Hodgkin's Disease

HODGKIN¶S DISEASE Gayapa, Al Quin S. Bongcaras, Eunice Phoebe B. Cumayas, Sarah N. Jumamoy, Danilyn L. Reroma, Fairylane P. Group 6 BSN IV-D

Def initio inition Hodgkin's disease

is a typ type of lympho ymphoma. ma.

Lymphoma is cancer of   the lymph ymphat atic ic sy syst ste em and is the the thir d most commo mmon typ type of  canc  cancer  er  in kids and tee teens ns age ages 10 to to 14. But But it is stil still very  r are for   kids to to get it. 

The l ymph ymphat atic ic syst system em is the syste system in th the body that is res responsi ponsib ble for figh ig   hting off  infe infecti ctio ons and keeping eeping yo you healthy. It's t's made ade up of  y  your  tonsi l l s, s, spl  spl een, bone marrow, and chains of l  f l ymp y mph nodes (round (rounde ed masses of  tissu tissue found throug hroughout hout the body). body).  Alt  Althoug hough many type types s of canc of  cancer  er can can spre spread ad to the lymph ymph syste system, lympho ymphoma ma actu actually lly begins begins in the the cells ells of t of the lymph ymph syste system itself  itself . 

Def initio inition

differe differentiat ntiate es H odgkin's odgkin's l ymphoma ymphoma is the pres presence nce of  Reed Reed-S -Ste tern rnbe berg rg cell  cell s in the cancerou cancerous s tissue tissue.. The presence nce of  thes hese cells, ells, detectab ctable only throug hrough an open open biopsy, opsy, is the the def ining ining ch char acter  acter istic istic of Hodgkin's dgkin's dise disease ase, as oppos opposed to non-Hodgkin's -Hodgkin's lympho ymphoma. ma. 

What

Hodg Hodgki kin' n's s dis disease ase is named for  Dr. Thomas r ibed bed sever al case of  the cancer  H odgkin, odgkin, who desc scr  cases of t cancer  with within the lymph ymph syste system in 1832.  About  About 4 0 ye year s later  ater , other  doctor  ctor s began began to to repor t differe different nt type types s of  lympho ymphomas. mas. 

Def inition

 Types

of Hodgkin¶s Disease

Nodular Sclerosing Hodgkin Lymphoma (NSHL): This is the most common type of Hodgkin Lymphoma. In the developed countr ies 60-80% of  the people affected by Hodgkin disease have the Nodular  Sclerosing subtype. It i s commoner  in females and mostly affects younger people ± adolescents and young adults. The disease mainly affects nodes in the neck or ar mpits, or within the chest.

Def inition

Mixed

Cellularity Hodgkin Lymphoma (MCHL): This is another common type of Hodgkin Lymphoma. 15-30% of  those affected have mixed cellular ity disease. This type is more common i n developing countr ies. People of any age may be affected. Males and females are equally affected. This type of  disease is more likely to involve the abdomen than the more common nodular sclerosing var iety, and less likely to involve nodes within the chest.

Def inition

Lymphocyte Depleted Hodgkin Lymphoma (LDHL): The Lymphocyte depletion subtype is a ver y r are form   of Hodgkin Lymphoma that makes up only about 1% of  those affected by the disease. It affects older people and is of ten diagnosed in an advanced stage when the lymphoma has affected different or gans of the body. It is also more common in those who are HIV affected.

Def inition

Lymphocyte-rich Classic Hodgkin Lymphoma (LRCHL): This is another uncommon subtype that makes up about 5-6% of Hodgkin patients. It is more common in males and affects people most commonly in their  thir ties or forties.   Most individuals are diagnosed in early stages and response to treatment is excellent.

Def inition

Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL): Now considered to be a special type of Hodgkin disease that is different from the other  types mentioned above, this var iant accounts for  4-5% of  all cases of Hodgkin disease.  Accor ding to pathologists this type has many similar ities with Non-Hodgkin Lymphoma (NHL). In all clinical aspects, however , the features are similar  to the lymphocyte-r ich type of Hodgkin lymphoma. Most individuals are diagnosed early and do very  well af ter  treatment.

Incidence

 Accor ding to the Leukemia and Lymphoma Society, Hodgkin's Lymphoma represents about 11% of all lymphoma diagnoses. Approximately 8,000 cases (4,400 males and 3,820 females) of Hodgkin's Lymphoma are detected per year which represents less than 1% of all cancer s. Never theless, this is a still a signif icant disease worldwide and incidents are on the r ise.

