Hodgkin's Disease

Gayapa, Al Quin S.Bongcaras, Eunice Phoebe B.

Cumayas, Sarah N.Jumamoy, Danilyn L.Reroma, Fairylane P.

Group 6BSN IV-D

HODGKIN’S DISEASE

Hodgkin's disease is a type of lymphoma.

Lymphoma is cancer of the lymphatic system and is the third most common type of cancer in kids and teens ages 10 to 14. But it is still very rare for kids to get it. The lymphatic system is the system in the body that is responsible for fighting off infections and keeping you healthy. It's made up of your tonsils, spleen, bone marrow, and chains of lymph nodes (rounded masses of tissue found throughout the body). Although many types of cancer can spread to the lymph system, lymphoma actually begins in the cells of the lymph system itself.

Definition

What differentiates Hodgkin's lymphoma is the presence of Reed-Sternberg cells in the cancerous tissue. The presence of these cells, detectable only through an open biopsy, is the defining characteristic of Hodgkin's disease, as opposed to non-Hodgkin's lymphoma. Hodgkin's disease is named for Dr. Thomas Hodgkin, who described several cases of the cancer within the lymph system in 1832. About 40 years later, other doctors began to report different types of lymphomas.

Definition

Types of Hodgkin’s Disease• Nodular Sclerosing Hodgkin Lymphoma (NSHL):

This is the most common type of Hodgkin Lymphoma. In the developed countries 60-80% of the people affected by Hodgkin disease have the Nodular Sclerosing subtype. It is commoner in females and mostly affects younger people – adolescents and young adults. The disease mainly affects nodes in the neck or armpits, or within the chest.

Definition

• Mixed Cellularity Hodgkin Lymphoma (MCHL): This is another common type of Hodgkin Lymphoma. 15-30% of those affected have mixed cellularity disease. This type is more common in developing countries. 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 variety, and less likely to involve nodes within the chest.

Definition

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

Definition

• 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 thirties or forties. Most individuals are diagnosed in early stages and response to treatment is excellent.

Definition

• 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 variant accounts for 4-5% of all cases of Hodgkin disease. According to pathologists this type has many similarities with Non-Hodgkin Lymphoma (NHL). In all clinical aspects, however, the features are similar to the lymphocyte-rich type of Hodgkin lymphoma. Most individuals are diagnosed early and do very well after treatment.

Definition

According 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 cancers. Nevertheless, this is a still a significant disease worldwide and incidents

are on the rise.

Incidence

Hodgkin ' s disease is considered one of the most curable forms of cancer, especially if it is diagnosed and treated early. Unlike other cancers, Hodgkin's disease is even

potentially curable in late stages Five-year survival rates 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 rates of 90%, although it is not yet certain if their cancer will return.

Patients who survive 15 years after treatment are more likely to later die from other causes than Hodgkin ' s

disease.

Prognosis

Survival rates are poorest for:

Those who relapse within a year of treatment

Patients who do not respond to the first-line

therapy and have signs of disease progression

Prognosis

Age (between ages 15 and 40 and greater than 55) Family history (first-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 organ transplant) Geography (U.S., Canada, Northern Europe) Socioeconomic status (higher background) Occupation (seen in woodworkers and those veterans of the military who were exposed to herbicide agent orange)

Risk Factors

The exact cause of Hodgkin's lymphoma is UNKNOWN.

Infectious agents, particularly 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 immunodeficiency syndrome (AIDS)-defining neoplasm.

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

Etiology

A key step in Hodgkin's lymphoma involves the development of abnormal B cells. B cells are a type of

lymph cell that's an important part of your immune system's response to foreign invaders. B cells normally work with T

cells, which mature in the thymus, to fight infection.

Etiology

When B cells develop into large abnormal cells, these abnormal, cancerous cells are called REED-STERNBERG CELLS. Instead of undergoing the normal cell cycle of life

and death, Reed-Sternberg cells don't die, and they continue to produce abnormal B cells in a malignant

process. These cells also attract other normal immune cells that cause the lymph nodes to enlarge.

