Presentation on theme: "Care of Patients with Leukemia and Lymphoma"— Presentation transcript:
1Care of Patients with Leukemia and Lymphoma Hematologic ProblemsProliferation or accumulation of malignant cells originating fromBone marrowLymphatic tissueLeukemia – CA bone marrowLymphoma – CA lymphoid tissueCare of Patients withLeukemia and Lymphoma
2Leukemia: 2007-2010 U.S. Demographics 44,000 new cases resulting in 21,700 deaths in 200743,050 new cases in 2010Am. Cancer Society 2007Leukemia & Lymphoma Society 2011
3Lymphoma 2007: 2007-2010 Demographics Hodgkin’s Disease 8,000 new cases, 1,000 deaths ( ;1350)Non-Hodgkin’s Lymphoma 63,000 new cases, 18,000 deaths ( ,000;19,000)2010: 628,000 people living with diseaseBlack, J., Hawks, J., 2009Lewis, S., Dirksen, S., Heitkemper, M., et al, 2011
4Immune Response D I F E R N T Infection Control A O Carry O2 Clotting LymphoidInfection ControlReview of A/PStem cells differentiate along pathways into lymphoid (B&T cells), Myeloid (granulocytes), Erythroid (RBC’s & platelets)In leukemias, CONTROL of this process is abnormal or missing abnormal and UNCONTROLLED PROLIFERATION of leukocytes (BLASTS)that CIRCULATE in the blood and INFILTRATE the blood forming organs (liver, spleen and lymph nodes) and other sites throughout the body …like “TEENS CRASHING A PARTY”Carry O2ErythroidClottingMegakaryocytes
5LeukemiaLoss of control of cell division → malignant bone marrow cells accumulate or proliferate, causing disorders affecting the blood and blood-forming tissuesEtiology is unknown but risk factors alter DNA, preventing cellular maturityOverexposure to ionizing radiation developing after years of exposureAlkylating agents for other cancers in conjunction with radiation therapyBenzene exposure/other toxic chemicalsGenetic/Hereditary FactorsDown’s SyndromeTwins and siblingsFamilial tendency CML (Philadelphia chromosome)ExposureRadiationChemotherapy/ChemicalsHuman T-cell leukemia virus type 1 (HTLV-1)
6Leukemia Further classified by type of leukocyte involved site of originlymphocytic – lymphatic systemmyelogenous – bone marrow
7Leukemia Four major types acute lymphocytic (ALL) acute myelogenous (AML)chronic myelogenous (CML)chronic lymphocytic (CLL)Treatment Goal: destroy neo-plastic cells & maintain remission.Medical management varies for the 4 typesNursing Principles for 4 types are sameImportant to determine Rx and prognosisWe will focus on ALL in subsequent slides:AML – develops when stem cells over commit to one type of cell – neutrophilsDx: bone marrow biopsyFavorable factors - < 60 years; Spontaneous; WBC < 10,000 mm3 ; Complete remission w/one cycle of chemoCML – includes Philadelphia chromosomeChronic phase - can go on for years with mild symptoms; blasts < 10%Accelerated phase – 6-12 months with progressive symptoms (night sweats, fevers, unexplained wt. loss) blasts 10-30%Blast phase can lead to death; transforms to very aggressive acute myelogenous leukemia; blasts > 30% (Stem cell transplant)CLL – survival < 19 months (with advanced disease) to >10 years (early stage)LymphocytosisLymphadenopathyHepatosplenomegalyDeath usually occurs d/t recurrent bacterial and viral disease; generally not curable – Rx delayed until s/sx as Rx is harsh
8LeukemiaIncidenceaffects all ages: adults 10X more than childrenage of peak incidenceALL – between 2-9 years oldAML – between years oldCML – Philadelphia chromosomeCLL - most common in AdultsALL – acute lymphoblastic leukemiaAML – acute myelogenous leukemiaIn acute leukemias, single cell transforms, then leukemic cell proliferates, blocking the differentiation of cells in hematopoietic cell lineTwo major categoriesAcute – immature (“blast”) cellsChronic – cells more mature but not functional
