Вы находитесь на странице: 1из 16

Non-Hodgkin’s Lymphoma  Persistent fatigue

Non-Hodgkin’s lymphomas (NHL) are  Fever


cancers of mature B, T, and NK cells, these are
tumors that develop from lymphocytes — a  Night sweats
type of white blood cell.
 Unexplained weight loss
Lymphoma occurs when the lymph-node
cells or the lymphocytes begin to multiply  Swollen lymph nodes
uncontrollably, producing cancerous cells that
have the abnormal capacity to invade other
tissues throughout the body.
Causes
Non-Hodgkin's lymphoma can begin in the:
The exact cause of non-Hodgkin lymphoma is
unknown. However, there are multiple medical
 B cells. B cells fight infection by producing
conditions that are associated with an increased
antibodies that neutralize foreign
risk of developing the disease:
invaders. Most non-Hodgkin's lymphoma
arises from B cells. Subtypes of non-
 Inherited immune deficiencies
Hodgkin's lymphoma that involve B cells  Genetic syndromes: Down syndrome,
include diffuse large B-cell lymphoma, Klinefelter's syndrome (a genetic
follicular lymphoma, mantle cell condition in men caused by an extra X
chromosome)
lymphoma and Burkitt lymphoma.
 Immune disorders, and their
 T cells. T cells are involved in killing treatments: Sjögren's syndrome (an
immune disorder characterized by
foreign invaders directly. Non-Hodgkin's unusual dryness of mucus
lymphoma occurs less often in T cells. membranes), rheumatoid arthritis,
Subtypes of non-Hodgkin's lymphoma systemic lupus erythematosus
 Celiac disease, a disease involving the
that involve T cells include adult T-cell
processing of certain components of
lymphoma and Mycosis Fungoides. gluten, a protein in grains
 Inflammatory bowel disease, particularly
Crohn’s disease, and its treatment
 Psoriasis
 Family history of lymphoma
Signs and symptoms  Bacteria: Helicobacter pylori, associated
May include: with gastritis and gastric ulcers; Borrelia
burgdorferi, associated with Lyme
 Painless, swollen lymph nodes in your disease; Campylobacter jejuni; Chalmydia
psittaci
neck, armpits or groin  Viruses: HIV, HTLV-1, SV-40, HHV-
8, Epstein Barr virus, hepatitis virus
 Abdominal pain or swelling
 Non-random chromosomal translocations
and molecular rearrangements
 Chest pain, coughing or trouble breathing
number of chemicals used in industries
such as farming, welding, and lumber
 Exposure to nuclear accidents, nuclear
Risk factors testing, or underground radiation leaks
 Treatment with immunosuppressant
drugs, for prevention of organ
Some factors that may increase the risk of non- transplantation rejection, or for
Hodgkin's lymphoma include: treatment of inflammatory and
autoimmune disorders
 Tumor necrosis factor agents used to
 Medications that suppress your immune treat psoriatic and rheumatoid
system. If you've had an organ transplant, arthritis and inflammatory bowel disease
you're more susceptible because  Prior exposure to chemotherapy and/or
radiation used to treat a prior diagnosis
immunosuppressive therapy has reduced
of cancer
your body's ability to fight new illnesses.  Treatment with
a medication called Dilantin (phenytoin),
 Infection with certain viruses and commonly used to treat seizure disorders
bacteria. Certain viral and bacterial  Use of hair dyes, especially dark and
infections appear to increase the risk of permanent colors, used before 1980
non-Hodgkin's lymphoma. Viruses linked (research is inconclusive)
 High levels of nitrates found in drinking
to increased non-Hodgkin's lymphoma water
risk include HIV and Epstein-Barr  Diets high in fat and meat products
infection. Bacteria linked to an increased  Ultraviolet light exposure
risk of non-Hodgkin's lymphoma include  Alcohol intake
the ulcer-causing Helicobacter pylori.
Types of NHL can also be grouped based on
 Chemicals. Certain chemicals, such as how fast they grow and spread:
those used to kill insects and weeds, may
increase your risk of developing non-
 Indolent lymphomas grow and spread
Hodgkin's lymphoma. More research is
slowly Some indolent lymphomas might
needed to understand the possible link
not need to be treated right away, but
between pesticides and the development can be watched closely instead. The
of non-Hodgkin's lymphoma. most common type of indolent
 Older age. Non-Hodgkin's lymphoma can lymphoma in the United States is
follicular lymphoma.
occur at any age, but the risk increases
with age. It's most common in people 60  Aggressive lymphomas grow and
or over. spread quickly, and usually need to be
treated right away. The most common
Other Factors Include: type of aggressive lymphoma in the
United States is diffuse large B cell
 Regular exposure to certain chemicals,
including insect and weed killers, and a lymphoma (DLBCL).
 Some types of lymphoma, like mantle Diffuse large B-cell lymphoma (DLBCL) is
cell lymphoma, don’t fit neatly into the most common histologic subtype of NHL
diagnosed, representing about one-third of all
either of these categories.
cases. Previously felt to be “one disease” it is
Classifying types of NHL now recognized as a heterogeneous collection
of multiple entities. It is slightly more common
in Caucasians and men, and the median age at
There are many different types of non-Hodgkin diagnosis is 64. The relative risk of DLBCL is
lymphoma (NHL), so classifying it can be quite higher amongst people with affected first-
degree relatives (RR 3.5-fold), and patients with
confusing, that’s why several different systems congenital or acquired immunodeficiency,
have been used, but the most recent system is patients on immunosuppression, and patients
the World Health Organization (WHO) with autoimmune disorders also have a higher
risk of developing DLBCL, often EBV-related.
classification. The WHO system groups
lymphomas based on:
Follicular Lymphoma

