INSTITUTE OF LIVER AND BILIARY SCIENCES (ILBS)

COLLEGE OF NURSING

SEMINAR
ON
HODGKIN’S AND NON-HODGKINS
LYMPHOMA

SUBMITTED TO- SUBMITTED BY-

Ms. Monika Maan Ms. Sangeeta Yadav

Lecturer, M.Sc. Nursing, 1st Year

ILBS CON ILBS CON

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Definition

The lymphatic system is a network of vessels, nodes, and ducts that pass through almost all
bodily tissues. It allows the circulation of a fluid called lymph through the body in a similar
way to blood. It is part of the immune system.

The lymphatic system is essential for fluid balance, absorption of fatty acids in the stomach,
and immune system regulation.

Anatomy

The lymphatic system consists of lymph vessels, ducts, nodes, and other tissues throughout
the body. Lymphatic vessels collect interstitial fluid and transport it to lymph nodes. These
nodes filter out damaged cells, bacteria, and other foreign bodies.

Once this fluid passes out of the lymph nodes, it travels to larger vessels and eventually
lymph ducts, which converge in the thoracic duct at the base of the neck.

The thoracic duct returns filtered lymph into the bloodstream.

Other lymphatic tissues

Lymph nodes are not the only lymphatic tissues in the body. The tonsils, spleen, and thymus
glands are also lymphatic tissues.

* Thymus gland: The thymus gland is a lymphatic organ and an endocrine gland behind the
sternum. It secretes hormones and is crucial to the production, maturation, and differentiation
of immune T cells.

Tonsils: The tonsils produce lymphocytes and antibodies. They can help protect against
inhaled foreign bodies .

Spleen: The spleen is not part of the connected lymphatic system, but it is lymphoid tissue. It
produces white blood cells and filters the blood to remove microbes as well asold and
damaged red blood cells and platelets.

Bone marrow: Bone marrow is not lymphatic tissue but is part of the lymphatic system
because it is here that the B cell lymphocytes of the immune system mature.

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Function

The lymph system has three main functions.

Fluid balance

The lymphatic system returns excess fluid and proteins from the tissues that cannot return
through the blood vessels. The fluid often collects in the tiny spaces surrounding cells, known
as the interstitial spaces. Small lymph capillaries connect these spaces to the lymphatic
system.

Around 90% of the plasma that reaches tissues from the arterial blood capillaries returns

through the venous capillaries and veins. The remaining 10% travels through the lymphatic
system.

A disruption of fluid processing can result in localized swelling, known as lymphedema.

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Absorption

the lymphatic system plays a key role in intestinal function. It assists in transporting fat,
fighting infections, and removing excess fluid.

Part of the gut membrane in the small intestine contains tiny finger-like protrusions called
villi. Each villus contains tiny lymph capillaries, known as lacteals. These absorb fats and fat-
soluble vitamins to form a milky white fluid called chyle.

This fluid contains lymph and emulsified fats, or free fatty acids. It delivers nutrients
indirectly when it reaches the venous blood circulation. Blood capillaries take up other
nutrients directly.

The immune system

The third function of lymph nodes is to defend the body from exposure to potentially
hazardous microorganisms, such as infections.

The body’s first line of defence involves;

 physical barriers, such as the skin

 toxic barriers, such as the acidic contents of the stomach
 "friendly" bacteria in the body

However, pathogens often do succeed in entering the body despite these defenses. In this
case, the lymphatic system enables the immune system to respond appropriately.

How does the lymphatic system fight infection?

The lymphatic system produces white blood cells called lymphocytes. There are two types of
lymphocytes: T cells and B cells. They both travel through the lymphatic system.

As they reach the lymph nodes, they come into contact with viruses, bacteria, and foreign
particles in the lymph fluid.

following contact, lymphocytes form antibodies and start to defend the body. They can also
produce antibodies from memory if they have already encountered the specific pathogen in
the past.

The lymphatic system and the action of lymphocytes form part of the body's adaptive
immune response. These are highly specific and long lasting responses to particular
pathogens.

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LYMPHOMA

The lymphomas are neoplasms of cells of lymphoid origin These tumors usually start in
lymph nodes but can involve lymphoid tissue in the spleen, GI tract (e.g., the wall of the
stomach), liver, or bone marrow They are often classified according to the degree of cell
differentiation and the origin of the predominant malignant cell. Lymphomas can be broadly
classified into two categories: Hodgkin lymphoma and non-Hodgkin lymphoma (NHL).