9Leukemia - Pathophysiology Divide more slowly than normalTake longer to synthesize DNABlocks differentiation of blood cell precursorsCompete with normal cell proliferationLeukemic cells apparently divide more slowly and take longer to synthesize DNA than other blood precursors.Not caused by rapid proliferation but by blocking blood cell precursors accumulate relentlessly in affected clients and thenCompete with normal cell proliferation by crowding out marrow and causing other cell lines to cease pancytopeniaCrowd out marrow and cause normal proliferation of other cell lines to cease,Resulting in pancytopenia
10Acute Leukemia (review) proliferation of immature cells (blasts) infiltration of blasts into bone marrowrapid onset (6 months-1 year)requires aggressive interventionDefect in maturation
11Leukemia - ChronicDifferentiated, impaired mature neoplastic granulocytesmore gradual onsetCMLAges 25-60Peripheral blood test shows Anemia, elevated PMN’s, Lymph’s WNL, Mono’s WNL/low, and elevated Platelets which drop later3-4 years, then “blast” crisis resembles AML90% of cases - Philadelphia chromosome (translocation of long arms of chromosomes 9 & 22)Develops more gradually so rarely seen in people < 20 years oldCaused by eitherUnregulated proliferation of hematopoietic cellsDisordered cell death (apoptosis)Blast crisis has 70% mortality rate within 6 months, crisis is refractory to treatmentCLL – 15 year survival without treatment
12CML Blastic PhaseIncreasing #’s of immature myeloid precursor cells (esp. myeloblasts) proliferateBlast cells comprise >20% of blood, >30% in marrowIncreased fibrotic tissue in bone marrowPancytopeniaRefractory to treatment, many patients die within 2 mos. of onset
13Leukemia – Chronic Cont’ed CLL (immature B lymphocytes)Age: men > 50 yearsInfiltration of spleen, liver, lymph nodes & bone marrowSurvive 15 years without treatment
14Acute Lymphocytic Leukemia Abrupt or gradual manifestationsweakness, fatigue, headachefeverBleeding, petichae, bruisingBone tendernessRBC’s, HbWBC’sPlateletspressure in intermedullary spaceAnorexia weight loss, sensitivity to sweet/sour, muscle wasting, dysphagiaCBC – WBC can be either up or down… anywhere from 1000 to > 300K. With abnormal blasts. Decreased Hb & plateletsBone Marrow Aspiration is necessary in order to identify the malignant cell type to prescribe treatment. It will show increased marrow cells and increased blasts. LP not done until after induction to avoid introducing leukemic cells into CNS .
15Treatment of Acute Leukemia Initial goal is REMISSION: Restoration of Hematopoiesiscomplete remissionno evidence of disease on physical exam, bone marrow or blood work – bone marrow function restored“blasts” cells < 5%partial remissionevidence of disease in bone marrow onlyrelapse usually means a more difficult course of disease process with progressively shorter periods of remissionALL – 70-80% of adults achieve remission with 35-40% surviving 2 yearsAML – 60-70% adults achieve remission with 25% surviving 5 yearsTreatmentchemotherapy, cranial radiationintrathecal (into spinal canal to allow entry into brain) methotrexate – bypasses blood-brain barrier
16Treatment of Acute Leukemia Induction therapy Aggressive chemotherapy treatment aimed at all abnormal cells: reduce ‘Blastic Cells’ to less than 5% of total bone marrow cells & return CBC to normal values for at least 1 month:approximately 70% success (in newly dx’d.):associated with many complicationsanemianeutropeniathrombocytopeniaInduction Therapy is the initial treatment of an intense course of Chemotherapy with goal of complete remissionWhy?
