HODGKINS DISEASE

FAMADOR O. GENALDO, RN, MD

The Lymph Nodes

Definition Hodgkins disease is a lymphoma Lymphomas are malignant disorders of the reticuloendothelial system that results in an accumulation of dysfunctional, immature lymphoid-derived cellsIt originates in the lymphoid system and involves predominantly lymph nodes

They are classified according to the predominant cell type and by the degree of cell maturity:Well differentiatedPoorly differentiatedUndifferentiated

Pathophysiology and EtiologyEtiology is unknownCharacterized by appearance of Reed-Sternberg multinucleated giant cell in tumorGenerally spreads via lymphatic channels, involving lymph nodes, spleen, and ultimately extralymphatic sites

May also spread via bloodstream to sites such as GIT, bone marrow, skin, upper air passages, and other organsIncidence demonstrates two peaks, at ages 20 - 40 and after age 60

FOUR STAGESStage I Hodgkin's disease is found in only 1 lymph node area, or has extended locally into adjacent tissue (IE). Stage II Hodgkin's disease is found in 2 or more lymph node areas on the same side of the diaphragm (muscle beneath the lungs that moves up and down to help you breathe). The cancer extends locally from the lymph node(s) to adjacent tissue (IIE).

Stage III Either of the following means that the disease is a Stage III: Hodgkin's disease is found in lymph node areas on both sides of the diaphragm. The cancer may also have extended to an area or organ adjacent to the lymph node and/or to the spleen (IIIE/IIISE).

Stage IV Hodgkin's disease has spread to 1 or more organs outside the lymphatic system such as the bone marrow or liver. Progressive or Recurrent Hodgkin's Disease:

Progressive disease is the term used when the disease progresses while you are still being treated. Recurrent disease means that Hodgkin's disease has come back after it has been treated. It may return in the area where it first started or in another part of the body. This may occur shortly after treatment or years later.

Clinical ManifestationsCommon symptoms include:Painless enlargement of lymph nodes (generally unilateral)Fever and chills Night sweatsWeight lossPruritusVarious symptoms may occur with pulmonary involvement, superior vena cava obstruction, hepatic or bone involvement

Diagnostic EvaluationTests are used to determine extent of disease involvement before treatment and followed at regular intervals to assess response to treatmentCBC: determines abnormal cellsLymph node biopsy: determines type of lymphomaBilateral bone marrow aspirate and biopsy: determine whether bone marrow is involved

Radiographic tests: to detect deep nodal involvementX-ray, CT scanning, MRIGallium-67 scan: detects areas of active disease and may be used to determine aggressive of diseaseLiver function tests and scan: determine hepatic involvement Liver biopsy: done if results are abnormal

Lymphangiogram: detects size and location of deep nodes involved, including abdominal nodes, which may not be readily seen via CT scanSurgical staging: laparotomy with splenectomy, liver biopsy, multiple lymph node biopsiesLumbar puncture: to obtain spinal fluid for cytopathology if meningeal lymphoma is suspected

Medical ManagementChoice of treatment depends on extent of disease, histopathologic findings, and prognostic indicatorsHodgkins disease is more readily cured than other lymphomas5-year survival: 80%More than one treatment strategy is availableCombination of radiation and chemotherapy are commonly used

Radiation TherapyTreatment of choice for localized diseaseAreas of body where lymph node chains are located can generally tolerate high radiation dosesHigh-energy rays are used (or particles) to destroy cancer cells or slow their rate of growth.Vital organs are protected with lead shielding during radiation treatment

External Beam radiation.Hodgkin's disease is usually treated with a carefully focused beam of radiation, delivered from a machine outside the body. This is known as external beam radiationIt is most useful when the disease is localized to one part of the body or is so bulky that even if chemotherapy is used, it won't get rid of all the cancer in the area.

Involved Field RadiationTreating only the known areas of disease with radiation The preferred form of radiation therapy.It is often combined with chemotherapy, although they are not given at the same time. After 3 to 4 courses of chemotherapy, involved field radiation will be given to areas that have clinically obvious disease.