 The type of lymphocyte the lymphoma FLs are the second leading NHL
diagnosis in the United States and Europe and
starts in
makes up 22% of NHL worldwide and at least
 How the lymphoma looks under a 30% of NHL diagnosed in the United States.
microscope This type of lymphoma can be diagnosed
accurately on morphologic findings alone and
 The chromosome features of the has been the diagnosis in the majority of
lymphoma cells patients in therapeutic trials for “low-grade”
lymphoma in the past.
 The presence of certain proteins on the
surface of the cancer cells
Burkitt Lymphoma

Burkitt lymphoma is considered a highly


Types of Non-Hodgkin’s Lymphoma aggressive lymphoma. First discovered in
African children in the 1950s, the disease is
Non-Hodgkin’s B-Cell Lymphoma associated with the Epstein-Barr virus. Patients
with limited disease have an excellent
These are the most common form of prognosis. The overall survival rate ranges from
lymphoma. 50%–70%, although when central nervous
system or bone marrow involvement is present,
Diffuse Large B Cell Lymphoma long-term survival is reduced to less than 30%.
The immunophenotypes of Burkitt lymphoma
are the expression of CD19, CD20, CD22, and
CD10 and typically are CD5 and CD23 negative.

Mantle Cell Lymphoma

Mantle cell lymphoma comprises a


distinct subset of aggressive lymphomas.
Accounting for approximately 5%–8% of all Adult T-cell leukemia/ lymphoma (ATLL)
NHLs, patients with mantle cell lymphoma is a disease that is most prevalent in Japan and
typically have a poor prognosis with standard the Caribbean basin. It is a neoplasm that is
therapy. Mantle cells may appear as atypical driven by HTLV-1, often contracted through the
small lymphoid cells with irregular, indented breast milk of infected mothers. The average
nuclei. The immunophenotype expresses CD19, age at diagnosis is 60, so there is a long latency
CD20, CD22, and CD5 but is negative for CD23. between viral infection and viral
Most patients with mantle cell lymphoma transformation, and only 4% of infected
present with advanced-stage disease, including patients will develop the disease.
bone marrow involvement, and require therapy
Mycosis fungoides
immediately to control their symptoms.
Mycosis fungoides is also known as
Marginal Zone Lymphoma
cutaneous T-cell lymphoma. This lymphoma is
Marginal zone lymphomas, which are more often seen by dermatologists than
indolent, can be divided into three types: internists. The median age of onset is in the
splenic marginal zone B-cell lymphoma, mid-fifties, and the disease is more common in
extranodal marginal zone B-cell lymphoma males and in blacks. Mycosis fungoides is an
(mucosa-associated lymphoid tissue [MALT]), indolent lymphoma with patients often having
and nodal marginal zone B-cell lymphoma. several years of eczematous or dermatitic skin
Marginal zone cells appear as small B lesions before the diagnosis is finally
lymphocytes with varied features that are established. The skin lesions progress from
dependent on the type of marginal zone. The patch stage to plaque stage to cutaneous
immunophenotype of marginal zone tumors.
lymphomas express CD19, CD20, and CD22 and
are negative for CD5, CD10, and CD23. Staging