Prognosis

Hodgkin ' s disease is considered one of the most cur able for ms of cancer , especially if it is diagnosed and treated early. Unlike other cancer s, Hodgkin's disease is even  potentiall y curabl e in l ate stages Five-year survival r ates for patients diagnosed with stage I or stage II Hodgkin ' s disease are 90 - 95%. With advances in treatment, recent studies have indicated that even patients with advanced Hodgkin ' s disease have 5-year survival r ates of 90%, although it is not yet cer tain if their cancer will retur n. Patients who survive 15 year s af ter treatment are more likely to later die from other causes than Hodgkin ' s disease.

Prognosis

Survival r ates are poorest for: Those

who relapse within a year of treatment

Patients

who do not respond to the f ir st-line

ther apy and have signs of disease progression

Risk Factor s 

Age (between ages 15 and 40 and greater than 55)



Family history (f ir st-degree relatives)



Sex (more on males)

Past Epstein-Barr infection / Infectious Mononucleosis (caused by Epstein-Barr Virus/EBV) 

Compromised immune system (HIV/ AIDS and with or gan tr ansplant)  

Geography (U.S., Canada, Nor ther n Europe)



Socioeconomic status (higher background) Occupation

(seen in woodwor ker s and those veter ans of  the militar y who were exposed to herbicide agent or ange) 

Etiology The exact cause of Hodgkin's lymphoma is UNKNOWN .  Infectious

agents, par ticularly EBV, may be involved in the pathogenesis.

 Patients

with HIV infection have a higher incidence of  Hodgkin lymphoma compared with the population without HIV infection. However , Hodgkin lymphoma is not considered an acquired immunodef iciency syndrome (AIDS)-def ining neoplasm.

 Genetic

predisposition may play a role in the pathogenesis of Hodgkin lymphoma.

Etiology

 A key step in Hodgkin's lymphoma involves the devel opment of abnormal  B cell s. B cells are a type of  lymph cell that's an impor tant par t of your immune system's response to foreign invader s. B cell s nor mally wor k with T cells, which mature in the thymus, to fight infection.

Etiology W hen

B cells develop into lar ge abnor mal cells, these abnor mal, cancerous cells are called REED-STERNBERG CELLS. Instead of under going the nor mal cell cycle of life and death, Reed-Ster nber g cells don't die, and they continue to produce abnormal B cell s in a malignant process. These cells also attract other normal immune cell s that cause the l ymph nodes to enl arge.

Clinical Manifestations 

Painless swelling of lymph nodes in your neck,

armpits or groin Per sistent f atigue; doesn't go away 

weakness

and tenderness that



Fever and chills that doesn't go away



Soaking Night sweats

Unexplained weight loss ² as much as 10 per cent or  more of your body weight  

Coughing, trouble breathing or chest pain



Loss of appetite



Itching; itchy skin

Increased sensitivity to the effects of alcohol or pain in your lymph nodes af ter dr inking alcohol 

Diagnostic Studies Medical Biopsy

histor y and physical exam

procedures used to diagnose Hodgkin disease

 A. Types of biopsies 1.

Excisional  or incisional  biopsy : In this procedure, the doctor  cuts through the skin to remove the entire lymph node (excisional biopsy) or a small par t of a lar ger tumor or  node (incisional biopsy). If  the node is near  the skin surf ace, this is a f airly simple oper ation that can sometimes be done with numbing medicine (local anesthesia). But if the node is inside the chest or  abdomen, the patient is given gener al anesthesia (where he or she is in a deep sleep).

Diagnostic Studies  A. Types of biopsies 2 .

Fine needl  e aspiration (FNA)   or core needl  e biopsy: In an FNA biopsy, the doctor uses a ver y thin needle attached to a syr inge to withdr aw (aspir ate) a small amount of fluid and tiny bits of  tissue from a lymph node or organ   in the body. For  a core needle biopsy, the doctor uses a lar ger  needle to remove a slightly lar ger piece of  tissue. For an enlar ged node near the surf ace of the body, the doctor  can aim the needle while feeling the node. If a tumor is deep inside the body, the doctor  can guide the needle using a computed tomogr aphy (CT) scan or ultr asound (see discussion of imaging tests later in this section).

Diagnostic Studies  A. Types of biopsies 3.

Bone marrow aspiration and biopsy: These tests are not used to diagnose Hodgkin disease, but in some cases they may be done af ter  the diagnosis is made to see if the Hodgkin disease is in the bone marrow.



Lab tests used to diagnose and classif y Hodgkin disease (All biopsy samples are looked at under a microscope by a pathologist, who looks at the size and shape of the cells and deter mines if any of them are R eed-Sternberg cells.)



Immunohistochemistr y (cer tain proteins, such as C D15  and C D30 , on the surf ace of the Reed-Ster nber g cells)

Diagnostic Studies 

Staging Hodgkin's disease 

Stage I. The cancer is limited to one lymph node region or a single or gan.  A. B.

