Lymphoma, Non-Hodgkin

DRG Category:	824
Mean LOS:	8.1 days
Description:	SURGICAL: Lymphoma and Non-Acute Leukemia With Other OR Procedure With CC
DRG Category:	841
Mean LOS:	6.4 days
Description:	MEDICAL: Lymphoma and Non-Acute Leukemia With CC

Malignant lymphoma, also called lymphosarcoma or non-Hodgkin lymphoma (NHL), is a diffuse group of neoplastic diseases characterized by rampant proliferation of lymphocytes. Lymphomas fall into two main categories: Hodgkin and non-Hodgkin lymphomas, based primarily on the presence or absence of the Reed-Sternberg cell; when the cells are absent, the disease is classified as NHL (Table 1).

Comparison of Hodgkin Lymphoma and Non-Hodgkin Lymphoma

Table 1. Comparison of Hodgkin Lymphoma and Non-Hodgkin Lymphoma
CHARACTERISTIC	HODGKIN	LOW-GRADE NON-HODGKIN	ALL OTHER NON-HODGKIN
Site(s) of origin nodal distribution	Nodal axial (centripetal)	Extranodal, about 10% centrifugal	Extranodal, about 35% centrifugal
Nodal spread	Contiguous	Noncontiguous	Noncontiguous
Central nervous system involvement	Rare, < 1%	Rare, < 1%	Uncommon, < 10%
Hepatic involvement	Uncommon	Common, > 50%	Uncommon, < 10%
Bone marrow involvement	Uncommon, < 10%	Common, > 50%	Uncommon
Marrow involvement adversely affects prognosis	Yes	No	Yes
Curable by chemotherapy	Yes	No	Yes

Nearly 70,000 people are diagnosed with NHL in the United States annually. In the past 30 years, the incidence of NHL has increased by more than 80%, making it one of the largest increases of any cancer. This increase is unexpected and is only partially explained by earlier detection because of improved diagnostic techniques or HIV-associated lymphomas.

Malignant lymphoma, or NHL, is a heterogeneous grouping of several disease types that range from the aggressive, rapidly fatal diffuse histiocytic lymphoma to the indolent nodular varieties. Still, all have a less promising prognosis than Hodgkin lymphoma. NHL can be divided in two groups based on prognosis: indolent lymphomas and aggressive lymphomas. Indolent lymphomas have a comparatively good prognosis with a survival time of up to 10 years. Most are nodular (or follicular) in nature. People with aggressive lymphoma have a poor overall prognosis, although a number of these patients can be cured with chemotherapy. Complications of NHL include hypercalcemia, increased uric acid levels, meningitis, and anemia. As tumors grow, they may compress the vital organs and cause organ dysfunction; problems from organ compression include complications such as increased intracranial pressure.

Causes

The cause of NHL is unknown. Exposures to viruses and immunosuppression are thought to be related to NHL. Organ transplantation, a history of cancer treated with radiation, acquired immune deficiencies, and autoimmune disorders are considered risk factors. Some believe that both Hodgkin lymphoma and NHL result from an immune defect or from the activation of an oncogenic virus. One form of NHL, Burkitt’s lymphoma, seems to be related to a herpes virus (Epstein-Barr virus). Exposure to nuclear explosions or reactor accidents, certain pesticides and herbicides, and chemicals (benzene, lead, paint thinner, and formaldehyde) may place patients at risk.

Genetic considerations

A family history of NHL as well as other cancers increases one’s risk of developing disease, but the amount of increased risk and the mechanism by which it occurs remain unclear. There also appear to be sporadic forms of the disease, but little information is available on phenotypic differences. There are known somatic mutations associated with NHL.

Gender, ethnic/racial, and life span considerations

The peak incidence of NHL occurs later than with Hodgkin lymphoma, which is more common in men than in women and is a disease of the middle years. About 25% of cases develop in patients between ages 50 and 59. Maximal risk is between the ages 60 and 69. Small lymphocytic lymphomas occur in the elderly, lymphoblastic lymphomas occur most often in males younger than age 20, and follicular lymphomas are uncommon in the young. Burkitt’s lymphoma occurs in children and young adults. Whites have a higher risk than African Americans and Asian Americans.

Global health considerations

In North America, the incidence of NHL is increasing. Burkitt’s lymphoma is most common in sub-Saharan Africa, where it is likely responsible for 50% of childhood cancers.