17Treatment of Acute Leukemia Post-Induction Therapy Intensification Therapyeliminate remaining leukemic cells.high doses of same of 1-2 drugs used in induction therapy;combination therapy: Radiation added if infiltration of CNS, skin, testes, rectum, mediastinal massConsolidation Therapy:after remission, this phase of treatment to kill any possible remaining leukemic cellsMaintenance therapymaintain remission using similar drugsSmall doses every 3-4 weeks for 1 – 3 yearsUsed mostly for adults with ALLThis also includes Radiation Rx as an adjunct to chemo when leukemic cells infiltrate theCNSSkinRectumTestesMediastinal masses
18Post Therapy Management of Complications Therapy destroys normal and aberrant cells causing pancytopeniaTransfusions of Red Blood Cells (RBC’s)IV Antifungal agent Amphotericin B
19What CM’s would you anticipate? Tumor Lysis SyndromeLarge number of WBC tumor cells destroyed release of intracellular contentsrenal involvement uric acid crystalsmetabolic effects serum uric acid, PO4, K, serum CaPotentially fatal complication that occurs with rapid cell death:CM’s: Confusion, weakness, numbness, tingling, muscle cramps, oliguria, Bradycardia, EKG dysrhythmias d/t K, CaRasburicase (Elitek) an antigout agent – oxidizes uric acid crystalsWhat CM’s would you anticipate?
21Prevention & Treatment Prevention is the best treatmentidentify high risk patientsIV hydrationprevention of electrolyte imbalancesAllopurinol & Rasburicase to uric acid formationHemodialysis: ↓ Creatinine levelsLeukapheresis: ↓ WBC count
22Lymphomas: Hodgkin’s and non-Hodgkin’s Malignant conditionsabnormal lymph cell proliferationunknown etiologies: ? viral, immune-related ?starts at one site; spreads through lymphatic systemLymphatics undergo malignant changes and produce tumors in lymphoid tissueEpstein-Barr Virus is implicatedImmune deficiency disease…..3rd World 15 year olds to young adult development and declining in older peopleReed-Sternberg Cells: distinctive large/giant cellsBi-modal pattern in economically advantaged countries vs disadvantaged countries overall HD ocurance is lower except higher incidence in <15 y.o.
23Hodgkin’s and non-Hodgkin’s How do they differ?Non-Hodgkin’s: spreads by skipping lymph node areas (no Reed-Sternberg cells);Hodgkin’s: spreads in “orderly” fashion, has characteristic Reed-Sternberg (giant) cells, found in 2 age groups (mid-20’s and 50+ years) in “1st World” countries
25Hodgkin’s DiseaseCan start anywhere-most commonly in upper body: chest, neck, axillaSpreads in orderly fashionReed-Sternberg (giant) CellsAssociated with : Genetic Predisposition, Epstein-Barr Virus, Hx of Mononucleosis, Organ Transplant, Immunodeficiency DiseaseCopstead & Banasik 2009Also supraclavicular nodes, mediastinal nodesReed-Sternberg cells (giant cells with 1-2 large nuclei3. Exact Cause Unknown– associated with decreased immunity and infection (mononucleosis due to Epstein-Barr virus- 2-3 X more prevelant), genetic component (more common in people with Jewish heiratige, and 1st degree relatives, siblingsOverall survival 10 years post diagnosis – 77% with radiation and chemoSpecific survival depends upon stage on diagnosis
26Clinical manifestations Painless swelling of >1 inchLasting > 6 weeksUnrelated to infectious processStage B (Systemic) symptomsOlder clientsUnexplained weight loss (>10% in last 6 months)Unexplained fever >100 F.Drenching night sweatsStage A symptomsOften asymptomatic
27Staging- Cotswold Staging Classification for Hodgkin’s Disease Stage IConfined to one node region or lymphoid structureStage II2 or more nodal regionssame side of diaphragmStage III Involved lymphoid regions or structures on both sides of diaphragmStage IV extranodal sites (present in non-lymphoid tissue such as liver, bone marrow)Staging by symptomsA - asymptomaticB - fever, chills, night sweats, weight loss
28Stage 1Single lymph node region or lymphoid structure – spleen, thymus, tonsil
29Stage 22 or more lymph node regions on same side of diaphragm
30Stage 3Involvement of lymph regions or structures on both sides of diaphram
32PET ScanPositron Emission Tomography Scan can detect malignant tumor cells in the body. A small amount of radioactive glucose is injected into a vein and then the PET scanner rotates around the body, taking pictures of where glucose is being used in the body. More glucose is metabolized by malignant tumor cells than normal cells, leaving more radioactive material as a residue, so they show up brighter in the picture.Cleveland Clinic 2011