Lymphoplasmacytic Lymphoma NHL is staged based on the Ann Arbor staging


system, which is used to summarize the extent
About 1% of all NHLs will be of the disease8:
lymphoplasmacytic lymphomas, which are
indolent B-cell NHLs with lymphoplasmacytic • Stage I: The cancer is located in a single
differentiation, most commonly associated with region, usually 1 lymph node and the
a monoclonal IgM paraprotein. Nearly all surrounding area. Stage I will often not have
patients will have stage IV disease at diagnosis obvious, outward symptoms.
with bone marrow involvement. Patients with
• Stage II: The cancer is located in 2 separate
high levels of circulating IgM paraproteins
lymph node regions, and both regions are on
constitute a specific entity known as the same side of the diaphragm (either above
Waldenstrom macroglobulinemia and can have or below the diaphragm).
symptoms due to hyperviscosity as a result of
the circulating IgM. • Stage III: The cancer involves lymph nodes
or organs on both sides of the diaphragm (both
above and below the diaphragm).
Non-Hodgkin’s T-Cell Lymphoma
• Stage IV:
Adult T-Cell Lymphoma
o The cancer has spread to multiple spots of o The cancer is in the liver, bone marrow,
an organ (or multiple organs) outside the lungs (other than by growing there directly
lymph system. Cancer cells may or may not be from another site), or cerebrospinal fluid.
found in the lymph nodes near these organs.

o The cancer has spread to only 1 organ


outside the lymph system, but lymph nodes far In both NHL and HL, one of the following
away from that organ are involved. letters can be added to the stage to provide
further detail (stage IIA, stage IIIB)8:
o There is bone marrow involvement.
A: The patient has no symptoms.
The staging of HL is based on the Cotswold
system, a modification of the Ann Arbor B: The patient has one or more “B
system9: symptoms”: loss of more than 10% of body
weight over the previous 6 months (without
• Stage I: The cancer is found in only 1 lymph dieting), unexplained fever of at least 100.4°F
node area or lymphoid organ such as the (38°C), or drenching night sweats.
thymus (stage I), or the cancer is found in only
1 area of a single organ outside the lymph E: The disease is “extranodal” (not in the
system (stage IE). lymph nodes) or has spread from lymph nodes
to adjacent tissue.
• Stage II: The cancer is found in 2 or more
lymph node areas on the same side of the X: The largest tumor is larger than 10 cm
diaphragm (stage II), or the cancer extends (also called “bulky disease”), or the lymph
locally from one lymph node area into a node mass in the center of the chest
nearby organ (stage IIE). (mediastinum) is wider than one-third of the
chest on a chest X-ray.
• Stage III:

o The cancer is found in lymph node areas


on both sides of the diaphragm (stage III). Diagnostic Tests:
o The cancer is in lymph nodes both above
and below the diaphragm, and it has also Medical history and physical exam
spread to a nearby organ (stage IIIE), to the
spleen (stage IIIS), or to both (stage IIIES).
The doctor will get a complete medical history,
• Stage IV: including information about the symptoms,

o The cancer has spread widely through 1 or possible risk factors, and other medical
more organs outside the lymph system. Cancer conditions.
cells may or may not be found in nearby
lymph nodes.
Also, the doctor will do a physical examination,
o The cancer is found in organs in 2 distant
paying special attention to the lymph nodes and
parts of the body (and not in nearby lymph
nodes). other areas of the body that might be affected,
including the spleen and liver. Because
infections are the most common cause of
enlarged lymph nodes, the doctor will look for  For a core needle biopsy, the doctor
an infection near the swollen lymph nodes. uses a larger needle to remove a slightly
larger piece of tissue.
Other types of biopsies
Biopsy

