Lymphoma News

Bone Marrow Transplantation for Non-Hodgkin's Lymphoma

2006-06-20T15:22:00.000-07:00

If you have non-Hodgkin's lymphoma, or NHL, then you have one of the three different subgroups: either low grade, intermediate grade, or high grade. I will discuss the use of bone marrow transplantation for each grade of NHL, but let us first examine the different ways bone marrow can be transplanted.
Types of Bone Marrow Transplantation

There are three types of bone marrow transplantation: autologous, allogeneic, and syngeneic.

Autologous Bone Marrow Transplantation
With autologous bone marrow transplants, a portion of your own bone marrow cells are removed and stored in a freezer before you receive chemotherapy, or chemotherapy and radiation therapy together (chemoradiotherapy), in powerful doses so that as many cancer cells can be killed as possible. Then your bone marrow cells that were stored in the freezer—and which were saved from the toxic effects of your therapy—are put back in your body. The benefit of this type of bone marrow transplantation is that higher doses of chemotherapy can be given to knock out the cancer without fear of harming the bone marrow.

Allogeneic Bone Marrow Transplantation
An allogeneic bone marrow transplant uses bone marrow cells from another person (donor). The donor could be a family member (usually a sibling) or be unrelated. Bone marrow cells from unrelated donors come through programs such as the National Marrow Donor Program or one of the Umbilical Cord Blood banks recently established around the country.

There are three benefits of allogeneic bone marrow transplantation. The first is similar to that with autologous bone marrow transplantation: the ability to administer very high doses of chemotherapy and radiotherapy to hit the cancer the hardest. The second benefit is the possibility of a "graft versus tumor effect." (Physicians refer to transplanted organs or bone marrow as grafts.) When an allogeneic transplant is performed successfully, the recipient in effect receives a new immune system (from the donor's cells). The new immune system can then attack the cancer in the recipient. This effect is particularly powerful in leukemias, and its importance in NHL is being actively studied. A serious side effect of an allogeneic transplant may occur if this new immune system reacts against your normal cells in what is called "graft-versus-host disease." However, when this occurs along with a graft-versus-tumor effect, the benefit to you may outweigh any unwanted side effects.

A third benefit of this type of bone marrow transplant is of particular importance in diseases in which there may be cancer cells in your bone marrow (which can happen with NHL) because with allogeneic transplantation you receive "new" healthy bone marrow.

more >>http://www.lymphomafocus.org/focus_article.asp?b=lymphoma&f=lymphoma_treatment&c=trreatment_bonemarrow&pg=2

Cutting Edge Therapy: Monoclonal Antibody Treatment for Non-Hodgkin's Lymphoma

2006-06-20T15:17:00.000-07:00

Chemotherapy and radiation therapy have been effective treatments for patients with non-Hodgkin’s lymphoma, or NHL. Patients with NHL usually respond well to either treatment, and some can be cured. However, for many patients, these treatments are not that effective and can be very toxic. Because of these limitations, intensive efforts have been made to develop new therapies to fight NHL.
"Monoclonal-antibody–based" therapy is a new development in NHL therapy and has been demonstrated to be safe and effective for certain types of patients. One drug rituximab (also known as Rituxan®) has been approved by the FDA for treatment of NHL. (I will discuss it in detail later in this article). Other monoclonal antibody treatments, such as Bexxar®, are being studied and may soon be available as well. All offer great promise in further improving the effectiveness and tolerability of the current treatment for NHL. (rituxumab, Bexxar, and other similar treatments will be discussed later in the article.)

What Are Monoclonal Antibodies?

Antibodies are substances made by our own immune system to fight against various foreign substances. Our bloodstream contains many different types. Each antibody has a specific target (antigen) that it looks for and binds to, like a key, which fits only into one lock. When an antibody binds to its antigen target, the antibody alerts the immune system to respond against the foreign substance. This is an important part of our body’s defense against infection.

A monoclonal antibody is one that is generated in a laboratory, not in our body, to be directed against one single target. Rather than a diverse group of antibodies like those found in our bodies, monoclonal antibodies are made to be all exactly the same. The reason why they were developed was to allow a treatment to be directed to one specific target. Monoclonal antibodies developed to treat cancers are made to be directed against a single target on a tumor to cause anti-tumor effects.