Assessment

History

Note any history of infection with HIV, AIDS, organ transplant, congenital immunodeficiency, autoimmune diseases, or other treatment with immunosuppressive drugs. Patients often have complaints of painless enlarged lymph nodes (commonly in the neck, mediastinum, or chest wall), fevers, night sweats, weight loss, weakness, and malaise. Because nodes and extranodal sites are more likely to be involved in NHL, the patient may also report vague abdominal distress (bleeding, bowel obstruction, cramping, ascites), symptoms of spinal cord compression, or back pain. Cough, dyspnea, and chest pain occur about 20% of the time and are indicative of lung involvement.

Physical examination

Carefully inspect all the locations for lymph nodes and the abdomen for signs of hepatosplenomegaly and ascites. Skin lesions that look like nodules or papules with a tendency to ulcerate appear in about 20% of cases. When palpating lymph node chains, examine the submental, infraclavicular, epitrochlear, iliac, femoral, and popliteal nodes. Involved nodes are characteristically painless, firm, and rubbery in consistency; they are in contrast to the rock-hard nodes of carcinoma because they are freely movable and of varying size. Palpate the liver or spleen, which may be enlarged. The patient may also have weight loss and fever.

Psychosocial

The diagnosis of cancer is devastating at any time of life. Because the disease is most common in the older adult, the patient may be planning retirement. The diagnosis of NHL throws all retirement plans into disarray and may lead to feelings of loss, grief, and anger.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Lymph node biopsy; bone marrow biopsy	Normal cells	Positive for lymphoma cells	Determines extent of disease and allows for staging of disease; bone marrow biopsy is generally done only for patients with anemia or fever and night sweats
Computed tomography (CT) or magnetic resonance imaging of chest, abdomen, and pelvis	Normal structures	Spread of NHL into organs and body cavities	Used to assist with staging; common sites of extralymphatic involvement include spleen, stomach, small intestine; combined with lymphangiography, can predict nodal involvement in 90% of cases
Lymphangiography: A radiographic test of lymphatic vessels and nodes; radiopaque iodine contrast medium is injected into lymphatics of foot or hand	Normal lymphatic system	Identification of structural abnormalities or tumor involvement	Test has been replaced in many situations by CT scanning but may still be used for staging; not usually performed in children

Other Tests: Complete blood cell count with peripheral smear and erythrocyte sedimentation rate (shows anemia, fluorescence in situ hybridization [FISH], leukocytosis, elevated platelet count, and erythrocyte sedimentation rate), chest x-ray; tests for liver and renal function, including lactate dehydrogenase, alkaline phosphatase, blood urea nitrogen, and creatinine; gallium scan

Primary nursing diagnosis

Diagnosis

Risk for infection related to impaired primary and secondary defenses

Outcomes

Immune status; Knowledge: Infection control; Risk control; Risk detection; Nutritional status; Tissue integrity: Skin and mucous membranes; Treatment behavior: Illness or injury

Interventions

Infection control; Infection protection; Surveillance; Nutritional management; Medication management; Teaching: Disease process

Planning and implementation

Collaborative

Treatment is based on classification of the cell and staging of the disease (see Hodgkin Lymphoma, Table 2, for staging). Some of the indolent types of NHL do well with only supportive therapy. The disease process may be slow enough that treatment is saved until the disease takes a more aggressive path. Most patients with intermediate-grade and high-grade lymphomas receive combination chemotherapy.

Radiation is effective for many patients with stage I or II NHL. Radiation is delivered to the chest wall, mediastinum, axilla, and neck (the region known as the mantle field). Most patients, however, are at stage III or IV at diagnosis. Surgery has limited use in the treatment of NHL. It may be part of the diagnostic and staging process, but diagnostic laparotomy is much less common than in Hodgkin lymphoma. A therapeutic splenectomy may be performed for severe spleen enlargement. Gastric or bowel resection may be done if the patient has a primary gastrointestinal lymphoma or has obstructions from bulky nodes. Stem cell transplantation may be considered for patients who have relapsed, are at high risk for relapse, or have tried conventional therapy without success.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Biological therapy	Varies with drug	Interferon and monoclonal antibodies	May slow disease progression
Chemotherapy	Varies with drug	Some common regimens are CHOP (cyclophosphamide doxorubicin, vincristine, prednisone); BACOP (bleomycin, doxorubicin, cyclophosphamide, vincristine, prednisone); and MACOP-B (methotrexate with leucovorin rescue factor, doxorubicin, cyclophosphamide, vincristine, prednisone, bleomycin, plus trimethoprim-sulfamethoxazole and ketoconazole)	Chemotherapy is used for stage IVA and all stage B patients; usually lasts for 6–8 mo

Other Drugs: Common side effects are alopecia, nausea, vomiting, fatigue, myelosuppression, and stomatitis. Patients who are receiving chemotherapy are administered antinausea drugs, antiemetics, and pain medicines as needed to help control adverse experiences. Experimental drugs currently in clinical trials include paclitaxel, topoisomerase-3 inhibitors, and nucleoside analogues.