Lymphomas are broadly divided into Hodgkin lymphoma and non-Hodgkin lymphoma. This
distinction is important because their presentation, biology, prognosis and treatment
approaches are different.

Hodgkin lymphomas frequently present in lymph nodes and in most cases have an orderly
pattern of spread to contiguous lymph node regions, with frequent involvement of the
mediastinal and cervical lymph node areas. The non-Hodgkin lymphomas are a very
heterogeneous group of disease in terms of aetiology, pathology and molecular genetics,
clinical presentation, sites of involvement, the specific treatment required and prognosis.

1. Hodgkin’s lymphoma
Hodgkin’s lymphomas typically start in RS cells. While the main cause of Hodgkin’s
lymphoma isn’t known, certain risk factors can increase your risk of developing this type of
cancer.

Reed-sternberg cells are large , abnormal lymphocytes (a type of white blood cells)that may
contain more than one nucleus . These cells are found in people with Hodgkin lymphoma.

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Reed Sternberg cell are also called Hodgkin and Reed-sternberg cells.

Hodgkin lymphomas (HL) share the following characteristics:

(1) They usually arise in lymph nodes, preferentially in the cervical region
(2) The majority of them manifest clinically in young adults;
(3) Neoplastic tissues usually contain a small number of scattered large mononucleated
and multinucleated tumour cells (designated Hodgkin and Reed-Sternberg cells or
HRS cells) residing in an abundant heterogeneous admixture of non- neoplastic
inflammatory and accessory cells;
(4) The tumour cells are often ringed by T lymphocytes in a rosette-like manner.
Hodgkin lymphomas account for ~30% of all lymphomas. Their absolute incidence
has not apparently changed, in contrast with non-Hodgkin lymphomas where there
has been a steady increase in incidence.

Sub classification

 NLPHL (nodular lymphocytic predominant HL)

Patients with NLPHL generally present with localized, non- bulky disease. The only
symptom for most people with NLPHL is one or more lumps. These are enlarged
lymph nodes (swollen glands). They are often in only one place in the body. A few
people have other general symptoms of lymphoma, like night sweats, weight loss and
fevers.

Classical Hodgkins Lymphoma

 Hallmark of classic Hodgkin lymphoma is the Reed- Sternberg cell. This is a
binucleated or multinucleated giant cell that is often characterized by a bilobed
nucleus, with two large nucleoli, giving an owl’s eye appearance to the cells.

INCIDENCE

 Hodgkin’s lymphoma global incidence – Age standardize rate (ASR) per 100,000 for
women 0.8 and for men
 Hodgkin lymphoma is a relatively rare malignancy that has a high cure rate. It is
somewhat more common in men than in women and has two peaks of incidence: one
in the early 20s and the other after 55 years of age.
 Disease occurrence has a familial pattern: First-degree relatives have a higher- than-
normal frequency of disease, but the actual incidence of this pattern is low.
 No increased incidence for non-blood relatives (e.g., spouses) has been documented.
Hodgkin lymphoma is seen more commonly in patients receiving chronic
Immunosuppressive therapy ( e .g. for renal transplant) and also in veterans of the
military who were exposed to the herbicide Agent Orange.

Pathophysiology

Unlike other lymphomas, Hodgkin lymphoma is unicentric in origin in that it initiates

in a single node. The disease spreads by contiguous extension along the lymphatic
system. The malignant cell of Hodgkin lymphoma is the Reed-Stern- berg cell, a
gigantic tumor cell that is morphologically unique and thought to be of immature

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 lymphoid origin . It is the pathologic hallmark and essential diagnostic criterion.
However, the tumor is very heterogeneous and may actually contain few Reed-
Sternberg cells. Repeated biopsies may be required to establish the diagnosis.

The cause of Hodgkin lymphoma is unknown, but a viral etiology is suspected.

Although fragments of the Epstein- Barr virus have been found in some Reed-
Sternberg cells, the precise role of this virus in the development of Hodgkin
lymphoma remains unknown. Other viruses may also be implicated, including human
immunodeficiency virus (HIV) and herpesvirus 8. The incidence of developing
Hodgkin lymphoma is also higher in patients with immunoglobulin A (IgA) or certain
types of immunoglobulin G (IgG) deficiency.