Different antibodies have been engineered and developed through different processes. For several reasons, most antibodies are initially created as murine (or mouse) type. This does not mean that they are made in an animal but simply that the antibody structure is from a mouse antibody. Antibodies can be chimeric (half mouse, half human) or humanized (mostly human). All types have been evaluated, yet the potential differences in efficacy or toxicity have not definitively been established.

How Do Monoclonal Antibody Treatments Work in Lymphoma?

Most non-Hodgkin’s lymphoma patients (about 90%) have tumors that are made up of B cells (B lymphocytes), a type of white blood cell. Since most NHL patients have these similar B cells, treatment using a monoclonal antibody directed against these tumor B cells has great potential to be effective in different patients. Several different monoclonal antibodies have been evaluated as potential treatments for lymphoma.
As treatment for NHL, monoclonal antibodies have been tested either alone ("naked" antibodies) or have been joined with a toxin which can kill cells, in order to target this toxin directly towards tumor cells. Radioactive particles have also been attached to monoclonal antibodies (radiolabeled antibodies) to make radiation therapy more effective. Patients who have low blood counts or have a lot of tumor cells in their bone marrow may not be candidates for treatment with radiolabeled antibodies because the radiation may destroy too many of their red and white blood cells (a side effect called hematologic toxicity). The differences in monoclonal antibody structure and targets, whether or not they are linked to radioactive particles or toxins, as well as the differences in patients, play an important role in the choice of treatment and how effective and safe a particular type of monoclonal antibody will be.

What Monoclonal Antibody Treatments Are Available for NHL?

Rituximab (Rituxan®)
Rituxan is the only monoclonal antibody treatment currently approved for NHL. Rituxan is a chimeric antibody that binds to a specific antigen target present on the surface of B cells (again -- this is the cancer cell type in most NHL patients). If Rituxan is given as a course of treatment without anything else, it is usually given once a week for 4 weeks. People receive it as outpatients, but it is given intravenously, over a period of several hours. Most of the common side effects are fever, chills, rigors or shakes, and are most likely to occur during the first treatment. In contrast to many chemotherapy agents, Rituxan does not have other significant side effects like nausea, vomiting, hair loss, and low blood counts. Rituxan has been most extensively studied in patients that have relapsed low grade NHL: about 50% of the patients respond with about 5% having a complete remission. Rituximab has also been combined with a radioactive particle to enhance its effect with directed radiation therapy, as mentioned above. This treatment (called Y2B8 or Zevalin) is given twice intravenously in an outpatient clinic, with a week between doses. During the week between doses, nuclear medicine scans are used to determine the dosing in the second treatment. In the initial studies the anti-tumor effects and response rates are significantly higher using this radiolabeled combination, and the toxic side effects like low blood counts appear to be manageable.

more >> http://www.lymphomafocus.org/focus_article.asp?b=lymphoma&f=lymphoma_treatment&c=treatment_monoclonal&pg=3

Immunohistochemistry is a diagnostic test

2006-06-20T15:16:00.000-07:00

Immunohistochemistry is a diagnostic test. It uses antibodies previously marked with a substance that can be seen under the microscope. The antibodies are specific to an antigen that the test is able to detect. These antibodies have high affinity to their antigens so the test has high specificity, not necessarily high sensitivity which depends on other factors.

It is widely used to detect and classify cancer cells Antibodies can be polyclonal or monoclonal. How can this test affect treatment options for a given disease? I will explain this through an example:

Cells, cancer or not, have, different antigens (markers) on their membranes, such as receptors, glycoproteins, etc. This markers define populations of cells like CD4 and CD8 T-lymphocytes and B-lymphocytes (CD-20 + or -). This markers, when they are unique to a specific type of cell, can help not only to differentiate them, but also to target them with specific antibodies. These antibodies can be used for tests and also as treatments.

I will explain this through an example:

A patient comes to the office with a biopsy of his pleura, and it reports "Diffuse large B-cell lymphoma". The immunoperoxidase shows CD20 (+) (a B cell marker) and Bcl-6 (a marker of its origin from the germinal center).

