Non-Hodgkin’s Lymphoma Disease

Non- Hodgkin’s Lymphoma or NHLs are a heterogenous group of cancers that originate from the neoplastic growth of lymphoid tissue. As in CLL, the neoplastic cells are thought to arise from a single clone of lymphocytes; however, in NHL, the cells may vary morphologically. Most NHLs involve malignant B lymphocytes; only 5% involve T lymphocytes. In contrast to Hodgkin’s disease, the lymphoid tissues involved are largely infiltrated with malignant cells. 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 (extra nodal tissue).

The incidence of NHL has increased dramatically over the past decade; it is now the fourth most common type of cancer diagnosed in the United States and the fifth most common cause of cancer death.  The incidence increases with each decade of life; the average age at diagnosis is 50 to 60 years old.

Although no common etiologic factor has been identified, there is an increased incidence of NHL in people with immunodeficiencies or autoimmune disorders, viral infections including Epstein- Barr virus and HIV, or exposure to pesticides, solvents, dyes, helicobacter pylori, human T cell leukemia, and hepatitis C virus. Researchers also say that obesity could be one of the risk factors of having Non- Hodgkin’s lymphoma and those whose occupation involves chemicals and herbicides.  Prognosis varies greatly among the various types of NHL. Long term survival more than 10 years is commonly achieved in low- grade, localized lymphomas. Even with aggressive disease forms, cure is possible in at least one third of patients who receive aggressive treatments.

Symptoms are highly variable, reflecting the diverse nature of these diseases. With early- stage disease, or with the types that are considered more indolent, symptoms may be virtually absent or very minor, and the illness typically is not diagnosed until it progresses to a later stage, when the patient is more symptomatic. At these stages III or IV, lymphadenopathy is noticeable. One third of patients have “B” symptoms like recurrent fever, drenching night sweats, and unintentional weight loss of 10% or more.

Non- Hodgkin’s lymphoma usually begins with the presence of one or more swollen lymph nodes on the side of the neck, collarbone, and under the arms. The most common sites for lymphadenopathy are the cervical, supraclavicular, and mediastinal nodes, involvement of the iliac or inguinal nodes or spleen is much less common. A mediastinal mass maybe seen on the chest x- ray; occasionally, the mass is large enough to compress the trachea and cause dyspnea.  Pruritus is common; it can be extremely distressing, and the cause is unknown. Approximately 20% of patients experience brief but severe pain after drinking alcohol.

All organs are vulnerable to invasion of NHL. The symptoms result from compression of organs by the tumor, such as cough and pulmonary effusion, jaundice from hepatic involvement or bile duct obstruction, abdominal pain from Splenomegaly or retroperitoneal adenopathy, or bone pain which is from skeletal involvement. Herpes zoster infections are common. A cluster of constitutional symptoms has important prognostic implications. A mild anemia is the most common hematologic finding. The WBC count may be elevated or decreased. The platelet count is suppressing hematopoiesis. The erythrocyte sedimentation rate or ESR and the serum copper level are used by some clinicians to assess disease activity.

The actual diagnosis of NHL is categorized into a highly complex classification system based on histopathology, immunophenotyping, and cytogenetic analyses of the malignant cells. The specific histopathologic type of the disease has important prognostic implications. Treatment also varies and is based on these features. Indolent or less aggressive types tend to have small cells and are distributed in a follicular pattern. Aggressive types tend to have large or immature cells distributed through the nodes in a diffuse pattern. Staging, also an important factor is typically based on data obtained from CT 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 1 disease is highly localized and may respond well to localize therapy like radiation therapy. In contrast, stage IV disease is detected in at least one extra nodal site. Although low- grade lymphomas may not require treatment until the disease progresses to a later stage, historically they have also been relatively unresponsive to treatment in that most therapeutic modalities did not improve overall survival. More aggressive types of NHL like

Lymphoblastic lymphoma and Burkitt’s lymphoma require prompt initiation of chemotherapy; however, these types tend to be more responsive to treatments.

Treatment is based on the actual classification of disease, the stage of disease, prior treatment, and the patient’s ability to tolerate therapy. If the disease is not an aggressive form and is truly localized, radiation alone may be the treatment of choice. With aggressive types of NHL, aggressive combinations of chemotherapeutic agents are given even in early stages.