33Treatment of Hodgkin’s Disease Stages I & IIChemotherapy w/wo RadiationTherapy95% - complete remission90% - 95% 5 Year Survival& 20 Years for 70-80%Stages III & IVChemotherapyPartial remissionFollow up with radiation RxUp to 90% 5 Year Survival
34Chemotherapy Systemic Chemotherapy: Administered Orally, Intravenous or Intramuscular for systemic treatmentRegional Chemotherapy: injected into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areasCleveland Clinic 2011
35Radiation Therapyhigh-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. The way the radiation therapy is given depends on the type, location and stage of the cancer being treated.External radiation therapy: uses a machine outside the body to send radiation toward the cancer.Internal radiation therapy: uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.Cleveland Clinic 2011
36Prognosis – 5 year survival rates Stage I - >95%Stage II - >95%Stage III – 85-90%Stage IV – 60-90%Factors survivalB stage symptomsWBC > 15,000Hb < 10.5Lymphocyte < 600Male gender> 45 years serum albuminB stage symptoms: fever, chills, night sweats, weight lossOverall 10 year survival – 77%
37Late Effects from Childhood and Adolescent Hodgkin Lymphoma Treatment Side effects may appear months or years after treatment. Regular follow-up exams are important.Late effects may include problems with the following:Development of sex organs in males.Fertility (ability to have children).
38Late Effects Thyroid, heart, or lung disease. An increased risk of developing a second primary cancer.Bone growth and development.The risk of these long-term side effects will be considered when treatment decisions are made.Cleveland Clinic 2011
39Non-Hodgkin’s Lymphoma low-grade - indolentintermediate and high-grade – aggressivemultiple possible causes include EBV,H pylori, immuno-deficency, autoimmune disorders, infectious physical & chemical agentspainless lymph node enlargementlymphadenopathy d/t obstructionCopstead & Banasik 2009TypesEtiologyCM’sIncidence has increased by 73% between 1973 & Why??AIDS – NHL 60 times more common in people with AIDS than the general population.Middle aged white Males greatest prevailanceAges 50-60, caucasianRisk Factors: Immune deficiencies, autoimmune diseases, infections, chemical and agents: EBV, HTLV-1, Herpes virus 8, H. pylori
40Non-Hodgkin’s Lymphoma DiagnosisHistory & Physical (H&P)radiologic studies (including PET Scan)CBC, ESR, chemistry panelslymph node, bone marrow biopsyIndications for biopsyAdenopathy for > 3 weeks, progresses in size or spreads to other areasB symptoms that cannot be explained; fever, night sweats, weight lossAbnormal blood tests suggestive of lymphoma (ESR elevation-nonspecific sign of infection)X-rays to suggest extra-nodal sitesImmunodeficiency diseases
41Non-Hodgkin’s Lymphoma Treatmentinstituted after stagingcure rates vary with each grade International Index used for predicting survivalsingle or combined treatment depending upon stage of diseasePurpose: Eradication of tumor cellsRadiation and ChemotherapyHigher growth fraction (measure of the number of cells undergoing mitosis in a tissue—ratio between replication/resting cells) in intermediate and high grade tumors, so greater response to radiation and chemoCombination chemo-shrinkage and remission – numerous protocolsLow grade – Stage I-II – radiation aloneIntermediate grade – Stage III-IV – aggressive chemo especially under 60 years oldHigh grade – immediate and aggressive treatment (lymphoma doubles in bulk in hours days (BMT and stem cell transplants)Normal Lymphocyte count is 16 to 46 % of all WBC’s (Corbett 2004)
42Nursing Diagnoses Coping, ineffective (individual or family) Encourage expression of feelingsRelaxation techniques/support groupTake prednisone in a.m. to prevent insomniaInfection, risk for r/t bone marrow suppressionPrednisone: adverse reactions: insomnia, euphoria, increased appetite, n/v, H/A,
43Nursing Diagnoses Body Image disturbance Wig/hats prior to first chemo Skin changes/photosensitiveReproductive issuesSperm bankingContraceptionMenstrual changes and menopausal symptoms
44Alternative & Complimentary Therapy Herbals/TincturesSupplementsChiropractic/ MassageSpiritualityImageryNutritionalImportant for the client to inform health care providers of use of alternative treatments – adjust dose of chemo? drug interactions?
