief but severe pain after drinking
alcohol, usually at the site of the tumor.

20-Sep-16

Clinical Manifestations

Symptoms result from compression of organs by the tumor, such as cough
and pulmonary effusion (from pulmonary infiltrates),

Jaundice (from hepatic involvement or bile duct obstruction), abdominal
pain (from splenomegaly or retroperitoneal adenopathy),

Bone pain (from skeletal involvement)

Herpes zoster infections are common.

A cluster of constitutional symptoms has important prognostic
implications.

B symptoms, i.e. fever (without chills), drenching sweats (particularly at
night), and unintentional weight loss of more than 10% of body weight.

B symptoms are found in 40% of patients and are more common in
advanced disease.

Medical Management

Treatment is determined by the stage of the disease instead of
the histologic type.

a short course (2 to 4 months) of chemotherapy followed by
radiation therapy (5 times a week, for 2-10 weeks, it
depends)to the specific involved area.

Combination chemotherapy with doxorubicin (Adriamycin),
bleomycin (Blenoxane), vinblastine (Velban), and dacarbazine
(DTIC), referred to as ABVD, is often considered the standard
treatment for more advanced disease.

Chemotherapy is often successful in obtaining remission even
when relapse occurs.

Transplant is used for advanced or refractory disease.

Assessment and diagnostic findings

Excisional lymph node biopsy and the finding of the ReedSternberg cell.

Assessment for any B symptoms

Physical examination to evaluate the lymph node chains, as well as the
size of the spleen and liver.

Chest x-ray and a CT scan of the chest, abdomen, and pelvis; positron
emission tomography (PET) scan

Laboratory tests: CBC count, platelet count, ESR, and liver and renal
function studies; CSF; hepatitis B and C and HIV; Lactate dehydrogenase
(tumor marker) [ref:John Hopkins]

Bone marrow biopsy and sometimes bilateral biopsies.

Bone scans may be performed.

Nursing management

Encourage patient to reduce the factor that increase the risk of
developing second cancers e.g. use of tobacco and alcohol and
exposure to environmental carcinogens

Advise the patient for screening for late effects of treatment is
needed

Provide education about self care strategies and disease
management

20-Sep-16

Nursing management

Nursing management -psychological

Assess for pain, nausea and diarrhea as a result of treatment

Administer analgesics, sedatives, antiemetics and antidiarrheal
medication as ordered

Provide good oral care

Provide careful skin care

Monitor vital signs and severity of symptoms, assess all physiologic
systems, and review laboratory/diagnostic study results

Follow facility pre- and posttreatment protocols if patient becomes a
candidate for chemotherapy or radiation therapy

Assess patients anxiety level and coping ability

Assure the patient the HL is often curable

Educate and encourage open communication about treatment risks
e.g. infertility and benefits

Listen with empathy to patient concerns and fears

Non-Hodgkin lymphoma (NHL)

overview

Non-Hodgkin lymphoma (NHL)

The non-Hodgkin lymphomas (NHLs) are a heterogeneous group of

cancers that originate from the neoplastic growth of lymphoid tissue.

Most NHLs involve malignant B lymphocytes; only 5% involve T
lymphocytes.

The spread of these malignant lymphoid cells occurs unpredictably,
and true localized disease is uncommon.

Lymph nodes from multiple sites may be infiltrated, as may sites
outside the lymphoid system(extranodal tissue).

20-Sep-16

Non-Hodgkin lymphoma (NHL) overview

no common etiologic factor has been identified

the incidence of NHL has increased in people with
immunodeficiency or autoimmune disorders; prior
treatment for cancer; prior organ transplant; viral infection
(e.g. HIV and Epstein-Barr virus) exposure to pesticides,
solvents, dyes, or defoliating agents.

The prognosis varies greatly among the more than 30
subtypes of NHL.

For example, diffuse large B-cell lymphoma, the most
common form, accounts for 30% of all newly diagnosed
lymphomas (80% of all aggressive types); 5-year survival
rates are 26% to 73%.

Assessment and diagnostic methods

Staging is typically based on data obtained from CT and PET scans,
bone marrow biopsies, and occasionally cerebrospinal fluid analysis

The stage is based on the site of disease and its spread to other sites.

For example, in stage I disease, only one area of involvement is detected;
thus, stage I disease is highly localized and may respond well to localized
therapy (e.g. radiation therapy).

In contrast, in stage IV disease at least one extra-nodal site is

detected.

Clinical manifestation

Vary based on the type and location of the lymphoma

For example,

a mass in the mediastinum can cause respiratory distress

abdominal masses can compromise the ureters, leading to renal
dysfunction

splenomegaly can cause abdominal discomfort, nausea, early satiety,
anorexia, and weight loss.