Hodgkin lymphoma is customarily classified into five subgroups based on pathologic

analyses that reflect the natural history of the malignancy and suggest the prognosis.
For example, when lymphocytes predominate, with few Reed-Sternberg cells and
minimal involvement of the lymph nodes, the prognosis is much more favorable than
when the lymphocyte count is low and the lymph nodes are virtually replaced by
tumor cells of the most primitive type. Most patients with Hodgkin lymphoma have
the types currently designated as "nodular sclerosis" or "mixed cellularity."
The nodular sclerosis type tends to occur more often in young women, at an earlier
stage but with a worse prognosis, than the mixed cellularity subgroup, which occurs
more.

Causes of lymphoma

● Are in 60s or older for non-Hodgkin lymphoma.

● Between 15 and 40 or older than 55 for Hodgkin lymphoma.
● Are male, although certain subtypes may be more common in females.
● Have a weak immune system from HIV/AIDS, an organ transplant, or because
you were born with an immune disease.
● Have an immune system disease such as rheumatoid arthritis, lupus, or celiac
disease.
● Have been infected with a virus such as Epstein-Barr, hepatitis C, or human T-cell
leukemia/lymphoma (HTLV-1).
● Have a close relative who had lymphoma.

● Were exposed to benzene or chemicals and pesticides that kill bugs and weeds.eg
organophosphate, phenoxyherbicides.
● Were treated for Hodgkin or non-Hodgkin lymphoma in the past.

Clinical Manifestation
 Hodgkin lymphoma usually begins as an enlargement of one or more lymph node.
the individual sites for lymphadenopathy nodes are painless and firm but not hard.
 The most common cervical, supraclavicular, and mediastinal nodes; involvement
of iliac or inguinal nodes or spleen is much less common.

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  A mediastinal mass may be seen on chest X-ray; occasionally, the mass is large
enough to compress the trachea and cause dyspnea.
 Pruritus is common; it can be extremely distressing, and the cause is unknown.
 Some patients experience brief but severe pain after drinking alcohol, usually at
the site of the tumor. Again, the cause of this is unknown.
 All organs are vulnerable to invasion by tumor cells. The symptoms result from
compression of organs by the tumor, such as cough and pulmonary effusion (from
pulmonary infiltrates), jaundice (from hepatic involvement or bile duct
obstruction),
 abdominal pain (from splenomegaly or retroperitoneal adenopathy),
 or bone pain (from skeletal involvement)
 Herpes zoster infections are common.
 A cluster of constitutional symptoms has important prognostic implications.
 Referred to as B symptoms, they include fever (without chills), drenching sweats
(particularly at night), and unintentional weight loss of more than 10% of body
weight. B symptoms are found in 40% of patients and are more common in
advanced disease.
 A mild anemia is the most common hematologic finding. The leukocyte count
may be elevated or decreased. The platelet count is typically normal, unless the
tumor has invaded the bone marrow, suppressing hematopoiesis. The erythrocyte
sedimentation rate (ESR) and the serum copper level are sometimes used to assess
disease activity; elevations may reflect increases in disease activity.
 Patients with Hodgkin lymphoma have impaired cellular immunity, as evidenced
by an absent or decreased reaction to skin sensitivity tests (e.g., Candida, mumps).
Infections, including viral infections are common

STAGING
Ann Arbor stage summary:Hodgkin lymphoma
STAGE DEFINITION
I Involvement of a single lymph node region or lymphoid structure.(eg; spleen,
thymus ).

II Two or more region, same side of diaphragm(the mediastinum is asingle site ,

hilar lymph nodes are lateralized)

III Involvement of lymph node region or structure on both sides of the diaphragm.
III(1) With or without splenic ,hilar or portal nodes.
III(2) With spleen
III(3) Both
IV Diffuse or multifocal involvement of extra lymphatic organs
All stages Without weight loss/fever/sweats- A
divided

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 With weight loss/fever /sweats-B

Diagnostic Evaluation
 History collection and physical examination-As many manifestation are similar to
those occuring with infection, so, the patient is assessed for any B symptoms, physical
examination requires a careful, systematic evaluation of all palpable lymph node .
 Chest x-ray
 Computed tomography (CT scan) of chest, abdomen and pelvis.
 PET Scan
 Blood test, (CBC, platelets count, ESR, LFT, KFT)
 A bone marrow aspiration, where a small amount of liquid is taken from bone marrow
and tested
 A lumbar puncture (spinal tap), where a small amount of fluid from the spine is
removed and tested
 An abdominal ultrasound
 Bone marrow biopsy is performed if there are sign of marrow involvement , and
some physician also performed bilateral biopsies , it is thought that unilateral biopsies
may sometimes gives false result.
 Bone scans .