These procedures are not normally done to


For a biopsy, a small piece of a lymph node or,
diagnose lymphoma, but they might be used to
more often, an entire lymph node is removed
help determine the stage or extent of a
for testing in a lab.
lymphoma that has already been diagnosed.
Excisional or incisional biopsy: This is the
preferred and most common type of biopsy if
Bone marrow aspiration and biopsy: These
lymphoma is suspected, because it almost
procedures are often done after lymphoma has
always provides enough of a sample to
been diagnosed to help determine if it has
diagnose the exact type of NHL.
reached the bone marrow. The samples are
In this procedure, a surgeon cuts through the
usually taken from the back of the pelvic (hip)
skin to remove the lymph node.
bone, although in some cases they may be
 If the doctor removes the entire lymph taken from other bones.
node, it is called an excisional biopsy.
 If a small part of a larger tumor or node
Lumbar puncture (spinal tap): This test looks
is removed, it is called an incisional
biopsy. for lymphoma cells in the cerebrospinal fluid
(CSF). Doctors may order it for certain types of
lymphoma or if a person has symptoms that
Needle biopsy: Needle biopsies are less invasive suggest the lymphoma may have reached the
than excisional or incisional biopsies, but the brain.
drawback is that they might not remove enough
of a sample to diagnose lymphoma or to Pleural or peritoneal fluid
determine which type it is. sampling: Lymphoma that has spread to the
There are 2 main types of needle biopsies: chest or abdomen can cause fluid to build up.
Pleural fluid (inside the chest) or peritoneal
 In a fine needle aspiration (FNA)
biopsy, the doctor uses a very thin, fluid (inside the abdomen) can be removed by
hollow needle attached to a syringe to placing a hollow needle through the skin into
withdraw (aspirate) a small amount of the chest or abdomen.
tissue from an enlarged lymph node or
a tumor mass.
 When this procedure is used to remove organs in the body are enlarged. CT scans are
fluid from the area around the lung, it’s useful for looking for lymphoma in the
called a thoracentesis.
abdomen, pelvis, chest, head, and neck.
 When it is used to collect fluid from
inside the abdomen, it’s known as Magnetic resonance imaging (MRI) scan
a paracentesis.

Like CT scans, MRI scans show detailed images


of soft tissues in the body. But MRI scans use
Imaging tests
radio waves and strong magnets instead of x-
rays. This test is not used as often as CT scans
Imaging tests use x-rays, sound waves,
for lymphoma, but if the doctor is concerned
magnetic fields, or radioactive particles to
about spread to the spinal cord or brain, MRI is
produce pictures of the inside of the body.
very useful for looking at these areas.
These tests might be done for a number of
reasons, including:
Ultrasound

 To look for possible causes of certain


Ultrasound can be used to look at lymph nodes
symptoms (such as enlarged lymph
near the surface of the body or to look inside
nodes in the chest in someone having
chest pain or trouble breathing) the abdomen for enlarged lymph nodes or
organs such as the liver and spleen. It can also
 To help determine the stage (extent) of
detect kidneys that have become swollen
the lymphoma
because the outflow of urine has been blocked
 To help show if treatment is working by enlarged lymph nodes.
 To look for possible signs of lymphoma
coming back after treatment Positron emission tomography (PET) scan
Chest x-ray
For a PET scan, you are injected with a slightly
The chest might be x-rayed to look for enlarged radioactive form of sugar, which collects mainly
lymph nodes. in cancer cells. A special camera is then used to
create a picture of areas of radioactivity in the
Computed tomography (CT) scan body. The picture is not detailed like a CT or
MRI scan, but it can provide helpful information

A CT scan combines many x-rays to make about your whole body.

detailed, cross-sectional images of the body.


