NURS 443 Lecture Notes - Lecture 2: Mucosa-Associated Lymphoid Tissue, Ifosfamide, Chlorambucil
Hodgkin’s lymphoma
Description
Hodgkin’s lymphoma, also called Hodgkin’s disease, is a malignant condition characterized by proliferation of
abnormal, giant, multinucleated cells called Reed-Sternberg cells, which are located in lymph nodes. The disease
makes up 11% of all lymphomas and has a bimodal age-specific incidence, occurring most frequently in people
from 15 to 35 years old and above 50 years old. In adults it is twice as prevalent in men as in women. Each year,
approximately 9060 new cases of Hodgkin’s lymphoma are diagnosed and approximately 1200 deaths occur.
However, long-term survival exceeds 85% for all stages.
Pathophysiology
Although the cause of Hodgkin’s lymphoma remains unknown, several key factors are thought to play a role in its
development. The main interacting factors include infection with the Epstein-Barr virus, genetic predisposition, and
exposure to occupational toxins.
In Hodgkin’s lymphoma the normal structure of the lymph nodes is destroyed by hyperplasia of monocytes and
macrophages. The disease is believed to arise in a single location (it originates in the cervical lymph nodes in 70%
of patients) and then spreads along adjacent lymphatics. It eventually infiltrates other organs, especially the lungs,
spleen, and liver.
Clinical manifestations
The initial sign is most often an enlargement of the cervical, axillary, or inguinal lymph nodes. The enlarged nodes
are not painful unless pressure is exerted on adjacent nerves.
● ■The patient may note weight loss, fatigue, weakness, fever, chills, tachycardia, or night sweats. A
group of initial findings, including fever, night sweats, and weight loss (referred to asB symptoms),
correlates with a worse prognosis.
● ■Generalized pruritus without skin lesions may develop. Cough, dyspnea, stridor, and dysphagia may
all reflect mediastinal node involvement.
● ■In more advanced disease there may be hepatomegaly and splenomegaly. Anemia results from
increased destruction and decreased production of erythrocytes. Intrathoracic involvement may lead to
superior vena cava syndrome. Enlarged retroperitoneal nodes may cause palpable abdominal masses or
interfere with renal function.
● ■Jaundice may result from liver involvement.
● ■Spinal cord compression leading to paraplegia may occur with extradural involvement.
Diagnostic studies
Peripheral blood analysis, excisional lymph node biopsy, bone marrow examination, and radiologic studies are
important means of evaluating Hodgkin’s lymphoma.
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● ■Microcytic hypochromic anemia, leukopenia, and thrombocytopenia may develop, but they are
usually a consequence of treatment, advanced disease, or hypersplenism (related to the disease process).
● ■Other blood studies may show hypoferremia caused by excessive iron uptake by the liver and spleen,
elevated alkaline phosphatase from liver and bone involvement, hypercalcemia from bone involvement,
and hypoalbuminemia from liver involvement.
● ■Positron emission tomography (PET) scans with or without CT is used to stage and then assess
response to therapy. The scans may show increased uptake of carbohydrate by cancer cells (by PET)
and masses (by CT) such as mediastinal lymphadenopathy, renal displacement caused by
retroperitoneal node enlargement, abdominal lymph node enlargement, and liver, spleen, bone, and
brain infiltration.
Collaborative care
Treatment decisions are made based on the clinical stage of the disease. The standard for chemotherapy is the
ABVD regimen: doxorubicin (Adriamycin), bleomycin, vinblastine, anddacarbazine given for two to eight cycles of
treatment depending on disease stage and prognosis.
Combination chemotherapy works well because, as in leukemia, the drugs used have an additive antitumor effect
without increasing side effects. As with leukemia, therapy must be aggressive. Therefore potentially life-threatening
problems are encountered in an attempt to achieve a remission.
A variety of chemotherapy regimens and newer agents, such as brentuximab vedotin (Adcetris), are used to treat
patients who have relapsed or refractory disease. Ideally, once remission is obtained, a treatment option with the
goal of cure may be intensive chemotherapy with the use of autologous or allogeneic hematopoietic stem cell
transplantation.
