1. (Relates to Chapter 31, “Nursing Management: Hematologic Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Malignant neoplasms originating in the bone marrow and lymphatic structures  Result in the proliferation of lymphocytes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

3. Fifth most common type of cancer in the United States Two major types  Hodgkin’s lymphoma  Non-Hodgkin’s lymphoma (NHL) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

4. Malignant condition with  Proliferation of abnormal giant, multinucleated cells ▪ Reed-Sternberg cells ▪ Located in the lymph nodes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

5. Bimodal age-specific incidence 15 to 35 years of age >50 years of age  Twice as prevalent in males as in females Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

6. Cause remains unknown. Key factors  Infection with Epstein-Barr virus  Genetic predisposition  Exposure to occupational toxins Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

7. Normal structure of lymph nodes destroyed by hyperplasia of monocytes and macrophages Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

8. Main diagnostic feature  Presence of Reed-Sternberg cells in lymph node biopsy specimens Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

9. Believed to arise in a single location  Spreads along adjacent lymphatics  Eventually infiltrates other organs ▪ Lungs, spleen, or liver Two thirds of patients are affected first in the cervical lymph nodes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

10. Disease begins above diaphragm.  Remains in lymph nodes for variable amount of time Below the diaphragm  Frequently spreads to extralymphoid sites Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

11. Insidious onset Enlargement of cervical, axillary, or inguinal lymph nodes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

12. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Fig. 31-13. Hodgkin’s lymphoma (stage IIA). This patient has enlargement of the cervical lymph nodes.

13. Nodes remain movable and nontender Painless unless nodes exert pressure on adjacent nerves Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

14. May experience  Weight loss, fatigue, weakness, fever, chills, tachycardia, or night sweats Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

15. Initial symptoms correlate with worse prognosis  Called B symptoms ▪ Fever ▪ Night sweats ▪ Weight loss Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

16. Alcohol-induced pain Generalized pruritus without lesions Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

17. Mediastinal node involvement is evident with  Cough  Dyspnea  Stridor  Dysphagia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

18. Advanced cases  Hepatomegaly  Splenomegaly  Anemia  Other physical signs vary, depending on disease location. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

19. Peripheral blood analysis Excisional lymph node biopsy Bone marrow examination Radiologic evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

20. Using diagnostic studies, a stage of disease is determined. Disease may be localized or diffuse. Treatment depends on the nature and extent of the disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

21. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Fig. 31-14. Staging system for Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Stage I, involvement of single lymph node (e.g., cervical node). Stage II, involvement of two or more lymph nodes on one side of diaphragm. Stage III, lymph node involvement above and below the diaphragm. Stage IV, involvement outside of diaphragm (e.g., liver, bone marrow). The stage is followed by the letter A (absence) or B (presence) to indicate significant systemic symptoms (e.g., fever, night sweats, weight loss).

22. Nomenclature used in staging  A or B classification ▪ Presence of symptoms when disease is found  Roman numeral (I to IV) ▪ Location and disease extent Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

23. Management focuses on selecting a treatment plan.  Least amount to achieve cure  Minimize short- and long-term complications Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

24. Combination chemotherapy  Favorable early-stage disease, receive 2 to 4 cycles  Unfavorable early stage, receive 4 to 6 cycles  Advanced stage, receive 6 to 8 cycles Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

25. Radiation as a supplement varies, depending on sites of disease and presence of disease after chemotherapy. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

26. Therapy must be aggressive. Maintenance chemotherapy does not contribute to increased survival once a complete remission has been achieved. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

27. Risk of secondary malignancies  2% to 6%  Generally occur within the first 10 years Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

28. Skin in radiation field needs attention. Psychosocial considerations Fertility issues Overall better prognosis than many cancers Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

29. Heterogeneous group of malignant neoplasms of the immune system affecting all ages  Primarily B- and T-cell origin Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

30. Classified according to  Different cellular characteristics  Lymph node characteristics Varies from slow to rapid disease progression Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

31. Unknown cause Most common in those who have used immunosuppressive meds or have received chemotherapy or radiation No hallmark feature  All NHLs involve lymphocytes arrested at various stages of development. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

32. Can originate outside lymph node Spread can be unpredictable. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

33. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Fig. 31-15. Non-Hodgkin’s lymphoma involving the spleen. The presence of an isolated mass is typical.

34. Widely disseminated disease usually present at time of diagnosis Painless lymph node enlargement  Primary clinical manifestation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

35. Patients with high-grade lymphomas  Lymphadenopathy  B symptoms Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

36. Peripheral blood is usually normal.  Some lymphomas manifest in “leukemic” phase. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

37. Similar to Hodgkin’s lymphoma Lymph node biopsy  Establishes cell type and pattern Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

38. Staging guides therapy. Prognosis for NHL generally is not as good as that for Hodgkin’s lymphoma. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

39. Treatment  Chemotherapy  Radiation therapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

40. More aggressive lymphomas are more responsive to treatment.  More likely to be cured Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

41. Hematopoietic stem cell transplant Rituximab (Rituxan) Ibritumomab tiuxetan (Zevalin) Tositumomab (Bexxar) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

42. Phototherapy α-Interferon Bexarotene (Targretin), vorinostat (Zolinza), or denileukin diftitox (Ontak) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

43. Largely based on managing problems related to the disease, pancytopenia, and other side effects Must know about subtype and extent of disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

44. Skin in the radiation field requires special attention. Psychosocial considerations Fertility concerns Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

45. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45

46. 74-year-old man visits his primary care physician with gastrointestinal complaints. Enlarged nodes are noted on assessment. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46

47. Blood work and a CT are ordered.  Followed by a lymph node biopsy He is diagnosed with intermediate- grade, diffuse, large non-Hodgkin’s lymphoma. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

48. 1.What is his primary treatment option? 2.What other treatments may he receive? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

49. 3.What is the most important nursing care for him? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49