This scan can help tell if any lymph nodes or PET scan might be done to:
 See if an enlarged lymph node contains Other tests
lymphoma.
Blood tests
 Find small areas that might be
lymphoma, even if the area looks
normal on a CT scan. Blood tests are not used to diagnose lymphoma,
but they can sometimes help determine how
 Check if a lymphoma is responding to
treatment. Some doctors will repeat the advanced the lymphoma is.
PET scan after 1 or 2 courses of
chemotherapy. If the chemotherapy is  A complete blood count (CBC) measures
working, the lymph nodes will no longer the levels of different cells in the blood.
absorb the radioactive sugar. For a person already known to have
lymphoma, low blood cell counts might
 Help decide whether an enlarged lymph
mean that the lymphoma is growing in
node still contains lymphoma or is just
the bone marrow and affecting new
scar tissue after treatment.
blood cell formation.
Bone scan
 Blood chemistry tests are often done to
look at how well the kidney and liver
This test is usually done if a person is having
function are working.
bone pain or has lab results that suggest the
 If lymphoma has been diagnosed,
lymphoma may have reached the bones.
the lactate dehydrogenase (LDH) level
may be checked. LDH levels are often
For bone scans, a radioactive substance increased in patients with lymphomas.
called technetium is injected into a vein. It
 For some types of lymphoma or if
travels to damaged areas of bone, and a special certain treatments might be used, your
camera can then detect the radioactivity. doctor may also advise you to have
Lymphoma often causes bone damage, which tests to see if you’ve been infected with
may be seen on a bone scan. But bone scans certain viruses, such as hepatitis B virus
can’t show the difference between cancers and (HBV), hepatitis C virus (HCV), or human
immunodeficiency virus
non-cancerous problems, such as arthritis and
(HIV). Infections with these viruses may
fractures, so further tests might be needed.
affect your treatment.

Tests of heart and lung function

These tests are not used to diagnose


lymphoma, but they might be done if you are
going to get certain chemotherapy drugs
commonly used to treat lymphoma that could  Chlorambucil
affect the heart or the lungs.  Bendamustine

 Ifosfamide
 Your heart function may be checked
with an echocardiogram (an ultrasound Corticosteroids
of the heart).
 Prednisone
 Your lung function may be checked
with pulmonary function tests, in which  Dexamethasone
you breathe into a tube connected to a Platinum drugs
machine.

 Cisplatin
Chemotherapy  Carboplatin

 Oxaliplatin
Chemotherapy (chemo) is the use of anti-
Purine analogs
cancer drugs that are usually injected into a
vein (IV) or taken by mouth. These drugs
 Fludarabine
enter the bloodstream and reach almost all
 Pentostatin
areas of the body, making this treatment very
useful for lymphoma.  Cladribine (2-CdA)

Anti-metabolites
Chemo is the main treatment for most people
with non-Hodgkin lymphoma (NHL). Depending  Cytarabine (ara-C)
on the type and the stage of the lymphoma,  Gemcitabine
chemo may be used alone or combined with
 Methotrexate
other treatments, such as immunotherapy
drugs or radiation therapy.  Pralatrexate

Anthracyclines
Here are some of the drugs more commonly
used to treat lymphoma (divided into groups  Doxorubicin (Adriamycin)
based on how they work):  Liposomal doxorubicin (Caelyx)

Others
Alkylating agents
 Vincristine
 Cyclophosphamide
 Mitoxantrone
 Etoposide (VP-16) Certain chemo drugs can have other possible side
 Bleomycin effects. For example:

 Platinum drugs such as cisplatin can cause


Intrathecal chemo nerve damage (neuropathy), leading to
numbness, tingling, or even pain in the
hands and feet.
Most chemo drugs given systemically (IV or
by mouth) can’t reach the cerebrospinal fluid  Ifosfamide can damage the bladder. The
risk of this can be lowered by giving it along
(CSF) and tissues around the brain and spinal
with a drug called mesna.
cord. To treat lymphoma that might have
reached these areas, chemo may also be  Doxorubicin can damage the heart. Your
given into the CSF. This is called intrathecal doctor may order a test of your heart
function (like a MUGA scan or
chemo. The chemo drugs most often used for
echocardiogram) before starting you on
intrathecal chemo are methotrexate and
this drug.
cytarabine.
 Bleomycin can damage lungs. Doctors
often test lung function before starting
Possible side effects
someone on this drug.