The first symptom often is lymphadenopathy of the arm, neck, or

groin

Other possible symptoms include fever, night sweats, weight loss
(e.g., > 10% body weight over 6 months), and fatigue (these
systemic symptoms are commonly referred to as B symptoms).

Assessment and diagnostic methods

Laboratory Tests

CBC may be normal in early NHL, but in advanced stages, may indicate
anemia ( RBCs),thrombocytopenia ( platelets), leukopenia ( WBC),
pancytopenia ( RBCS, WBCs, and platelets), lymphocytosis (
lymphocytes), or thrombocytosis ( platelets)

LDH (The protein LDH is in many living body tissues,

especially the heart, liver, kidney, muscles, brain, blood cells,
and lungs)

calcium levels

Liver and kidney function tests -abnormal

20-Sep-16

Assessment and diagnostic methods

Histological analysis of affected lymph node(s) -for diagnosis and
staging

histological analysis of bone marrow aspirate and biopsy -determines
bone marrow involvement

Whole body PET scan- extent or stage of disease and may be used to
assess treatment response

Chest X-ray, MRI, or CT scan -the extent of disease

Lumbar puncture for cerebral spinal fluid (CSF) analysis may be
ordered in patients with neurologic signs and symptoms, a primary
CNS tumor

Nursing management

The most commonly used treatment methods are
chemotherapy and radiation therapy.

Monitor the side effect of chemotherapy (e.g.
myelosuppression, nausea, hair loss, risk of infection)

Monitor input and output

Encourage small and frequent meal

all patients may experience fatigue

Assess activity level

Place object near reach

Offer quiet environment

Medical management

Treatment is determined by the classification of disease, the
stage of disease, prior treatment (if any), and the patients
ability to tolerate therapy.

Tolerance to therapy is largely dictated by renal, hepatic, and
cardiac function

If the disease is not aggressive and is localized, radiation
alone maybe the treatment of choice.

With aggressive types of NHL, aggressive combinations of
chemotherapeutic agents are used

Nursing management

The risk of infection is significant for these patients, not only from
treatment-related myelosuppression but also from the defective
immune response that results from the disease itself.

Teach the patient to minimize the risks of infection, to recognize signs
of possible infection, and to contact their health care provider if such
signs develop

20-Sep-16

Nursing management

Additional complications depend on the location of the lymphoma.

Assess the tumor location so that assessments can be targeted
appropriately.

For example, patients with lymphomatous masses in the upper chest
should be assessed for superior vena cava obstruction or airway
obstruction, if the mass is near the bronchus or trachea.

Educate the patient about the risk of second malignancies,
particularly AML or MDS

Instruct the patient to have regular screening for the development of
second malignancies.

Lymphatic disorders
Lymphangitis
Lymphedema

Lymphatic system

The lymphatic system consist of a set of vessels that
spread throughout most of the body

The fluid drained from the interstitial space to the
lymphatic system is called lymph

The flow of lymph depends on the intrinsic
contractions of the lymph vessels, the contraction of
muscles, respiratory movements and gravity

The lymphatic system of the abdominal cavity
maintains a steady flow of digested fatty food (chyle)
from the intestinal mucosa to the thoracic duct.

In other parts of the body, the lymphatic systems function is regional;

the lymphatic vessels of the head

for example, empty into clusters of lymph nodes located in the neck

those of the extremities empty into nodes of the axillae and the groin.

20-Sep-16

Lymphangitis

Lymphangitis

An acute inflammation of lymphatic channels

Infection in the extremity
the infectious organism is a hemolytic streptococcus
Red, enlarged and tender (acute stage)
Become necrotic and form an abscess (unusual)
Nodes involved often those in the groin, axilla or cervical
region

Caused by bacteria and sensitive to the antibiotics

Lymphedema and elephantiasis

Lymphedema and elephantiasis

Lymphedema is classified as primary (congenital malformations) or

secondary (acquired obstruction).

Tissues in the extremities swell because of an increased quantity of
lymph that results from an obstruction of the lymphatic vessels.

It is especially marked when the extremity is in a dependent position.

The most common type is congenital lymphedema caused by hypoplasia
(un-development) of the lymphatic system of the lower extremity.

It is usually seen in women and appears first between the ages of 15 and
25 years.

The obstruction may be in both the lymph nodes and the lymphatic
vessels.

At times, it is seen in the arm after a radical mastectomy

20-Sep-16

Clinical manifestation

Pharmacologic therapy

Painful, chronic swelling of an extremity

A feeling of tightness in the skin

Primarily lower extremity involvement (80%) but can also involve the
upper extremities, face, genitalia, and trunk

Fevers, chills, and generalized weakness

Fatigue related to the size and weight of the extremity

Recurrent bacterial or fungal infections

Recurrent episodes of cellulitis, lymphangitis, fissuring, ulcerations

Diuretic therapy, initially with furosemide (Lasix) to prevent fluid

overload

Antibiotic therapy if lymphangitis or cellulitis is present

Surgical Management

Lymphaticovenular bypass

For severe and uncontrolled cases, when the mobility is severely
compromised

Excision of the affected subcutaneous tissue and fascia, with skin
grafting to cover the defect, or

Surgical relocation of superficial lymphatic vessels into the deep
lymphatic system by means of a buried dermal flap to provide a
conduit for lymphatic drainage.