Independent

Maintain the patient’s comfort, protect the patient from infection, provide teaching and support about the complications of the treatment, and provide emotional support. Fatigue, one of the most common side effects of cancer treatment, can last for several months to several years. A program called Fatigue Initiative Research and Education (FIRE) is available through the Oncology Nurses Society (http://www.ons.org).

During irradiation, the patient may suffer from dry mouth, loss of taste, dysphagia, nausea, and vomiting, which can be managed with frequent mouth care. Explore ways to limit discomfort, such as ice chips. Attempt to provide desired foods to support the patient’s nutrition. Keep any foul-smelling odors clear of the patient’s environment, particularly during meals. Manage skin irritation and redness by washing the skin gently with mild soap, rinsing with warm water, and patting the skin dry. Encourage the patient to avoid applying lotions, perfumes, deodorants, and powder to the treatment area. Explain that the patient needs to protect the skin from sunlight and extreme cold. Before starting treatments, arrange for the patient to have a wig, scarf, or hat to cover any hair loss, which occurs primarily at the nape of the neck.

If the patient develops bone marrow suppression, institute infection controls. Treat the discomfort that may arise from chemotherapy—joint pain, fever, fluid retention, and a labile emotional state (euphoria or depression)—all of which need specific interventions, depending on their incidence and severity. The complexity of the diagnostic and staging process may make the patient feel lost in a crowd of specialists. It is important for the nurse to provide supportive continuity. Patience and repeated explanations are needed. Provide the patient with information about support groups and refer the patient to a clinical nurse specialist, support groups associated with the American Cancer Society (http://www.cancer.org), or counselors.

Evidence-Based Practice and Health Policy

Drake, M.T., Maurer, M.J., Link, B.K., Habermann, T.M., Ansell, S.M., Micallef, I.N., …Cerhan, J.R. (2010). Vitamin D insufficiency and prognosis in non-Hodgkin’s lymphoma. Journal of Clinical Oncology, 28(27), 4191–4198.

Investigators conducted a prospective study among a cohort of 983 newly diagnosed patients with NHL and found that 44% of patients had insufficient circulating 25-hydroxyvitamin D levels less than 25 ng/mL. Mild to moderate vitamin D insufficiency (10 to 24 ng/mL) was identified in 38.7% of patients, and severe insufficiency (less than 10 ng/mL) was diagnosed in 5.6% of patients.
Vitamin D insufficiency was most prevalent in T-cell lymphoma (57.1%), followed by diffuse large B-cell lymphoma (51.9%), follicular lymphoma (38.6%), and mantle cell lymphoma (36.6%) (p = 0.02).
During a median follow-up period of 34.8 months (range, 0.5 to 77 months), 168 lymphoma-associated deaths occurred. Among patients with diffuse large B-cell lymphoma and T-cell lymphoma, vitamin D–deficient patients had inferior lymphoma-specific survival rates compared to those with normal vitamin D levels (p = 0.002 and p = 0.05, respectively).

Documentation guidelines

Emotional and physical response to diagnostic testing; healing of incisions; signs of ineffective coping; response to diagnosis; ability to participate in planning treatment options; response of significant others
Effects of chemotherapy or radiation therapy; response to treatment of symptoms; presence of complications (weight loss, infection, skin irritation)
Effectiveness of coping; presence of depression; interest in group support of counseling; referrals made

Discharge and home healthcare guidelines

Teach the patient the following strategies to limit infections: avoid crowds; avoid infected visitors, particularly children with colds; wash hands frequently; when an infection occurs, report it to a physician immediately; avoid direct contact with pets to limit the risk of infections from licks, scratches, or bites; do not change the cat litter or clean a birdcage.

Maintain a high-calorie and high-protein diet. Take sips of grapefruit juice, orange juice, or ginger ale if nausea persists. Drink at least 2,000 mL of fluid a day unless on fluid restriction.

Perform frequent mouth care with a soft toothbrush and avoid commercial mouthwashes. Contact support groups, the American or Canadian Cancer Society, or counselors as needed.