The role of radiation as a supplement to chemotherapy varies depending on site of disease and the presence of
resistant disease after chemotherapy.
Nursing management
Nursing care for patients with Hodgkin’s lymphoma is largely based on managing problems related to the disease,
such as pain, and side effects of therapy, such as pancytopenia.
● ■Because the survival of patients with Hodgkin’s lymphoma depends on their response to treatment,
supporting the patient through the consequences of treatment is extremely important.
● ■Psychosocial considerations are as important as they are with leukemia (see Leukemia, p. 387).
However, the prognosis for Hodgkin’s lymphoma is better than that for many forms of cancer or
leukemia. The physical, psychologic, social, and spiritual consequences of the patient’s disease must be
addressed.
● ■Evaluation of patients for long-term effects of therapy is important because delayed consequences of
the disease and treatment, such as secondary malignancies and long-term endocrine, cardiac, and
pulmonary toxicities, may not be apparent for many years.
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TABLE 31-28 COMPARISON OF HODGKIN'S AND NON-HODGKIN'S LYMPHOMA
Hodgkin's Lymphoma
Non-Hodgkin's Lymphoma
Cellular origin
B lymphocytes
B lymphocytes (85%)
T or natural killer lymphocytes
(15%)
Extent of disease
Localized to regional, but may be more
widespread
Disseminated
B symptoms *
Common
40%
Extranodal involvement
Rare
Common
*
B symptoms include fever (>100.4° F [38° C]), drenching night sweats, and weight loss (>10% from baseline within
6 mo).
Lymphomas
Lymphomas are malignant neoplasms originating in the bone marrow and lymphatic structures resulting in the
proliferation of lymphocytes. Lymphomas are the fifth most common type of cancer in the United States.49 Two
major types of lymphoma are Hodgkin's lymphoma and non-Hodgkin's lymphoma (NHL). A comparison of these
two types of lymphoma is presented in Table 31-28.
Hodgkin's Lymphoma
Hodgkin's lymphoma, also called Hodgkin's disease, makes up about 11% of all lymphomas. It is a malignant
condition characterized by proliferation of abnormal giant, multinucleated cells, calledReed-Sternberg cells, which
are located in lymph nodes. The disease has a bimodal age-specific incidence, occurring most frequently in persons
from 15 to 35 years of age and above 50 years of age. In adults, it is twice as prevalent in men as in women. Each
year, approximately 9060 new cases of Hodgkin's lymphoma are diagnosed and approximately 1200 deaths occur.
However, long-term survival exceeds 85% for all stages.50
Etiology and Pathophysiology
Although the cause of Hodgkin's lymphoma remains unknown, several key factors are thought to play a role in its
development. The main interacting factors include infection with Epstein-Barr virus (EBV), genetic predisposition,
and exposure to occupational toxins. The incidence of Hodgkin's lymphoma is increased among patients who have
HIV infection.50
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 nodes is destroyed by hyperplasia of monocytes and
macrophages. The main diagnostic feature of Hodgkin's lymphoma is the presence of Reed-Sternberg cells in lymph
node biopsy specimens. The disease is believed to arise in a single location (it originates in cervical lymph nodes in
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Document Summary
Hodgkin"s lymphoma, also called hodgkin"s disease, is a malignant condition characterized by proliferation of abnormal, giant, multinucleated cells called reed-sternberg cells, which are located in lymph nodes. The disease makes up 11% of all lymphomas and has a bimodal age-specific incidence, occurring most frequently in people from 15 to 35 years old and above 50 years old. In adults it is twice as prevalent in men as in women. Each year, approximately 9060 new cases of hodgkin"s lymphoma are diagnosed and approximately 1200 deaths occur. However, long-term survival exceeds 85% for all stages. Although the cause of hodgkin"s lymphoma remains unknown, several key factors are thought to play a role in its development. The main interacting factors include infection with the epstein-barr virus, genetic predisposition, and exposure to occupational toxins. In hodgkin"s lymphoma the normal structure of the lymph nodes is destroyed by hyperplasia of monocytes and macrophages.
