4.3 Hemato-oncologic Disorder

Question 1

Leukemia

Answer 1

• Unregulated proliferation of immature/abnormal WBC’s in bone marrow
• Malignant neoplasm of hematopoietic cells
• Proliferation occurs in bone marrow then spreads to lymph nodes, spleen, liver, etc

Question 2

Leukemia Types

Answer 2

• Characterized by predominant cell types

Lymphocytic vs Myelocytic
- Lymphocytic usually affects B-Cells and bone marrow stem cells
- Myelocytic affects blood forming cells in the bone marrow

Acute vs Chronic

Acute - Rapid increase of immature blood cells (usually blast cells)
(Acute Lymphocytic Leukemia or Acute Myelocytic Leukemia)

Chronic - Excessive buildup of mature but abnormal white blood cells
(Chronic Lymphocytic Leukemia or Chronic Myelocytic Leukemia)

Question 3

Leukemia Types

Answer 3

Acute Lymphoblastic Leukemia (ALL) - Most common in young children

Chronic Lymphoblastic Leukemia (CLL) - Most common in adults 55+
- Incurable. Affects men more than women

Acute Myelogenous Leukemia (AML) - Most common in adult men
- Treated with chemotherapy

Chronic Myelogenous Leukemia (CML) - Mainly affects adults
- Treatment is Gleevec

Question 4

Manifestations of Leukemia

Answer 4

• Frequent Infections
• Enlarged Lymph Nodes (Lymphadenopathy)
• Enlarged Liver/Spleen
• Weakness/Fatigue
• Low-grade fever and night sweats
• Generalized pain (bone pain)
• Tachycardia, Hypotension
• Bleeding
• CNS involvement
• Emboli

Question 5

Diagnosis of Leukemia

Answer 5

• Bone marrow biopsy (large number of immature leukocytes)
• Low HgB, Hct, RBCs, Platelets
• High ESR, Immature WBCs
• Prolonged PT, PTT, INR

Question 6

Treatment

Answer 6

ALL
- Chemotherapy (Vinca Alkaloids)
- Corticosteroids (Dexamethasone)
- Hematopoietic Stem Cell Transplant (HSCT)
- Monoclonal Antibodies

CLL
- “Watch and wait”
- Immunotherapy
- Chemotherapy
- Monoclonal Antibodies

AML
- Aggressive chemotherapy (induction therapy)
- HSCT
- Palliative Care

CML
- Tyrosine Kinase Inhibitor (Gleevec)
- HSCT
- Aggressive Chemotherapy for “BLAST CRISIS”

Question 7

Tumor Lysis Syndrome (Complication of Chemotherapy)

Answer 7

• Massive destruction of cells which releases intracellular electrolytes and fluids into systemic circulation
• Increased uric acid, potassium, and phosphate in the blood

Question 8

Goals and Education and of Leukemia

Answer 8

GOALS

• Absence of pain
• Maintenance of nutrition
• Activity tolerance
• Understanding the disease

Interventions are aimed at detecting changes in patients condition, see if they need transfusion, and monitor for infection.

EDUCATION
- Recognize symptoms of occult bleeding or infection
- Prevent constipation
- Use electric razor
- Increase fluid intake

IMPORTANT NOTE
- May not have classic signs of infection. Sore throats or diarrhea need to be followed up on

Question 9

Lymphoma

Answer 9

• Cancer of lymphocyte DNA which leads to malignant transformation
• Uncontrolled excessive malignant cells get produced in the lymph nodes or lymph tissue of the stomach/intestines that create tumors.
• Usually starts in lymph nodes but can travel to spleen, GI tract, or bone marrow

Question 10

Hodgkin’s Lymphoma

Answer 10

• Proliferation of Reed Sternberg Cells in lymph nodes

Question 11

Non-Hodgkin’s Lymphoma

Answer 11

• Any lymphoma that does not contain Reed-Sternberg Cells
• It frequently originates outside the nodes then spreads to nodes

Etiology - Unknown (possibly due to impaired immune system or virus)
Pathophysiology - Progressive clonal expansion of B, T, and Natural Killer Cells

Diagnosis
Lymph Node Biopsy
Bone Marrow Biopsy for Staging
Blood Studies
Chest/Abdomen CT Scans

Question 12

Manifestations of Lymphoma

Answer 12

• Lymphadenopathy
• Anorexia/Weight Loss
• Bone Pain
• Dysphagia
• Dyspnea/Cough
• Recurrent Fever
• Severe Pruritis
• Hepatomegaly/Splenomegaly

MAJOR ONES
- Enlarged, Non-Tender, Firm, Movable Lymph Nodes
- Fatigue, Dyspnea, Recurrent Fever

Question 13

Diagnosis

Answer 13

X-Ray
- Check for enlarged lymph nodes

Positron Emission Tomography (PET) Scan
- Check for malignant cells

Bone Marrow Aspiration
- Check for cell types (staging)

Lymph Node Biopsy
- Check for malignant cells or Reed-Sternberg cells

Increased Alkaline Phosphate
- Indicates it has spread to bone/liver

Question 14

Treatment for Hodkin’s Lymphoma

Answer 14

Radiation Therapy for early onset

Chemotherapy for advanced lymphoma that do not respond to radiation

HSCT

Question 15

Treatment for Non-Hodgkin’s Lymphoma

Answer 15

• Wait until symptoms develop
• RARELY HSC
• Radiation is therapy of choice for non-aggressive localized lymphoma
• Cranial radiation or intrathecal chemotherapy if CNS is involved
• Immunotherapy

INTERVENTIONS
- Monitor VS, I&O, Daily Weight, Bleeding
- Skin and mouth care to prevent breakdown of oral mucosa

Question 16

Multiple Mylenoma

Answer 16

• Malignant disease of B Lymphocytes (plasma cells)
• Production of M Protein and Bence Jones Protein
• FIRST SIGN IS BONE PAIN (these cancer cells proliferate in bone marrow and cause bone lesions)
• Associated with agent orange exposure in Vietnam

MANIFESTATIONS
- BONE PAIN in back and ribs
- Pathologic fractures from bone destruction
- Prone to infection (decreased humoral response)
- Hypercalcemia from increased bone resorption
- Osteolytic Lesions - Plasma cell tumors in the bone that cause breakdown

DIAGNOSIS
- Blood tests, marrow exam
- Lytic Bone Lesions
- Presence of M-Protein and Bence Jones Protein in Urine

Question 17

Treatment for Multiple Myeloma

Answer 17

• Initial treatment tries to reduce tumor burden (reduce myeloma cells and reduce monoclonal protein) without damaging stem cells (autologous HSCT)
• Corticosteroids induce apoptosis in melanoma cells and decrease bone pain (dexamethasone)