 Hair loss  Many chemo drugs can affect fertility (the


ability to have children).
 Mouth sores
 Some chemo drugs can raise your risk of
 Loss of appetite developing leukemia several years later.
 Nausea and vomiting

 Diarrhea or constipation
Immunotherapy
 Increased chance of infection (from a shortage
of white blood cells)
Immunotherapy is treatment that either boosts
 Bleeding or bruising after minor cuts or injuries
the patient’s own immune system or uses man-
(from a shortage of platelets)
made versions of the normal parts of the
 Fatigue and shortness of breath (from too few
immune system to kill lymphoma cells or slow
red blood cells)
their growth.
These side effects usually go away after treatment is
finished. If serious side effects occur, the dose of
chemo may be reduced or treatment may be
delayed.
Monoclonal antibodies

Antibodies are proteins made by your immune Antibodies targeting CD52


system to help fight infections. Man-made
versions, called monoclonal antibodies, can be Alemtuzumab (Campath) is an antibody
designed to attack a specific target, such as a directed at the CD52 antigen. It is useful in some
substance on the surface of lymphocytes (the cases of SLL/CLL and some types of peripheral T-
cells in which lymphomas start). cell lymphomas. This drug is infused into a vein
(IV), usually 3 times a week for up to 12 weeks.
Antibodies that target CD20 The most common side effects are fever, chills,
nausea, and rashes. It can also cause very low

A number of monoclonal antibodies target the white blood cell counts, which increases the risk

CD20 antigen, a protein on the surface of B for serious infections. Antibiotic and antiviral

lymphocytes. These include: medicines are given to help protect against


them, but severe and even life-threatening
infections can still occur. Rare but serious side
 Rituximab (Rituxan): This drug is often
used along with chemotherapy (chemo) effects can include strokes, as well as tears in the
for some types of NHL, but it may also be blood vessels in the head and neck.
used by itself.

 Obinutuzumab (Gazyva): This drug is Antibodies that target CD30


often used along with chemo as a part of
the treatment for small lymphocytic Brentuximab vedotin (Adcetris) is an anti-CD30
lymphoma/chronic lymphocytic antibody attached to a chemotherapy drug. The
leukemia (SLL/CLL). It can also be used antibody acts like a homing signal, bringing the
along with chemo in treating follicular
chemo drug to lymphoma cells, where it enters
lymphoma.
the cells and kills them.
 Ofatumumab (Arzerra): This drug is used
mainly in patients with SLL/CLL that is no
Brentuximab can be used to treat some types of
longer responding to other treatments.
T-cell lymphoma, either as the first treatment
 Ibritumomab tiuxetan (Zevalin): This (typically along with chemo) or if the lymphoma
drug is made up of a monoclonal
if it has come back after other treatments. This
antibody that is attached to a
drug is infused into a vein (IV), typically every 3
radioactive molecule. The antibody
brings radiation directly to the weeks. Common side effects can include nerve
lymphoma cells. damage (neuropathy), low blood counts, fatigue,
fever, nausea and vomiting, infections, diarrhea, Pembrolizumab can be used to treat primary
and cough. mediastinal large B-cell lymphoma (PMBCL) that
has not responded to or has come back after
Antibodies that target CD79b other therapies.

Polatuzumab vedotin-piiq (Polivy) is an anti- Immunomodulating drugs


CD79b antibody (polatuzumab) attached to a
chemotherapy drug (MMAE). The antibody finds Drugs such as thalidomide
the lymphoma cell and attaches to the surface (Thalomid) and lenalidomide (Revlimid) are
protein CD79b. Once connected, polatuzumab is thought to work against certain cancers by
drawn into the lymphoma cell where the chemo affecting parts of the immune system, although
is released and destroys it. exactly how they work isn’t clear. They are
sometimes used to help treat certain types of

Polatuzumab can be used with bendamustine lymphoma, usually after other treatments have

and rituximab to treat DLBCL, if the lymphoma been tried. Lenalidomide can be given with or

has come back after receiving two other without rituximab.