TREATMENT
 The goal in the treatment of Hodgkin lymphoma is cure. Treatment of limited-stage
Hodgkin lymphoma commonly involves a short course (2 to 4 months) of
chemotherapy followed by radiation therapy to the specific involved area. This
strategy has reduced the amount of radiation dosage, with subsequent decrease in long-
term side effects
 Combination chemotherapy with doxorubicin (Adriamycin), bleomycin (Blenoxane),
vinblastine (Velban), and dacarbazine (DTIC), referred to as ABVD, is considered the
standard treatment for more advanced disease (stages III and IV and all stages with B
symptoms).
 Other combinations of chemotherapy may afford higher response rates but result in
more toxicity, In addition, chemotherapy is often successful in obtaining remission
even when relapse occurs.
 Transplantation is used for advanced or refractory disease. Revised treatment
approaches are aimed at diminishing the risk of complications without sacrificing the
potential for cure.
 Because most patients diagnosed with Hodgkin lymphoma are either cured or
experience prolonged remissions, and thus live for many years post diagnosis, much is
now known about the long-term effects of chemotherapy and radiation therapy. The

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 development of complications may not occur for years after treatment; therefore, long-
term surveillance is crucial. In large population-based studies of Hodgkin lymphoma
survivors, the estimated risk of developing a second cancer was between 18% and 26.

NON-HODKIN LYMPHOMAS
The NHLs are a heterogeneous group of cancers that originate from the neoplastic growth of
lymphoid tissue. Most NHL involve malignant B lymphocytes and only 5% T lymphocytes.
In contrast to Hodgkin lymphoma, the lymphoid tissues involved are largely inhalated with
malignant cells. The spread of these malignant lymphoid cells occurs unpredictably, and true
localized dis- ease is uncommon. Lymph nodes from multiple sites may be infiltrated, as may
sites outside the lymphoid system.
Types of Non-Hodgkin Lymphoma-
Aggressive lymphomas
Aggressive lymphomas advance more quickly than indolent lymphomas. Patients with
aggressive lymphomas often develop symptoms sooner and require treatment immediately
after their diagnosis. Based on the subtype of lymphoma, symptoms may vary from enlarged
lymph nodes and weight loss to broader bone and skin issues. That said, aggressive
lymphomas tend to respond well to cancer treatments.

The subtypes of NHL that are usually considered aggressive include:

 Diffuse large B-cell lymphoma

 Mantle cell lymphoma

Indolent lymphomas
Indolent lymphomas advance more slowly than aggressive lymphomas, and they often don’t
cause apparent symptoms early on.

Many indolent lymphomas respond well to treatment, but they are usually challenging
remove completely. Treatment may not need to be initiated right away for these cancers.
When treatment is delayed, your care team will closely monitor the cancer’s progress and
recommend starting treatment if any problems or complications arise. Symptoms may vary
widely based on the subtype of the disease.

The subtypes of NHL that are usually considered indolent include:

 Follicular lymphoma
 Cutaneous T-cell lymphoma
 Lymphoplasmacytic lymphoma
 Marginal zone B-cell lymphoma
 MALT lymphoma
 Small-cell lymphocytic lymphoma

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Burkitt lymphoma
Burkitt lymphoma is considered the most aggressive form of lymphoma and is one of the
fastest growing of all cancers. But it is very rare, accounting for about 2 percent of all
lymphoma diagnoses. The disease originates in mature B-lymphocytes, which are cells of the
acquired immune system that produce antibodies to help fight off disease. Burkitt lymphoma,
a type of non-Hodgkin lymphoma, is most often diagnosed in young adults and children,
especially male. But certain types of Burkitt lymphoma have been diagnosed in adults,
especially those with a weakened immune system. The disease is named for Denis Burkitt,
the British surgeon who first identified the cancer in African children in the late 1950s.

The symptoms of Burkitt lymphoma vary greatly and depend on the disease’s type.
Symptoms may spread or worsen quickly as this aggressive cancer advances. Patients with
endemic Burkitt lymphoma may have swelling or disfigurement in the jaw or face. Patients
with sporadic Burkitt lymphoma may have swelling or pain in the abdomen. The disease may
also spread quickly to the central nervous system and brain, causing severe neurological
symptoms, including paralysis.

