Chapter 14: MNT for Hematologic Malignancies Flashcards
What is a hematologic malignancy?
- Cancers arise from hematopoietic and lymphoid tissues.
- Can affect hematopoiesis (production) and function of blood cells
- Normal process of blood cell development is interrupted by uncontrolled growth of abnormal cells. This inhibits the function of healthy cells.
What are the common functions of a normal blood cell?
Fighting infections
Forming blood clots
Carrying oxygen to other cells
Hematologic malignancies account for approximately ____% of cancer deaths in the USA.
9.4%
Risk factors for hematologic malignancies
Age: > 65 (except for Hodgkin lymphoma which can occur between ages 20-39)
Race: white (except for MM which is more common in black persons
Gender: male
Genetics: family history of blood disorders, inherited genetic syndromes
Previous cancer treatment: previous chemo, exposure to high dose radiation
Exposure to environmental toxins (Agent Orange, benzene)
Tobacco use
Autoimmune diseases
Certain viral infections
Weakened immune system
A high BMI in adulthood is associated with an increased risk of these 5 cancers
Hodgkin and non-Hodgkin lymphomas
AML
CML
CLL
Multiple Myeloma
Source: WCRF/AICR
List the 3 types of hematologic malignancies
Leukemias
Lymphomas
Plasma cell neoplasms
What are the main types of leukemia? List 4.
Acute Lymphoblastic (ALL)
Acute Myeloid (AML)
Chronic Lymphoblastic (CLL)
Chronic Myeloid (CML)
Leukemia
- caused mainly by increase in production of WBCs
- some leukemias originate in other blood cells
- large production of WBC impairs the body’s ability to fight infection and to produce new RBC and platelets
Signs and symptoms of leukemia include
Bone or joint paint
Anorexia
Weight loss
Enlarged lymph nodes
Fatigue
Fever
Multiple or lingering infections
Night sweats
Signs of bleeding (e.g., bruising)
Abdominal swelling
Splenomegaly
Shortness of breath
Lymphoma begins in the lymphatic system. What is the lymphatic system?
Lymphatic system is made up of lymph nodes, vessels, and organs. It fights infection and disease in the body. Lymphocytes are carried in the lymph and are distributed throughout the body via lymphatic vessels. Lymphoma can originate at multiple sites because of this.
What are the 2 main types of lymphoma?
Hodgkin lymphoma (HL)
Non-Hodgkin lymphoma (NHL)
Which is more prevalent? HL or NHL?
NHL.
NHL accounts for ~4.3% of new cancers. HL accounts for 0.5% of new cancers.
Signs and symptoms of HL
Cough or chest pain
Fatigue
Fever
Night sweats
Itching
Swelling in the lymph nodes
Weight loss
How many subtypes of NHL exist?
60
They are classified by the type of WBC involved. Some subtypes are fasting growing while others are slow growing
Diffuse Large B-Cell Lymphoma (DLBCL)
Fast growing, accounts for 30% of all NHL diagnoses.
Follicular Lymphoma
Slow growing, account for 20% of all NHL diagnoses.
Double hit DLBCL
Aggressive subtype of DLBCL
Accounts for 5% of all cases
General signs and symptoms of NHL include
Abdominal swelling
Fatigue
Fever
Night sweats
Pain
Skin rash or itchy skin
Swelling in the lymph nodes
Trouble breathing
Weight loss
Plasma Cell Neoplasms
Conditions in which plasma cells develop from B cells in the bone marrow in response to infection from bacteria and viruses. The plasm cells produce antibodies to fight the infection. They can be benign or malignant conditions.
What are 4 types of plasma cell neoplasms?
Monoclonal Gammopathy of Undetermined Significance
Plasmacytomas
Multiple Myeloma
Amyloidosis
Monoclonal Gammopathy of Undetermined Significance (MGUS)
Precancerous disease
Most cases are benign
Up to 25% of cases will convert to MM or another B-cell related disorder (including amyloidosis, lymphoma, macroglobulinemia)
Plasmacytomas
Usually form a tumor of abn’l plasma cells in 1 location.
2 types: isolated/solitary, extramedullary
Solitary Plasmacytoma
Uncommon
<6% of plasma cell neoplasms
Usually found in bone
Treated with radiation
Extramedullary Plasmacytoma
Found in soft tissue
Treated with surgical excision
Most often found in upper respiratory tract
Multiple Myeloma (MM) makes up ___% of plasma cell neoplasms?
90%
How does MM develop? How is MM differentiated?
- Myeloma plasma cells produce antibody protein called monoclonal immunoglobulin or M protein.
- M proteins build up in the blood or urine, causing damage to the kidneys and other organs.
- MM is differentiated by the M protein produced (immunoglobulin M or IgM is the most common)
What parts of the body does MM affect?