treatments. This drug is infused into a vein (IV),


typically every 3 weeks. Common side effects These drugs are taken daily as pills. Side effects
can include numbness or tingling of hands/feet of can include low white blood cell counts (with
(peripheral neuropathy), low blood counts, an increased risk of infection) and neuropathy
fatigue, fever, decreased appetite, diarrhea, and (painful nerve damage), which can sometimes be
pneumonia. severe and may not go away after treatment.
There is also an increased risk of serious blood
Immune checkpoint inhibitors clots (that start in the leg and can travel to the
lungs), especially with thalidomide. Thalidomide
Immune system cells normally have substances can also cause drowsiness, fatigue, and severe
that act as checkpoints to keep them from constipation.
attacking other healthy cells in the body. Cancer
cells sometimes take advantage of these Chimeric antigen receptor (CAR) T-cell therapy
checkpoints to avoid being attacked by the
immune system. In this treatment, immune cells called T cells are
removed from the patient’s blood and altered

Drugs such as pembrolizumab (Keytruda) work in the lab to have specific receptors

by blocking these checkpoints, which can boost (called chimeric antigen receptors, or CARs) on

the immune response against cancer cells. their surface. These receptors can attach to
proteins on the surface of lymphoma cells. The drug must also be given in centers with
T cells are then multiplied in the lab and given specialized training.
back into the patient’s blood, where they can
seek out the lymphoma cells and launch a Radiation Therapy
precise immune attack against them.

Radiation therapy uses high-energy rays to kill


Axicabtagene ciloleucel (Yescarta) is a type of cancer cells. Radiation might be used to treat
CAR T-cell therapy approved by the FDA to treat non-Hodgkin lymphoma (NHL) in some different
people with diffuse large B-cell lymphoma, situations:
primary mediastinal large B-cell lymphoma, high
grade B-cell lymphoma and diffuse large B-cell  It can be used as the main treatment
lymphoma arising from follicular lymphoma for some types of NHL if they are found
after at least two other kinds of treatment have early (stage I or II), because these
been tried. Because this treatment can have tumors respond very well to radiation.
serious side effects, it is only given in medical  For more advanced lymphomas and for
centers that have special training with this some lymphomas that are more
treatment. Potentially life-threatening side aggressive, radiation is sometimes used
effects can include high fever, chills, flu-like along with chemotherapy.

symptoms, and serious neurological changes.  People who are getting a stem cell
Other severe side effects include infection, low transplant may get radiation to the
blood cell counts, and a weakened immune whole body along with high-dose
system. chemotherapy, to try to kill lymphoma
cells throughout the body.