45Transplantation: Bone Marrow and Stem Cell Indications:Hematologic disordersrare genetic disorderstreatment of patients undergoing high-dose chemotherapy for solid tumorsProcedureIV administration of bone marrow that contains cells capable of differentiation into RBC’s, WBC’s and Plts.Approximately 20,000+ transplants/year
46Transplantation: Bone Marrow and Stem Cell Types of BMTallogenic - from a donor, often from a siblingautologous - transplanting to “self” after marrow is treatedsyngeneic - from an identical twinHLA: Human Leukocyte Antigen=system of recognition of host/foreign protein recognitionDonor marrow tested for matching HLANational Marrow Donor Program maintains registry and conducts donor drivesOnly perfect match is between identical twinsBone marrow is aspirated from multiple sites, Treated and stored for future use
47Transplantation: Bone Marrow and Stem Cell For allogenic BMT patient is conditioned pre-procedurereceives high-dose chemo and/or TBIassociated with many side effectsprotective isolationTreated marrow re-infused intravenouslyComplicationsinfectioninterstitial pneumoniagraft v. host disease (GVHD)host v. graftTBI=total body irradiationGVHD=donor T-lymphocytes form an immunological reaction against host cellsHost v. graft: recipient rejects graft from donor or own graft (skin from thigh to arm after a severe burn as an example)
48Preventing GVHD Suppression of: Recipient’s immune system before transplant.Drug Therapy: tacrolimus & cyclosporin prevent cell-mediated attacks upon transplant tissues/organs, no adverse effect upon bone marrow function/inflammatory response.Donor's immune cells in recipient after transplant
49Investigational and Other Treatments Molecular geneticsgene transfer therapyAlternative or complementary therapiesdiet supplementsmacrobiotic dietpharmacological therapiespsychological therapies
50Clinical Trials Planned investigation of a new regime Therapeutic or preventative4 phases of studies must be completed for FDA approvalRole of the Institutional Review BoardInformed consentPolit and Beck 2008Research—utilize research to create an Evidence Based Practice--an evidence building enterprise—design then implement a study—is the study utilizing ethical methods of data collection. 4 Phases: 1. small scale to develop safety measures, 2. preliminary evidence to establish effectiveness of treatment 3. Randomized Clinical Trials (randon/control groups) and gather evidence as to the effectiveness of new treatment/therapy – better than current methods? 4. study effectiveness in general population.
51Clinical Trials Role of the nurse in clinical trials Identifying risk study patientsProtecting the integrity of the studyDocumenting in the medical recordAdvocating for the patient
52ReferencesMedical-Surgical Nursing, Assessment and Management of Clinical Problems; Lewis, S., Dirksen, S., Heitkemper, M., et al, 8th Ed., 2011, Mosby, Inc.Medical-Surgical Nursing, Clinical Management for Positive Outcomes, Black, J., Hawks, J., 8th Ed., 2009 SaundersPathophysiology, Copstead, L., Banasik, J., 3rd Ed., 2005 ElsevierLeukemia and Lymphoma Society (lls.org retrieved 11/22/11)Polit, D., Beck, C., 2008, Nursing Research, Generating and Assessing Evidence for Nursing Practice, 8th Ed., Lippincott Williams & Wilkins, Philadelphia