W ithout W ith

the ³B symptoms´

the ³B symptoms´



Stage II. In this stage, the cancer is in two different lymph nodes, but is limited to a section of the body either above or below the diaphr agm. (classif ication, same with stage I)



Stage III. W hen the cancer moves to lymph nodes both above and below the diaphr agm, but hasn't spread from the lymph nodes to other or gans, it's considered stage III.

Diagnostic Studies 

Staging Hodgkin's disease 

Stage IV. This is the most advanced stage of  Hodgkin's disease.

Stage IV Hodgkin's disease affects not only the lymph nodes but also other par ts of your body, such as the bone marrow or your liver . -Additional def initions of the cancer (A,B,S & E) The l etter  A means that you don't have any signif icant symptoms as a result of the cancer .

Diagnostic Studies 

Staging Hodgkin's disease

The l etter B indicates that you may have signif icant signs and symptoms, such as a per sistent fever greater than 100 F with no other known cause, unintended weight loss of more than 10 per cent of your body weight or severe night sweats. The l etter E   stands for extr anodal, which means that the cancer has spread beyond your lymph nodes. The l etter S designates a cancer  that has spread into your  spleen. ==The letter s B, E and S indicate potentially more ser ious disease.==

Medical Management The treatment the doctor recommends depends in lar ge par t on the patient's age when they are diagnosed, the stage of the disease, whether or not the disease is bulky, and other prognostic f actor s. Stage IA and IIA (Favorable): chemother apy (usually 2 to 4 cycles of  the ABVD ±adriamycin, bl eomycin, vinbl istine, dacarbazine- regimen), followed by involved f ield r adiation to the initial site of the disease 

Stages

IB and IIB (Unfavorable): chemother apy (usually ABVD for 4 to 6 cycles or other regimens such as Stanfor d V). PET/CT scans are often   done af ter  sever al cycles of  chemother apy to deter mine how much more treatment you need

Medical Management Stages III and IV: chemother apy at full doses; although ABVD (for at least 6 cycles) can be used, some doctor s f avor more intense treatment with the Stanford V  or BE  AC OPP regimen which includes: 



Bleomycin, an anti-tumor antibiotic



Etoposide, a DNA toxin



Adr iamycin (Doxorubicin), an anti-tumor antibiotic



mustar d der ivative such as Cyclophosphamide



Vinblastine or Vincr istine (Oncovin), an alkaloid cell toxin



Procarbazine, an alkylating agent



Prednisone, a cor ticosteroid

Medical Management Resistant Hodgkin disease: Once initial treatment is complete, the doctor will probably do fur ther  tests to look for any signs of Hodgkin disease, such as PET and CT scans. If the Hodgkin disease is still there, most exper ts think that more of the same treatment is unlikely to cure the patient. 



Recurrent or relapsed o

o

o

Hodgkin

disease:

Radiation usually cannot be repeated i n the same area. If  the initial treatment was r adiation ther apy without chemother apy, chemother apy is usually given for  recurrent disease. Chemother apy with different drugs may be another  option.

Treatment Modalities Radiation therapy: W hen the disease is conf ined to a limited area, r adiation ther apy may be the treatment of  choice. It's typical to r adiate the affected nodes and the next area of nodes where the disease might progress. The length of r adiation treatment var ies depending on the stage of the disease. 

Chemotherapy: When the disease progresses and involves more lymph nodes or other or gans, chemother apy is the preferred treatment. Chemother apy uses specif ic drugs in combination to kill tumor  cells.  A major  concer n with chemother apy is the possibility of long-ter m side effects and complications. 

Treatment Modalities Chemotherapy regimens are commonly referred to by their initials, such as:  ABVD,

which consists of  doxorubicin (Adr iamycin ), bleomycin, vinblastine anddacarbazine

 BEACOPP,

which consists of bleomycin, etoposide,  Adr iamycin, cyclophosphamide, vincr istine (Oncovin), procarbazine and prednisone

 COPP/ABVD,

which consists of  cyclophosphamide, Oncovin, procarbazine, prednisone,  Adr iamycin, bleomycin, vinblastine and dacarbazine

Treatment Modalities Chemother apy regimens are commonly referred to by their  initials, such as:  Stanford

V, which consists of Adr iamycin, vinblastine, mechlorethamine, etoposide, vincr istine, bleomycin and prednisone



MOPP,

which consists of mechlorethamine, Oncovin, procarbazine and prednisone MOPP had been the basic regimen, but it's ver y toxic.  ABVD i s a newer regimen, with lesssevere side effects, and is currently the preferred treatment.