Other symptoms include:

 Swollen lymph nodes

 Night sweats
 Fever
 Fatigue
 Loss of appetite
 Weight loss

A biopsy, usually of an infected lymph node, is required for an accurate diagnosis if Burkitt
lymphoma is suspected

INCIDENCE
There are geographical variations in the incidence of individual subtypes, with follicular
lymphoma being more common in Western countries and T cell lymphoma more common in
Asia.
Overall, Non-Hodgkin lymphoma is common in ages 65 to 74, the median age being 67
years.
NHL is the seventh most common type of cancer diagnosed in the United States; incidence
rates have almost doubled in the past 35 years.
The incidence increases with each decade of life; the median age at diagnosis is 65 years .
Although no common etiologic factor has been identified, the incidence of NHL has
increased in people with immunodeficiencies or autoimmune disorders; prior treatment for
cancer; prior organ transplant; viral infections.
Recent study found that individuals who consumed more than 40 grams of alcohol weekly
and were obese had a worse prognosis for both diffuse large B-cell lymphoma and Follicular
lymphoma.

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Smoking was also associated with a worse prognosis and based on duration of smoking and
cigarette consumption (number smoked per day and pack-year history). In addition, those
who recently quit smoking had a worse prognosis than those who quit a longer time ago.

CLINICAL MANIFESTATION
 Symptoms are highly variable, reflecting the diverse nature of the NHLs.
Lymphadenopathy is most common; however, in indolent types of lymphomas, the
lymphadenopathy can wax and wane.
 In early-stage disease, or with the types that are considered indolent, symptoms may
be virtually absent or very minor, and the illness typically is not diagnosed until it
progresses to a later stage, when the patient is symptomatic. At these stages (III or
IV), lymphadenopathy is distinctly noticeable.
 One third of patients with NHLs have symptoms (fever, drenching night sweats, and
unintentional weight loss).
 Lymphomatous masses can compromise organ function. For example, a mass in the
mediastinum can cause respiratory distress; abdominal masses can compromise the
ureters, leading to renal dysfunction; and splenomegaly can cause abdominal
discomfort, nausea, early satiety, anorexia, and weight loss. Involvement of the CNS
with lymphoma becoming increasingly common.
Assessment and diagnostic Findings
The actual diagnosis of NHL, is categorized into a highly complex classification system
based on histopathology, immunophenotyping, and cytogenetic analyses of the malignant
cells.
The specific histopathologic type of the disease has important prognostic implications.
Treatment also varies and is based on these features.
Indolent types tend to have small cells that are distributed in a circular or follicular pattern.
Aggressive types tend to have large or immature cells distributed through the nodes in a
diffuse pattern.
Staging is typically based on data obtained from CT and PET scans, bone marrow biopsies,
and occasionally cerebrospinal fluid analysis.
The stage is based on the site of disease and its spread to other sites. For example, in stage I
disease, only one area of involvement is detected; thus, stage I disease is highly localized and
may respond well to localized therapy (e.g., radiation therapy). In contrast, in stage IV,
disease at least one extra nodal site is detected.
Although stage of disease is important, often it is not an accurate predictor of prognosis. Two
prognostic classification systems have been developed that are particularly useful in the older
patient population: the International Prognostic Index (IPI) and, for follicular lymphomas, the
Follicular Lymphoma Inter-national Prognostic Index (FLIPI). Age, performance status,