If this patient didn't have a CD20 (+) report then he wouldn't be eligible for Rituximab therapy and the prognosis would be far more somber.

Rituximab is a genetically engineered chimeric murine/human monoclonal antibody that targets CD20 receptors that are present in certain B-cell non-Hodgkin lymphomas. Once it reaches its intended target, it activates other immune cells and the complement system to destroy the b-cell. It is part of the new therapies that are being used in Hemato-oncology.

Before Rituximab, the standard therapy for B-cell lymphoma was CHOP therapy. This therapy had a success rate of 40% to 50%. (3-year event-free rate)

When Rituximab is used in conjunction with CHOP chemotherapy, it has shown a success rate of up to 99% (when used in early stages).

Now you see the difference.

However this new therapies are not exempt of potentially hazardous effects, and this page is not intended as an advertisement of Rituximab, but to show an example of the application of antibodies in different settings (diagnostic and therapeutic.

Francisco Santander M.D. Visit the source Immunohistochemistry and new lymphoma treatments

Lymphoma

2006-06-20T06:56:00.000-07:00

Summary
Lymphoma is cancer of the lymphoid tissue, which is part of the lymphatic system. A major component of the immune system, the lymphatic system consists of organs, lymph nodes and lymphatic vessels. This system manufactures lymphocytes and transports lymph (fluid made of plasma and white blood cells) from tissues to the bloodstream. Although other forms of cancer may spread to parts of the lymphatic system, lymphoma is the only form that originates in the system.

Lymphoid tissue is formed by various types of immune cells that work together to resist some types of infection and other threats, such as cancer. Lymphocytes are the main type of cell found in the lymphoid tissue. In lymphoma, abnormal lymphocytes continually grow for no reason. This results in abnormal enlargement of the lymph nodes and other body organs containing lymphocytes, causing lumps to develop in the body.

Lymphomas can be categorized into two main groups. One group, characterized by the presence of specific cells (called Reed-Sternberg cells), is known as Hodgkin’s lymphoma or Hodgkin’s disease. All other forms of lymphomas are known as non-Hodgkin’s lymphoma. Cases of non-Hodgkin’s lymphoma are far more common.

Most lymphomas develop as a result of noninherited mutations in the genes of growing lymphocytes. According to the National Cancer Institute (NCI), lymphomas account for about 5 percent of all cases of cancer in the United States. They can occur in both children and adults.

Non-Hodgkin's lymphoma

2005-10-03T03:27:00.000-07:00

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Non-Hodgkin's lymphoma

(Redirected from Non-Hodgkins lymphoma)
Non-Hodgkin's lymphoma
ICD-10 code: C82-C85
ICD-9 code:

Non-Hodgkin's lymphoma is a type of cancer. Lymphoma is a general term for cancers that develop in the lymphatic system. Hodgkin's disease is one type of lymphoma. All other lymphomas are grouped together and are called non-Hodgkin's lymphoma. Lymphomas account for about 5 percent of all cases of cancer in the United States.

The human lymphatic systemThe lymphatic system is part of the body's immune system. It helps the body fight disease and infection. The lymphatic system includes a network of thin tubes that branch, like blood vessels, into tissues throughout the body. Lymphatic vessels carry lymph, a colorless, watery fluid that contains infection-fighting cells called lymphocytes. Along this network of vessels are small organs called lymph nodes. Clusters of lymph nodes are found in the underarms, groin, neck, chest, and abdomen. Other parts of the lymphatic system are the spleen, thymus, tonsils, and bone marrow. Lymphatic tissue is also found in other parts of the body, including the stomach, intestines, and skin.

Cancer is a group of many related diseases that begin in cells, the body's basic unit of life. To understand non-Hodgkin's lymphoma, it is helpful to know about normal cells and what happens when they become cancerous. The body is made up of many types of cells. Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy. Sometimes cells keep dividing when new cells are not needed, creating a mass of extra tissue. This mass is called a growth or tumor. Tumors can be either benign (not cancerous) or malignant (cancerous).