More intermediate radiation therapy for stage 1 and II disease. The biologic agent interferon has been approved for the treatment of follicular low- grade lymphomas, and an antibody to CD20, rituximab (Rituxan), has been effective in achieving partial responses in patients with recurrent low- grade lymphoma. Studies of this agent in combination with conventional chemotherapy have demonstrated an improvement in survival as well. Central nervous system involvement is also common with some aggressive forms of NHL; in this situation, cranial radiation or intrathecal chemotherapy is used in addition to systemic chemotherapy. Treatment after relapse is controversial.

Much is known about the long term effects of chemotherapy and radiation therapy, primarily from the large numbers of people who were cured of by these treatments. The various complications are immune dysfunction, herpes infections, pneumococcal sepsis, acute myeloid leukemia or AML, Myelodysplastic syndrome or MDS, solid tumors, thyroid cancer, thymic hyperplasia, hypothyroidism,

Pericarditis, cardiomyopathy, pneumonotis, avascular necrosis, growth retardation, infertility, impotence and dental caries.

Aside from radiation therapy and chemotherapy, there are also stem cell transplantation, biologic therapy and radio immunotherapy. To diagnose Non-

Hodgkin’s lymphoma with a patient, a nurse or a health care professional should do physical examination and anamnesis or a family history of the patient which could present the possibilities that he or she could have NHL.

Most of the care for patients with Non- Hodgkin’s disease is performed in the outpatient setting, unless complications occur like infection, respiratory compromise due to mediastinal mass. For patients who require treatment, chemotherapy and radiation therapy are most commonly used. Chemotherapy cause systemic side effects like myelosuppression, nausea, hair loss, risk for infection, whereas the side effects from radiation therapy are specific to the area being irradiated. For example, patients receiving abdominal radiation therapy may experience nausea and diarrhea but not hair loss. Regardless of the type of treatment, all patients may experience fatigue.

The risk of infection is significant in patients, not only from treatment related myelosuppression but also from the defective immune response that results from the disease itself. Patients need to be taught to minimize the risk for infection, to recognize signs of possible infection, and to contact the health care professional should such signs develops.

Many lymphomas can be cured with current treatments. However, as survival rates increase, the incidence of second malignancies, particularly AML or MDs, also increases. Therefore, survivors should be screened regularly for the development of second malignancies.

The nurse should instruct the patient to stay away from strenuous activities. He should always have the time to get adequate rest. And the nurse should encourage the patient to take medications religiously, increase fluid intake. The patient should be instructed to keep himself from any injuries and falls. The nurse should raise side rails if the patient it admitted in a hospital. The family should also be instructed to just keep on showing some support towards the patient. Hhould always rie and falls. he patient to take medications religiously, increase fluid intake. the  uld always have the time to get adequate rest. an trenous . g NOn- could have NHL. amination and anamnesis or a family histor

Having Non-Hodgkin’s lymphoma is not that good. Patients are sometimes emotionally disturbed especially if they are working and they are the ones supporting their respective families. They would also think of the payments in the electricity, hospital bills and medication. Whenever patients asked something about his/ her condition, the health care professional should be able to answer it to help the patient alleviate worrying. The patient and his/ her family should be given support groups for counseling and for them to be able to express their emotions towards the current situation they are in.h care professional should be able to answer it to ent. ng whenever swollen lymphnodes are

References:

1 Cavalli, F. (1998). Rare syndromes in Hodgkin’s and Non- Hodgkin’s. Annals of Oncology. 9 (Suppl. 5), S109- S113.

2. Coiffer, B. (2002). Rituximab in the treatment of diffuse large B- cell lymphomas. Seminars in Oncology, 29 (1, Suppl. 2), 30- 35.

3. Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th Ed.).            Philadelphia: Lippincott Williams & Wilkins.

4. Skeel, R. (Ed.). (1999). Handbook of Cancer Chemotherapy (5th Ed.).

Philadelphia: Lippincott Williams & Wilkins

5. Smeltzer, Suzanne, and Brenda G. Bare. Medical- Surgical Nursing. Lippincott Williams & Wilkins, 2004.