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lactate dehydrogenase levels, stage of disease, and extra nodal involvement are scored to
determine risk of failure or death from disease.
In details certain findings done to evalute Non Hodgkin Lymphoma;
 Complete blood count: May show anemia, thrombocytopenia, leukopenia,
pancytopenia, lymphocytosis, and thrombocytosis. These changes in peripheral blood
counts can be due to extensive bone marrow infiltration, hypersplenism from splenic
involvement, or blood loss from gastrointestinal tract involvement.
 Serum chemistry tests: Can help rule out tumor lysis syndrome, commonly in
rapidly proliferative NHL such as Burkitt or lymphoblastic lymphoma. Lactate
dehydrogenase levels can also be elevated due to high tumor burden or extensive
infiltration of the liver.
 Imaging: usually a CT scan of the neck, chest, abdomen, and pelvis or a PET scan.
Dedicated imaging, such as an MRI of the brain and spinal cord or testicular
ultrasound, might be needed.
 Lymph node and/or tissue biopsy: A lymph node should be considered for a biopsy
if one or more of the following lymph node characteristics is present: significant
enlargement, persistence for more than four to six weeks, progressive increase in
size. In general, lymph nodes greater than 2.25 cm (i.e., a node with bi perpendicular
diameters of 1.5 x 1.5 cm) or 2 cm in a single diameter provide the best diagnostic
yields. Excisional lymph node biopsy is the gold standard for diagnosis. Fine needle
aspiration of the lymph node is avoided. An excisional biopsy of an intact node
allows sufficient tissue for histologic, immunologic, and molecular biologic
assessment and classification by hematopathologists. Specific yields of peripheral
lymph nodes in patients who are subsequently proven to have NHL are as follows:
supraclavicular nodes are 75 to 90 percent, cervical and axillary nodes are 60 to 70
percent, and inguinal nodes are 30 to 40 percent.
 Lumbar puncture: usually reserved in those with a high risk of CNS involvement,
i.e., highly aggressive NHL (Burkitt lymphoma, lymphoma, grade 3b FL, mantle cell ,
precursor T or B lymphoblastic leukemia/lymphoma, human immunodeficiency virus
(HIV)-positive NHL), who have epidural, bone marrow, testicular, or paranasal sinus
involvement, or at least two extranodal disease sites. CSF should be sent for both
cytology and flow cytometry.
 Immunophenotypic analysis of lymph node: peripheral blood, and bone marrow.
The tumor cells in Burkitt lymphoma express surface immunoglobulin (Ig) of the IgM
type and immunoglobulin light, B cell-associated antigens (CD19, CD20, CD22,
CD79a).
TREATMENT
Treatment is determined by the classification of disease, the stage of disease, prior treatment
(if any), and the patient's ability to tolerate therapy. Tolerance to therapy is largely indictated
by renal, hepatic, and cardiac function; the presence of concurrent diseases, functional status;
and age.
If the disease is not aggressive and is localized, radiation alone may be the treatment of
choice. With aggressive types of NHL, aggressive combinations of chemotherapeutic agents
are used; R-CHOP-the combination of the monoclonal antibody rituximab (Rituxan) with
conventional chemotherapy (cyclophosphamide [Cytoxan], doxorubicin, vincristine, and
prednisone) is now considered standard treatment for common lymphomas.

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CNS involvement is common with some aggressive forms of NHL; in this situation, cranial
radiation or intrathecal chemotherapy is used in addition to systemic chemotherapy. Survival
is very low when relapse occurs after being treated with rituximab-based regimens or with
transplantation.
There is no standard therapy for follicular lymphoma "Watchful waiting," symptoms develop,
has often been used in those with indolent ,"
More recently, immunotherapy (e.g., rituximab) is delayed until being used, often in
combination with conventional chemotherapy. Radiopharmaceutical agents (e.g.,
ibritumomab tiuxetan [Zevalin] or tositumomab/iodine-131 [Bexxar]) are also used, although
they cause technical difficulties with administration due to the radioactivity of the agent.
More aggressive treatment (often R-CHOP or rituximab plus bendamustine [Levact]) may
provide a longer duration of remission in which additional treatment is not needed.
Unfortunately, in most situations, relapse is commonly seen in patients with low-grade
lymphomas. Treatment after relapse is controversial; HSCT may be considered for patients
younger than 60 years.
Complication
Life-threatening emergent complications of NHL should be considered during the initial
workup and evaluation. Early recognition and prompt therapy are critical for these situations,
which may interfere with and delay treatment of the underlying NHL. These can include:
 Febrile neutropenia
 Hyperuricemia and tumor lysis syndrome - Presents with fatigue, nausea, vomiting,
decreased urination, numbness, tingling of legs, and joint pain. Laboratory findings
include an increase in uric acid, potassium, creatinine, and phosphate and a decrease
in calcium levels. This can be prevented with vigorous hydration and allopurinol.
 Spinal cord or brain compression
 Focal compression depending on the location and type of NHL - airway obstruction
(mediastinal lymphoma), intestinal obstruction and intussusception, ureteral
obstruction
 Superior or inferior vena cava obstruction
 Hyperleukocytosis
 Adult T-cell leukemia-lymphoma can cause hypercalcemia.
 Pericardial tamponade
 Lymphoplasmacytic lymphoma with Waldenstrom macroglobulinemia can cause
hyperviscosity syndrome.
 Hepatic dysfunction
 Venous thromboembolic disease
 Autoimmune hemolytic anemia and thrombocytopenia - can be observed with small
lymphocytic lymphoma