Etiology

Painless swelling of lymph nodes in your neck,

armpits or groin Persistent fatigue; weakness and tenderness that doesn't go away Fever and chills that doesn't go away Soaking Night sweats Unexplained weight loss — as much as 10 percent 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 after drinking alcohol

Clinical Manifestations

Medical history and physical examBiopsy 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 part of a larger tumor or node (incisional biopsy). If the node is near the skin surface, this is a fairly simple operation that can sometimes be done with numbing medicine (local anesthesia). But if the node is inside the chest or abdomen, the patient is given general anesthesia (where he or she is in a deep sleep).

Diagnostic Studies


2. Fine needle aspiration (FNA) or core needle biopsy: In an FNA biopsy, the doctor uses a very thin needle attached to a syringe to withdraw (aspirate) 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 larger needle to remove a slightly larger piece of tissue. For an enlarged node near the surface 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 tomography (CT) scan or ultrasound (see discussion of imaging tests later in this section).

Diagnostic Studies


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

Lab tests used to diagnose and classify 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 determines if any of them are Reed-Sternberg cells.)

Immunohistochemistry (certain proteins, such as CD15 and CD30, on the surface of the Reed-Sternberg cells)

Diagnostic Studies

Staging Hodgkin's diseaseStage I. The cancer is limited to one lymph node region

or a single organ.

A. Without the “B symptoms”

B. With the “B 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 diaphragm. (classification, same with stage I)

Stage III. When the cancer moves to lymph nodes both above and below the diaphragm, but hasn't spread from the lymph nodes to other organs, it's considered stage III.

Diagnostic Studies

Staging Hodgkin's diseaseStage 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 parts of your body, such as the bone marrow or your liver.

-Additional definitions of the cancer (A,B,S & E)

The letter A means that you don't have any significant symptoms as a result of the cancer.

Diagnostic Studies

Staging Hodgkin's disease

The letter B indicates that you may have significant signs and symptoms, such as a persistent fever greater than 100 F with no other known cause, unintended weight loss of more than 10 percent of your body weight or severe night sweats.

The letter E stands for extranodal, which means that the cancer has spread beyond your lymph nodes.

The letter S designates a cancer that has spread into your spleen.

==The letters B, E and S indicate potentially more serious disease.==

Diagnostic Studies

The treatment the doctor recommends depends in large part on the patient's age when they are diagnosed, the stage of the disease, whether or not the disease is bulky, and other prognostic factors.

Stage IA and IIA (Favorable): chemotherapy (usually 2 to 4 cycles of the ABVD –adriamycin, bleomycin, vinblistine, dacarbazine- regimen), followed by involved field radiation to the initial site of the diseaseStages IB and IIB (Unfavorable): chemotherapy (usually ABVD for 4 to 6 cycles or other regimens such as Stanford V). PET/CT scans are often done after several cycles of chemotherapy to determine how much more treatment you need

Medical Management

Stages III and IV: chemotherapy at full doses; although ABVD (for at least 6 cycles) can be used, some doctors favor more intense treatment with the Stanford V or BEACOPP regimen which includes:

Bleomycin, an anti-tumor antibiotic Etoposide, a DNA toxin Adriamycin (Doxorubicin), an anti-tumor antibiotic mustard derivative such as Cyclophosphamide Vinblastine or Vincristine (Oncovin), an alkaloid cell

toxin Procarbazine, an alkylating agent Prednisone, a corticosteroid

Medical Management

Resistant Hodgkin disease: Once initial treatment is complete, the doctor will probably do further tests to look for any signs of Hodgkin disease, such as PET and CT scans. If the Hodgkin disease is still there, most experts think that more of the same treatment is unlikely to cure the patient. Recurrent or relapsed Hodgkin disease:

o Radiation usually cannot be repeated in the same area.

o If the initial treatment was radiation therapy without chemotherapy, chemotherapy is usually given for recurrent disease.

o Chemotherapy with different drugs may be another option.