Affects multiple areas of the body including spine, skull, long bones, ribs
MM (signs and symptoms)
Anemia
Bone pain
Bones that break easily
Elevated serum Cr
Fatigue
Frequent infections
Hypercalcemia
Trouble breathing
Weakness
Weight loss
Amyloidosis
- Rare disease caused by insoluble amyloid proteins being deposited into body organs (kidney, heart, nervous system, and GI tract are most common).
- NOT cancer
- Abnormal protein buildup in tissues leads to organ dysfunction and death.
How to diagnose a hematologic malignancy
Physical exam
Bone marrow aspirate and biopsy
Peripheral blood smear
Elevated M protein level in blood or urine (for MM)
Imaging: CT, MRI, PET
Colonoscopy - for mantle cell lymphoma
Upper or lower GI endoscopy: for mucosa associated lymphoid tissue lymphoma
What staging system is used for HL and NHL?
Lugano Staging System
What is the Lugano Staging System Based on?
and location of cancerous lymph nodes
Whether the cancerous lymph nodes are on one of both sides of the diaphragm
Whether the disease has metastasized.
TNM System
Cannot be used as these malignancies do not form solid tumors
How is leukemia staged?
Characterized by blood cell counts and accumulating of leukemia cells in other organs (such as liver or spleen)
Treatment for hematologic malignancies
Includes systemic therapies, such as chemo or other anti-cancer agents, radiation, surgery, and sometimes high dose chemo followed by a hematopoietic cell transplant. responses to treatment vary based on the type of cancer.
Treatment for AML
Chemo remains the standard for AML.
Targeted therapies are also being used.
Radiation can be used to shrink myeloid sarcoma or when the disease has metastasized to the brain.
AML has 2 phases
Induction therapy and consolidation (postremission) therapy
Efficacy of induction therapy is evaluated by
using a bone marrow aspirate and biopsy 14-21 days after therapy initiation.
What is induction failure in AML?
Persistent disease after two courses of induction therapy is an induction failure.
Treatment for relapsed or refractory AML
Salvage chemotherapy, a clinical trial, or HCT.
HCT is the best current treatment to prevent a recurrence of AML and presently the only cure.
Treatment for ALL
- Treatment includes different stages and spans years
- Includes induction, consolidation, and the long term maintenance therapies.
- Goal of induction therapy is to achieve complete remission.
When is radiation used with ALL?
If it has spread to the central nervous system
Which patients with ALL may undergo HCT?
High risk patients. Usually undergo allogeneic HCT.
Treatment for CML
Treatment depends on the disease phase: chronic, accelerated, or blastic.
Standard treatment in the chronic phase includes targeted tyrosine kinase inhibitors (TKIs).
When is allogeneic HCT needed with CML?
if CML advances to the accelerated phase, the goal is to keep it from progressing to the blastic phase. A clinical trial is typically the standard treatment for accelerated CML, followed by TKIs as a second option
Leukemias require an ____ HCT
Allogenic (donor)
Lymphomas and MM can have an ____ HCT.
Autologous
B-cell lymphoma and B cell precursor ALL are candidates for _____ if they fail an auto HCT
CAR T-cell therapy
What is the % of patients with malnutrition at time of diagnosis?
27-50.4%
Standard frontline chemo for AML
7 day infusion of cytarabine
3 days of anthracycline (usually as daunorubicin)
Typically given as an inpatient
Chemotherapy induced nausea/vomiting is prevalent with this treatment.
Prevalence of bony lesions with MM (% at time of x and during treatment)
80% of patients will have an osteolytic bone lesion at time of dx.
60% of patients can expect to develop a bony lesion.
Prevalence of osteoporosis with MM
75% of patients
Serum Vitamin D
Deficiency appears to be associated with poorer prognosis, relapse and longer hospital stays, decreased rates of remission.
Are high doses of vitamin D (>1000 IU) effective for patients with MM?
No
What should the RD encourage for bone health with MM?
Adequate calcium intake or supplementation
Vitamin D supplementation
Weight bearing and weight strengthening exercises
When should you NOT recommend taking a calcium supplement? List 2 reasons
Pt has hypercalcemia or renal insufficiency
Renal Disease & MM
Approximately 50% of patients with MM have elevated Creatinine levels. AKI is common with initial MM diagnosis.
What % of patients with MM develop CKD within 1.2 years?
50%
What % of patients with MM develop renal impairment within 1.2 years?
61%
Hyperglycemia
Steroids (dexamethasone and prednisone usually) are part of the treatment regimens for lymphomas, leukemias, and MM.
Elevated triglycerides
Rare
Dietary intervention is first line treatment (limit fat to 10-15% of total energy intake)
Survivorship Concerns
- Cardiovascular events
- Osteoporosis
- Glucose intolerance / type 2 DM