Nursing diagnosis

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  Impaired Gas Exchange related to mediastinal mass compression, leading to
compromised lung function and impaired oxygenation.
 Acute Pain related to lymph node enlargement, pressure on surrounding tissues, and
possible infiltration of the bone marrow.
 Fatigue related to anemia, disease progression, and cancer treatment side effects.
 Risk for Infection related to compromised immune system function due to the
underlying disease and cancer treatments.
 Disturbed Body Image related to visible lymph node enlargement, changes in physical
appearance, and potential hair loss from chemotherapy.
 Anxiety related to the uncertainty of the disease prognosis, fear of treatment
outcomes, and potential disruptions in daily life.
 Deficient Knowledge regarding lymphoma, treatment options, and self-care
management.
 Risk for Impaired Skin Integrity related to pruritus (itching) associated with Hodgkin
lymphoma and its treatment.
 Ineffective Coping related to the emotional impact of the diagnosis, treatment, and
potential treatment-related side effects.
 Risk for Altered Nutrition: Less Than Body Requirements related to anorexia, nausea,
and difficulty eating due to the disease and its treatments.

Nursing Interventions:

1. Monitor Respiratory Status:

 Assess and document the patient’s respiratory rate, effort, and oxygen saturation
regularly to detect any signs of impaired gas exchange or respiratory distress.
2. Manage Pain:
 Implement pain management strategies, including administering prescribed analgesics
and providing comfort measures to alleviate pain associated with lymph node
enlargement and other symptoms.
3. Address Fatigue:
 Collaborate with the healthcare team to develop an activity plan that balances rest and
exercise, and provide energy conservation techniques to manage fatigue effectively.
4. Prevent Infection:
 Educate the patient and family on infection prevention strategies, such as hand
hygiene, avoiding crowds and sick individuals, and receiving necessary vaccinations
as approved by the healthcare provider.

5.Provide Emotional Support:

 Offer emotional support to the patient and their family, acknowledging their fears and
concerns about the diagnosis and treatment. Refer them to counselling or support
groups as needed.

6. Educate on Hodgkin Lymphoma and Treatment:

 Provide the patient and family with comprehensive education about Hodgkin
lymphoma, its stages, treatment options, potential side effects, and expected
outcomes.

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7. Promote Body Image Acceptance:

 Encourage the patient to express feelings about body changes, such as lymph node
enlargement or hair loss, and provide information about resources like wig banks or
support groups to enhance body image acceptance.

8. Implement Anxiety-Reducing Interventions:

 Offer relaxation techniques, deep breathing exercises, or mindfulness practices to help

manage anxiety and promote a sense of calm during treatment.

9. Provide Pruritus Relief:

 Offer strategies to relieve pruritus, such as providing cool compresses, using mild
moisturizers, and ensuring a comfortable environment.

10. Foster Coping Strategies:

 Encourage the patient to explore coping mechanisms that work for them, such as
journaling, art therapy, or engaging in hobbies, to navigate the emotional challenges
of the disease.

11. Nutritional Support:

Collaborate with the dietitian to create a balanced diet plan tailored to the patient’s nutritional
needs and preferences to maintain adequate nutrition during treatment.

Conclusion

Lymphoma is a cancer of the lymphatic system. The lymphatic system is part of the body's
germ-fighting and disease-fighting immune system. Lymphoma begins when healthy cells in
the lymphatic system change and grow out of control. The lymphatic system includes lymph
nodes. They are found throughout the body. Most lymph nodes are in the abdomen, groin,
pelvis, chest, underarms and neck. The lymphatic system also includes the spleen, thymus,
tonsils and bone marrow. Lymphoma can affect all these areas and other organs in the body.

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Brunner and Siddhartha, Medical surgical Nursing, Jaypee publisher, pageno.967-972,

American join committee on cancer: AJCC Cancer staging manual,5th ed, cooper is, Henson Deet
al(Eds),Philadelphia;Lippincot-raven,1997

http//medicine Medscape.com

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