 Radiation therapy can be used to ease


Tisagenlecleucel (Kymriah) is another type of
(palliate) symptoms caused by
CAR T-cell therapy approved to treat people
lymphoma that has spread to internal
with diffuse large B cell lymphoma, high grade B
organs, such as the brain or spinal cord,
cell lymphoma, and diffuse large B cell or when a tumor is causing pain
lymphoma arising from follicular lymphoma because it’s pressing on nerves.
after trying at least two other kinds of
treatment. Potentially life-threatening side
effects can include fever, headache, low blood Possible side effects
pressure, a fast heart rate, and trouble
breathing. Other severe side effects include The side effects of radiation therapy depend on
infection, diarrhea, swelling, and nausea. This where the radiation is aimed. Common side
effects include:
 Skin changes in areas getting radiation, Nursing Interventions:
ranging from redness to blistering and
peeling Physiological integrity
a. Monitor complete blood cell count, white
 Feeling tired
blood cell count, platelet count, uric acid
 Nausea level, and electrolytes.
 Diarrhea b. Initiate bleeding precautions if
thrombocytopenia occurs.
Nausea and diarrhea are more common if the
c. When the platelet count is less than
abdomen (belly) is treated with radiation.
50,000 mm3 (50Â109/L), minor trauma can
lead to episodes of prolonged bleeding;
Radiation given to several areas, especially after when less than 20,000 mm3 (20Â109/L),
chemotherapy, can lower blood cell counts and spontaneous and uncontrollable bleeding can
increase the risk of infections. occur; withhold the medication if the platelet
count drops (according to agency policy) and
Radiation to the head and neck area can lead notify the health care provider (HCP).
to mouth sores and trouble swallowing. Some Bleeding precautions are initiated.
people later have problems with dry mouth. d. Monitor for petechiae, ecchymoses,
bleeding of the gums, and nosebleeds
Surgery because the decreased platelet count can
precipitate bleeding tendencies.
e. Avoid intramuscular injections and
Surgery is often used to get a biopsy sample to
venipunctures as much as possible to
diagnose and classify a lymphoma, but it’s
prevent bleeding.
rarely used as a form of treatment.
f. Withhold the medication and initiate
neutropenic precautions if the segmented
Rarely, surgery may be used to treat
neutrophil count decreases below 18%
lymphomas that start in the spleen or in certain
conventional units (0.18 SI units); notify the
organs outside the lymph system, such as the
HCP.
thyroid or stomach, and that have not spread
g. Monitor for fever, sore throat, unusual
beyond these organs. But for treating
bleeding, and signs and symptoms of
lymphoma that’s completely confined to one
infection.
area, radiation therapy is usually preferred over
h. Inform the client that loss of appetite
surgery.
also may be the result of taste changes or a
bitter taste in the mouth from the
medications.
i. Monitor for nausa and vomiting and provide h. As prescribed, reduce IV site pain by
a high-calorie diet with protein supplements. altering IV rates or warming the injection
j. Administer antiemetics several hours site to distend the vein and increase blood
before chemotherapy and for 12 to 48 flow.
hours after as prescribed, because i. Monitor for extravasation (leakage of
antineoplastic medications stimulate the medication into surrounding skin and
vomiting center in the brain. subcutaneous tissue, which causes tissue
k. Encourage hydration; IV fluids are necrosis) and notify the HCP if this occurs;
administered before and during therapy. heat or ice is applied depending on the
l. Promote a fluid intake of at least 2000 medication, and an antidote may be injected
mL/ day to maintain adequate renal function. into the site.

Safe and effective care environment Psychosocial integrity


a. Prepare IV chemotherapy in an air-vented a. Instruct the client about the possibility of
space (biological safety cabinet). hair loss and that varying degrees of hair
b. Wear appropriate personal protective loss may occur after the first or second
equipment (PPE), including gloves, gown, eye treatment.
protectors, and mask as indicated, to reduce b. Discuss the purchase of a wig before
exposure whenever there is a risk of treatment starts and consider cutting hair
hazardous medications being released into short.
the environment. c. Inform the client that new hair growth
c. Nurses who are pregnant should avoid will occur several months after the final
chemotherapy preparation or the treatment.
administration of chemotherapy. d. Instruct the client about the need for
d. Discard IV equipment in designated contraception because these medications
(biohazard) containers. have teratogenic effects.
e. Administer antineoplastic medication e. Discuss the potential effect of infertility,
precisely as prescribed to maximize which may be irreversible.
antineoplastic effects while allowing normal f. Encourage pretreatment counseling and
cells to recover. encourage sperm banking or preservation of
f. Monitor for phlebitis with IV administration eggs if the client is still of childbearing age.
because these medications may irritate the
veins. g. Vesicants should be administered Health promotion and maintenance
through a central line when possible; if a a. Instruct the client, if diarrhea is a problem, to
peripheral line is used, blood return should avoid spicy foods, high-fiber foods, and foods
be checked prior to administration.
that are hot in temperature, which increase
peristalsis.
b. Instruct the client to inspect the oral
mucosa frequently for erythema and ulcers,
rinse the mouth after meals, and carry out
good oral hygiene.
c. Instruct the client to use mouth rinses as
prescribed for mouth sores if necessary.
d. Instruct the client in the use of antifungal
agents for mouth sores, if prescribed, for
the development of a fungal infection.
e. Instruct the client to avoid crowds and
persons with infections and to report signs of
infection such as a low-grade fever, chills, or
sore throat.
f. Instruct individuals with colds or infections
to wear a mask when visiting or to avoid
visiting the client.
g. Instruct the client to use a soft tooth brush
and electric razor to minimize the risk of
bleeding.
h. Instruct the client to avoid aspirin-
containing products to minimize the risk of
bleeding.
i. Instruct the client to consult the HCP
before receiving vaccinations (live vaccines
should not be administered).