Treatment Modalities Bone Marrow Transplant: If the disease recur s af ter an initial chemother apy-induced remission, high-dose chemother apy and tr ansplantation of your own (autol ogous) bone marrow or per ipher al stem cells may lead to prolonged remission. P eripheral  stem cell s are bone marrow cells mobilized from the bone marrow into the bloodstream. 

Because high doses of  chemother apy destroy bone marrow, your own marrow or per ipher al blood stem cells are collected before treatment and frozen. You'll under go chemother apy, and then your own cells, which have been protected from the effects of  the treatment, are injected back into your body.

Nur sing Diagnosis Risk

for Infection related to impaired pr imar y and secondar y defenses

Ineffective

Air way Clear ance R/T physical obstruction by tumor 

Imbalanced

Nutr ition: less than body requirements R/T increased metabolic demands of neoplastic process

Hyper ther mia Impaired

R/T suppressed the immune system

Comfor t: prur itis R/T inflammation in tissues

Chronic

Pain R/T presence of tumor 

Nur sing Interventions 

To protect the skin receiving r adiation, avoid rubbing, powder s, deodor ants, lotions, or ointments (unless prescr ibed) or application of heat or cold. 

Encour age patient to keep clean and dr y , and to bathe the area affected by r adiation gently with tepid water  and mild soap. 

Encour age wear ing loose-f itting clothes and to protect skin from exposure to sun, chlor ine, and temper ature extremes.  

Use soap spar ingly if the skin is already dr y.

 Apply cool compresses on the itching skin or have patient sit in cool bath water for relief .

Nur sing Interventions 

 Applying compresses of star ch solutions, such as oatmeal, may help relieve itching. 

Keep finger    nails shor t to prevent damage to skin from scr atching. 

Keep prur itic areas open to air .



Encour age mouth care at least twice per  day and af ter  meals using a sof t toothbrush and mild mouth r inse to prevent stomatitis. 

 Assess for ulcer s, plaques, or  dischar ge that may be indicative of   super imposed infection. Make regular  physical inspections of patient's or al structures and monitor for  inflammation or  infection secondar y to his/her  compromised immune system

Nur sing Interventions 

Teach patient about r isk of  infection.  Advice patient to monitor temper ature and repor t any fever or other sign of  infection promptly. 

Teach the patients to avoid irr itants such as alcohol, tobacco, spices, and extremely hot or cold foods. 

 Assess the patient for  nutr itional def iciencies and malnutr ition.  W eigh

weekly and recor d.



Offer  small meals at frequent intervals throughout the day to help deal with f atigue of eating. 

For children, offer f inger foods that are easy for them to eat.

Nur sing Interventions 

Offer high protein supplements between meals.



Offer  the patient gr apefruit juice, or ange juice, ginger  ale to alleviate nausea and vomiting. 

To protect or al and gastro-intestinal tr act mucous membr anes, encour age frequent, small meals, using bland and sof t diet at mild temper atures and to dr ink plenty of  fluids. 

For  diarrhea, switch to low-residue diet and administer  anti-diarrheals as or dered.  

Monitor the r ate and char acter of patient's respir ations.

Keep the head of the bed elevated 30 to 45 degrees to f acilitate patient's breathing effor ts.

Nur sing Interventions 

If there is likelihood of sputum production, teach patient how to deep breathe and cough to help clear the air way. 

Observe the color , volume and odor of   any sputum produced. 

Provide emotional suppor t when the patient is shor t of  breath. 

Perfor m comfor t measures that promote relaxation.



Explain all the procedures and treaments associated with the plan of care. 

If the patient is a woman of childbear ing age, advise her  to delay her pregnancy until long-ter m remission occur s.

Nur sing Interventions 

Instruct the patient to pace his activities to counter act ther apy induced f atigue. 

 Advise the patient to avoid crowds and any per son with a known infection. 

Make sure that the patient under stands the possible adver se effects of his treatments. 

 Advise the patient to seek follow-up care af ter he has completed the initial treatment. 

Explain to patient that r adiation ther apy may cause ster ility. 

 Administer or   teach self-administr ation of pain medication or  antiemetic before eating or  dr inking, if  needed.

Nur sing Interventions



 Assess the patient's level of pain using a numer ical pain r ating scale or a f ace pain r ating scale. 

If patient is young and cannot accur ately repor t pain, document and observe for behavior s that may indicate the presence o f pain. 

 Assess and document the location, intensity and any activity that acerbates the pain. 

Plan for patient to perfor m  ADLs around those times when the patient exper iences greatest comfor t from pain. 

 Assist the patient with ADLs as necessar y due to f atigue.

End of Presentation

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