Nursing Management
After surgery, the management of skin grafts and flaps is the same as
when these therapies are used for other conditions.
Skin care

Observe for complications e.g. infection

If infection happens, administer antibiotics may be prescribed for 5 to
7 days.

Monitor for complications may include flap necrosis, hematoma or
abscess under the flap, and cellulitis.

20-Sep-16

Nursing management

Nursing management physical therapy and

compression

Instruct the patient or caregiver to inspect the dressing daily.

Observe for any unusual drainage or any inflammation around the
wound margin, as it may suggest infection and should be reported to
the surgeon.

Inform the patient that there may be a loss of sensation in the skin
graft area.

Instruct the patient to avoid the application of heating pads or
exposure to sun to prevent burns or trauma to the area.

Avoid needle sticks or BPs in affected extremity

Elevate the affected extremity constantly

Perform manual lymphatic massage and exercise (Active or passive)

Apply compression stocking at a minimum of 40mmHg, multilayer
bandaging, or pneumatic pumps.

Nursing management

First week after surgery

When the leg is affected, continuous bed rest with the leg elevated
may aid in mobilizing the fluids.

Manual lymphatic drainage in combination with compression
bandages, exercices, skin care, pressure gradient sleeves, and
pneumatic pumps (depending on the severity and stage of the
lymphedema)

Lie on the unaffected side with the affected

arm straight out in front of you, above the
level of the heart (use pillows if needed).
Alternatively, sit in a chair with good back
support with the affected arm supported by
pillows.

Slowly open and close the hand. Repeat 15
25 times.

Slowly bend and straighten the elbow.
Repeat 1525 times.

20-Sep-16

Lift both shoulders up toward the ears. Hold

for 510 seconds, then slowly drop them down
and relax. Repeat 510 times.

Clasp hands together in front of the

chest. Extend the elbows so your
arms are out in front of you, but your
elbows are not locked.

Gently rotate both shoulders forward and up,

and then slowly back and down, making a
circle. Switch directions. Repeat 510 times in
each direction.

Slowly lift the arms upward until a

gentle stretch is felt. Hold for 12
seconds and then slowly return to the
start position.

Repeat 510 times.

3-6 week after surgery

Place arms at your sides with the elbows bent.

Gently squeeze the shoulder blades together.
Keep shoulders level and take care not to lift up
or shrug the shoulders. Hold for 510 seconds.

Relax and return to the start position.

Repeat 510 times

Lie on your back with knees bent. Hold the

wand in both hands (palms facing down), with
hands shoulder width apart and elbows bent.

Straighten your arms and lift the wand over
the head until you feel the stretch. The
unaffected arm helps lift the wand. Hold for
12 seconds. Lower arms.

Repeat 510 times

20-Sep-16

Lie on the back with knees bent. Clasp hands

behind the neck with elbows pointed up to the
ceiling. (If putting hands behind the neck is too
uncomfortable, place fingers on the forehead
with palms facing up.)

Move elbows apart and down toward the floor.
Hold for 12 seconds.

Repeat 510 times

References

Bardia, A., & Seifter, E.J. (2011).Patients guide to lymphoma. USA: The Johns
Hopkins University

Boland, E. G., Boland, J. W., Ezaydi, Y., Greenfield, D. M., Ahmedzai, S. H., &
Snowden, J. A. (2014). Holistic needs assessment in advanced, intensively treated
multiple myeloma patients. Supportive Care in Cancer, 22(10), 2615-2620.

Hinkle, J.L., & Cheever, K.H. (2014). Brunner and Suddarths Textbook of Medical
Surgical Nursing (13th ed.). Philadelphia: Wolter Kluwer Health / Lippincott
Williams & Wilkins.

Nursing reference center Hodgkin lymphoma in adults & non-Hodgkin lymphoma
an overview

Snowden, J. A., Ahmedzai, S. H., Ashcroft, J., DSa, S., Littlewood, T., Low, E., ... &
Bird, J. M. (2011). Guidelines for supportive care in multiple myeloma 2011. British
journal of haematology, 154(1), 76-103.

Stand facing the wall, about 5 cm (2

inches) away. Place both hands on the
wall at shoulder level.

Use the fingers to climb up, or slide hands
up, the wall until you feel the stretch.

Return to start position.

Repeat 510 times.