Medical Management

Radiation therapy: When the disease is confined to a limited area, radiation therapy may be the treatment of choice. It's typical to radiate the affected nodes and the next area of nodes where the disease might progress. The length of radiation treatment varies depending on the stage of the disease.

Chemotherapy: When the disease progresses and involves more lymph nodes or other organs, chemotherapy is the preferred treatment. Chemotherapy uses specific drugs in combination to kill tumor cells. A major concern with chemotherapy is the possibility of long-term side effects and complications.

Treatment Modalities

Chemotherapy regimens are commonly referred to by their initials, such as:

ABVD, which consists of doxorubicin (Adriamycin ), bleomycin, vinblastine anddacarbazine

BEACOPP, which consists of bleomycin, etoposide, Adriamycin, cyclophosphamide, vincristine (Oncovin), procarbazine and prednisone

COPP/ABVD, which consists of cyclophosphamide, Oncovin, procarbazine, prednisone, Adriamycin, bleomycin, vinblastine and dacarbazine


Chemotherapy regimens are commonly referred to by their initials, such as:

Stanford V, which consists of Adriamycin, vinblastine, mechlorethamine, etoposide, vincristine, bleomycin and prednisone

MOPP, which consists of mechlorethamine, Oncovin, procarbazine and prednisone

MOPP had been the basic regimen, but it's very toxic. ABVD is a newer regimen, with less-severe side effects, and is currently the preferred treatment.


Bone Marrow Transplant: If the disease recurs after an initial chemotherapy-induced remission, high-dose chemotherapy and transplantation of your own (autologous) bone marrow or peripheral stem cells may lead to prolonged remission. Peripheral stem cells are bone marrow cells mobilized from the bone marrow into the bloodstream.

Because high doses of chemotherapy destroy bone marrow, your own marrow or peripheral blood stem cells are collected before treatment and frozen. You'll undergo chemotherapy, and then your own cells, which have been protected from the effects of the treatment, are injected back into your body.


Risk for Infection related to impaired primary and secondary defenses

Ineffective Airway Clearance R/T physical obstruction by tumor

Imbalanced Nutrition: less than body requirements R/T increased metabolic demands of neoplastic

process Hyperthermia R/T suppressed the immune system

Impaired Comfort: pruritis R/T inflammation in tissues

Chronic Pain R/T presence of tumor

Nursing Diagnosis

To protect the skin receiving radiation, avoid rubbing, powders, deodorants, lotions, or ointments (unless prescribed) or application of heat or cold. Encourage patient to keep clean and dry, and to bathe the area affected by radiation gently with tepid water and mild soap. Encourage wearing loose-fitting clothes and to protect skin from exposure to sun, chlorine, and temperature extremes. Use soap sparingly if the skin is already dry. Apply cool compresses on the itching skin or have patient sit in cool bath water for relief.

Nursing Interventions

Applying compresses of starch solutions, such as oatmeal, may help relieve itching. Keep fingernails short to prevent damage to skin from scratching. Keep pruritic areas open to air. Encourage mouth care at least twice per day and after meals using a soft toothbrush and mild mouth rinse to prevent stomatitis. Assess for ulcers, plaques, or discharge that may be indicative of superimposed infection. Make regular physical inspections of patient's oral structures and monitor for inflammation or infection secondary to his/her compromised immune system


Teach patient about risk of infection. Advice patient to monitor temperature and report any fever or other sign of infection promptly. Teach the patients to avoid irritants such as alcohol, tobacco, spices, and extremely hot or cold foods. Assess the patient for nutritional deficiencies and malnutrition. Weigh weekly and record. Offer small meals at frequent intervals throughout the day to help deal with fatigue of eating. For children, offer finger foods that are easy for them to eat.