In non-Hodgkin's lymphoma, cells in the lymphatic system become abnormal. They divide and grow without any order or control, or old cells do not die as cells normally do. Because lymphatic tissue is present in many parts of the body, non-Hodgkin's lymphoma can start almost anywhere in the body. Non-Hodgkin's lymphoma may occur in a single lymph node, a group of lymph nodes, or in another organ. This type of cancer can spread to almost any part of the body, including the liver, bone marrow, and spleen.

Contents [hide]
1 Symptoms
2 Diagnosis
3 Types of Non-Hodgkin's Lymphoma
4 Etiology
5 Staging
5.1 Stages of NHL
6 Treatment
7 Getting a Second Opinion
8 Preparing for Treatment
9 Methods of Treatment
10 Clinical Trials
11 Side Effects of Treatment
11.1 Chemotherapy
11.2 Radiation Therapy
11.3 Bone Marrow Transplantation
11.4 Biological Therapy
11.5 Surgery
12 Nutrition During Cancer Treatment
13 Recovery and Outlook
14 Followup Care
15 Risk Factors Associated with Non-Hodgkin's Lymphoma
16 Notable NHL patients
17 References:

Symptoms
The most common symptom of non-Hodgkin's lymphoma is a painless swelling of the lymph nodes in the neck, underarm, or groin.

Other symptoms may include the following:

Unexplained fever
Night sweats
Constant fatigue
Unexplained weight loss
Itchy skin
Reddened patches on the skin
When symptoms like these occur, they are not sure signs of non-Hodgkin's lymphoma. They may also be caused by other, less serious conditions, such as the flu or other infections. Only a doctor can make a diagnosis. When symptoms are present, it is important to see a doctor so that any illness can be diagnosed and treated as early as possible. Do not wait to feel pain; early non-Hodgkin's lymphoma may not cause pain.

Diagnosis
If non-Hodgkin's lymphoma is suspected, the doctor asks about the person's medical history and performs a physical exam. The exam includes feeling to see if the lymph nodes in the neck, underarm, or groin are enlarged. In addition to checking general signs of health, the doctor may perform blood tests.

The doctor may also order tests that produce pictures of the inside of the body. These may include:

X-rays: Pictures of areas inside the body created by high-energy radiation.
CT scan (also known as a "CAT scan"): A series of detailed pictures of areas inside the body. The pictures are created by a computer linked to an x-ray machine.
MRI (magnetic resonance imaging): Detailed pictures of areas inside the body produced with a powerful magnet linked to a computer.
Lymphangiogram: Pictures of the lymphatic system taken with x-rays after a special dye is injected to outline the lymph nodes and vessels.
A biopsy is needed to make a diagnosis. A surgeon removes a sample of tissue so that a pathologist can examine it under a microscope to check for cancer cells. A biopsy for non-Hodgkin's lymphoma is usually taken from a lymph node, but other tissues may be sampled as well. Sometimes, an operation called a laparotomy may be performed. During this operation, a surgeon cuts into the abdomen and removes samples of tissue to be checked under a microscope.

A patient who needs a biopsy may want to ask the doctor some of the following questions:

Why do I need to have a biopsy?
How long will the biopsy take? Will it hurt?
How soon will I know the results?
If I do have cancer, who will talk with me about treatment? When?

Types of Non-Hodgkin's Lymphoma
Over the years, doctors have used a variety of terms to classify the many different types of non-Hodgkin's lymphoma. Most often, they are grouped by how the cancer cells look under a microscope and how quickly they are likely to grow and spread. Aggressive lymphomas, also known as intermediate and high-grade lymphomas, tend to grow and spread quickly and cause severe symptoms. Indolent lymphomas, also referred to as low-grade lymphomas, tend to grow quite slowly and cause fewer symptoms. One of the paradoxes of non-Hodgkin's lymphoma is that the indolent lymphomas generally cannot be cured by chemotherapy, while in a significant number of cases aggressive lymphomas can be. Current lymphoma classification is complex. Common types of lymphomas include follicular lymphoma and diffuse large B cell lymphoma.

Details of the most popular classifications of lymphoma can be found in the lymphoma page.

Etiology
The etiology of most lymphomas is not known. Rare types of lymphomas are caused by viruses. Burkitt's lymphoma, extranodal NK/T cell lymphoma and Hodgkin's disease are caused by the Epstein-Barr virus. Adult T-cell lymphoma/leukemia is caused by the HTLV-1 virus, endemic in parts of Japan and the Caribbean. Lymphoma of the stomach is often caused by the Helicobacter bacteria.