Chemotherapy Chemotherapy is systemic therapy, which means the drug enters the bloodstream and circulates throughout the body to reach and destroy cancer cells. Is the use of drugs for killing cancer cells.The drugs can be taken by mouth in pill or liquid form, or they can be injected into a vein under the skin or in a muscle.

MEDICAL MANAGEMENTMultiple drugs are always used in chemotherapy for Hodgkin's disease , because different drugs kill cancer cells in different ways.The many drugs used in combination to treat Hodgkin's disease are often referred to by abbreviations that are easier to remember.

Two common examples are MOPP and ABVD.

a) MOPP refers to Mechlorethamine (nitrogen mustard), vincristine (Oncovin), Procarbazine, and Prednisone.

b) ABVD refers to doxorubicin (Adriamycin), Bleomycin, Vinblastine, and Dacarbazine.

Autologous or Allogeneic Bone Marrow Transplant The patient's own bone marrow is taken out and stored (frozen). Then very high doses of chemotherapy, with or without radiation therapy, are given to kill the cancer. These high doses of chemotherapy will destroy bone marrow, too.

After the high-dose chemotherapy treatments, the stored marrow is thawed and given back through a vein where it enters the bloodstream and returns to the boneThis will replace the marrow that was destroyed and the blood cells needed to fight infection and carry oxygen throughout the body.

Bone Marrow Aspiration

Peripheral Blood Stem Cell Transplant

Another type of autologous transplant is called peripheral blood stem cell transplant (PBSCT). A machine removes the patient's blood a little at a time, takes out only the stem cells (immature cells from which all blood cells develop), and returns the rest of the blood to the body. This procedure is called leukapheresis and usually takes a few hours.

The stem cells that are collected are then frozen until they are returned to the patient.

The chances for recovery are greater if these procedures take place in a hospital that has done many bone marrow transplantations.

It is better to do these earlier in treatment rather than later.If the first set of treatments doesn't get rid of the cancer, then many doctors would recommend transplantation right away.

On the other hand, if the disease comes back after it had gone away for a long time with the first treatment, most doctors would favor a second course of standard treatment.

They would wait to see if the patient gets better with the standard treatment before recommending the transplant.

Complications Side effects of radiation:Acute side effects: during treatment to 6 months after treatmentFatigue and malaiseErythema at the site, dry-to-wet desquamationNausea and vomiting, diarrhea, esophagitisChanges in taste, mucositis, xerostomiaDyspnea, pneumonitisCystitis, urethritis

Chronic side effects: after 6 months with a variability of in time of expressionFibrosis, telangiectasia, atrophy, permanent darkening of skinFibrosis, adhesions, obstruction, ulcerationsPermanent xerostomia, permanent taste alteration, dental cariesRadiation nephritis

Nursing ManagementNursing DiagnosisImpaired Skin Integrity related to high-dose radiation therapyAltered Oral Mucous Membranes related to high-dose ration therapy

Nursing InterventionsMaintaining Tissue IntegrityAvoid rubbing, powders, deodorants, lotions, or ointments (unless prescribed) or application of heat/cold to treated areaEncourage client to keep treated area clean and dry, bathing gently with tepid water and mild soapEncourage wearing loose-fitting clothesAdvise the client to protect skin from exposure to sun, chlorine, temperature extremes

Preserving Oral and GIT Mucous MembraneEncourage frequent small meals, using bland and soft diet at mild temperatureAvoid irritants such as alcohol, tobacco, spices, extreme food temperaturesAdminister pain medications or anti-emetic before eating or drinking, if neededEncourage mouth care at least twice a day and after meals using soft toothbrush and mild mouth rinse

Patient Education and Health MaintenanceTeach the client about the risk of infectionTeach clients how to take medications as orderedExplain that radiation therapy may cause sterilitySperm banking before treatment should be doneWomen may develop ovarian failure and require hormonal replacement therapy

Daghang Salamat