Offer high protein supplements between meals. Offer the patient grapefruit juice, orange juice, ginger ale to alleviate nausea and vomiting. To protect oral and gastro-intestinal tract mucous membranes, encourage frequent, small meals, using bland and soft diet at mild temperatures and to drink plenty of fluids. For diarrhea, switch to low-residue diet and administer anti-diarrheals as ordered. Monitor the rate and character of patient's respirations. Keep the head of the bed elevated 30 to 45 degrees to facilitate patient's breathing efforts.


If there is likelihood of sputum production, teach patient how to deep breathe and cough to help clear the airway. Observe the color, volume and odor of any sputum produced. Provide emotional support when the patient is short of breath. Perform comfort measures that promote relaxation. Explain all the procedures and treaments associated with the plan of care. If the patient is a woman of childbearing age, advise her to delay her pregnancy until long-term remission occurs.


Instruct the patient to pace his activities to counteract therapy induced fatigue. Advise the patient to avoid crowds and any person with a known infection. Make sure that the patient understands the possible adverse effects of his treatments. Advise the patient to seek follow-up care after he has completed the initial treatment. Explain to patient that radiation therapy may cause sterility. Administer or teach self-administration of pain medication or antiemetic before eating or drinking, if needed.


Assess the patient's level of pain using a numerical pain rating scale or a face pain rating scale. If patient is young and cannot accurately report pain, document and observe for behaviors that may indicate the presence of pain. Assess and document the location, intensity and any activity that acerbates the pain. Plan for patient to perform ADLs around those times when the patient experiences greatest comfort from pain. Assist the patient with ADLs as necessary due to fatigue.


End of Presentation

•http://www.umm.edu/patiented/articles/how_serious_hodgkins_disease_000083_5.htm

•http://nursingfile.com/nursing-care-plan/nursing-interventions/nursing-interventions-for-hodgkin%E2%80%99s-disease.html

•http://allnurses.com/nursing-student-assistance/help-care-plan-181977.html

•http://gino-memoirofaschizo.blogspot.com/2010/07/nursing-care-plan-ncp-hodgkins-disease.html

•http://nursingcrib.com/nursing-notes-reviewer/hodgkin%E2%80%99s-disease/

•http://www.medicinenet.com/hodgkins_disease/page2.htm#symptoms

•http://www.mayoclinic.com/health/hodgkinsdisease/DS00186/DSECTION=symptoms

•http://www.mayoclinic.com/health/hodgkinsdisease/DS00186/DSECTION=causes

•http://emedicine.medscape.com/article/201886-overview#aw2aab6b2b3

•http://www.mayoclinic.com/health/hodgkins-disease/DS00186/DSECTION=risk-factors

•http://www.lymphomainfo.net/hodgkins/incidence.html

•http://kidshealth.org/kid/cancer_center/cancer_basics/hodgkins.html

References

•http://www.umm.edu/patiented/articles/how_serious_hodgkins_disease_000083_5.htm

•http://nursingfile.com/nursing-care-plan/nursing-interventions/nursing-interventions-for-hodgkin%E2%80%99s-disease.html

•http://allnurses.com/nursing-student-assistance/help-care-plan-181977.html

•http://gino-memoirofaschizo.blogspot.com/2010/07/nursing-care-plan-ncp-hodgkins-disease.html

•http://nursingcrib.com/nursing-notes-reviewer/hodgkin%E2%80%99s-disease/

•http://www.medicinenet.com/hodgkins_disease/page2.htm#symptoms

•http://www.mayoclinic.com/health/hodgkinsdisease/DS00186/DSECTION=symptoms

•http://www.mayoclinic.com/health/hodgkinsdisease/DS00186/DSECTION=causes

•http://emedicine.medscape.com/article/201886-overview#aw2aab6b2b3

•http://www.mayoclinic.com/health/hodgkins-disease/DS00186/DSECTION=risk-factors

•http://www.lymphomainfo.net/hodgkins/incidence.html

•http://kidshealth.org/kid/cancer_center/cancer_basics/hodgkins.html

References

Documents

Hodgkin's Disease