Staging
If non-Hodgkin's lymphoma is diagnosed, the doctor needs to learn the stage, or extent, of the disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Treatment decisions depend on these findings.

The doctor considers the following to determine the stage of non-Hodgkin's lymphoma:

The number and location of affected lymph nodes;
Whether the affected lymph nodes are above, below, or on both sides of the diaphragm (the thin muscle under the lungs and heart that separates the chest from the abdomen); and
Whether the disease has spread to the bone marrow, spleen, or to organs outside the lymphatic system, such as the liver.
In staging, the doctor may use some of the same tests used for the diagnosis of non-Hodgkin's lymphoma. Other staging procedures may include additional biopsies of lymph nodes, the liver, bone marrow, or other tissue. A bone marrow biopsy involves removing a sample of bone marrow through a needle inserted into the hip or another large bone. A pathologist examines the sample under a microscope to check for cancer cells.

Stages of NHL
The various stages of NHL (the Ann Arbor staging classification, developed for Hodgkin's lymphoma) are based on how far the cancer has spread throughout and beyond the lymphatic system, and whether constitutional symptoms (fever, night sweats, or weight loss) are present.

Stage I
"Stage I" indicates that the cancer is located in a single region, usually one lymph node and the surrounding area. Stage I often will not have outward symptoms.
Stage II
"Stage II" indicates that the cancer is located in two separate regions, an affected lymph node or organ within the lymphatic system and a second affected area, and that both affected areas are confined to one side of the diaphagm - that is, both are above the diaphragm, or both are below the diaphragm.
Stage III
"Stage III" indicates that the cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
Stage IV
"Stage IV" indicates that the cancer has spread beyond the lymphatic system and involves one or more major organs, possibly including the bone marrow or skin.
The absence of constitutional symptoms is denoted by adding an "A" to the stage; the presence is denoted by adding a "B" to the stage.

Staging in Non-Hodkin's lymphomas is far less significant in determining therapy than it is in Hodgkin's lymphoma.

Treatment
The doctor develops a treatment plan to fit each patient's needs. Treatment for non-Hodgkin's lymphoma depends on the stage of the disease, the type of cells involved, whether they are indolent or aggressive, and the age and general health of the patient.

Non-Hodgkin's lymphoma is often treated by a team of specialists that may include a hematologist, medical oncologist, and/or radiation oncologist. Non-Hodgkin's lymphoma is usually treated with chemotherapy, radiation therapy, or a combination of these treatments. In some cases, bone marrow transplantation, biological therapies, or surgery may be options. For indolent lymphomas, the doctor may decide to wait until the disease causes symptoms before starting treatment. Often, this approach is called "watchful waiting."

Taking part in a clinical trial (research study) to evaluate promising new ways to treat non-Hodgkin's lymphoma is an important option for many people with this disease.

Getting a Second Opinion
Before starting treatment, patients may want a second opinion to confirm their diagnosis and treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.

There are a number of ways to find a doctor who can give a second opinion:

The patient's doctor may be able to suggest specialists to consult.
In the United States, The Cancer Information Service, at 1-800-4-CANCER, can tell callers about cancer treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.
Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.
In the United States, The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and medical background. This resource, produced by the American Board of Medical Specialties, is available in most public libraries and on the Internet.

Preparing for Treatment
Many people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for people to think of everything they want to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

These are some questions a patient may want to ask the doctor before treatment begins:

What kind of non-Hodgkin's lymphoma do I have?
What is the stage of the disease?
What are my treatment choices? Which do you recommend for me? Why?
What are the risks and possible side effects of each treatment?
What side effects should I report to you?
How long will treatment last?
What are the chances that the treatment will be successful?
Will treatment affect my normal activities? If so, for how long?
Are new treatments under study? Would a clinical trial be appropriate for me?
What is the treatment likely to cost?
Patients do not need to ask all their questions or remember all the answers at one time. They will have other chances to ask the doctor to explain things and to get more information.

Methods of Treatment
Chemotherapy and radiation therapy are the most common treatments for non-Hodgkin's lymphoma, although bone marrow transplantation, biological therapies, or surgery are sometimes used.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for non-Hodgkin's lymphoma usually consists of a combination of several drugs. Patients may receive chemotherapy alone or in combination with radiation therapy.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most anticancer drugs are given by injection into a blood vessel (IV); some are given by mouth. Chemotherapy is a systemic treatment because the drugs enter the bloodstream and travel throughout the body.

Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. Treatment with radiation may be given alone or with chemotherapy. Radiation therapy is local treatment; it affects cancer cells only in the treated area. Radiation therapy for non-Hodgkin's lymphoma comes from a machine that aims the high-energy rays at a specific area of the body. There is no radioactivity in the body when the treatment is over.

Sometimes patients are given chemotherapy and/or radiation therapy to kill undetected cancer cells that may be present in the central nervous system (CNS). In this treatment, called central nervous system prophylaxis, the doctor injects anticancer drugs directly into the cerebrospinal fluid.

Bone marrow transplantation (BMT) may also be a treatment option, especially for patients whose non-Hodgkin's lymphoma has recurred (come back). BMT provides the patient with healthy stem cells (very immature cells that produce blood cells) to replace cells damaged or destroyed by treatment with very high doses of chemotherapy and/or radiation therapy. The healthy bone marrow may come from a donor, or it may be marrow that was removed from the patient, treated to destroy cancer cells, stored, and then given back to the person following the high-dose treatment. Until the transplanted bone marrow begins to produce enough white blood cells, patients have to be carefully protected from infection. They usually stay in the hospital for several weeks.

Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen the side effects that can be caused by some cancer treatments. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. Biological therapy is sometimes also called biological response modifier therapy.

Clinical Trials
Many people with non-Hodgkin's lymphoma take part in clinical trials (research studies). Doctors conduct clinical trials to learn about the effectiveness and side effects of new treatments. In some trials, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and the standard therapy to another group; or they may compare one standard treatment with another. Research like this has led to significant advances in the treatment of cancer. Each achievement brings researchers closer to the eventual control of cancer.

Doctors are studying radiation therapy, new ways of giving chemotherapy, new anticancer drugs and drug combinations, biological therapies, bone marrow transplantation, peripheral blood stem cell transplantation, and new ways of combining various types of treatment. Some studies are designed to find ways to reduce the side effects of treatment and to improve the patient's quality of life.

Side Effects of Treatment
Treatments for non-Hodgkin's lymphoma are very powerful. It is hard to limit the effects of therapy so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes side effects.

The side effects of cancer treatment depend mainly on the type and extent of the therapy. Side effects may not be the same for everyone, and they may even change from one treatment to the next. Doctors and nurses can explain the possible side effects of treatment. They can also lessen or control many of the side effects that may occur during and after treatment.

Chemotherapy
The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives. As with other types of treatment, side effects may vary from person to person.

Anticancer drugs generally affect cells that divide rapidly. In addition to cancer cells, these include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected, the patient is more likely to get infections, may bruise or bleed easily, and may feel unusually weak and tired. The patient's blood count is monitored during chemotherapy and, if necessary, the doctor may decide to postpone treatment to allow blood counts to recover.

Cells in hair roots also divide rapidly; therefore, chemotherapy may lead to hair loss. Patients may have other side effects such as poor appetite, nausea and vomiting, or mouth and lip sores. They may also experience dizziness and darkening of skin and fingernails. Another common side effect is peripheral neuropathy.

Most side effects go away gradually during the recovery periods between treatments or after treatment is over. However, certain anticancer drugs can increase the risk of developing a second cancer later in life.

In some men and women, chemotherapy causes a loss of fertility (the ability to produce children). Loss of fertility may be temporary or permanent, depending on the drugs used and the patient's age. For men, sperm banking before treatment may be an option. Women's menstrual periods may stop, and they may have hot flashes and vaginal dryness. Menstrual periods are more likely to return in young women. The National Cancer Institute booklet Chemotherapy and You has helpful information about chemotherapy and coping with side effects.

Radiation Therapy
The side effects of radiation depend on the treatment dose and the part of the body that is treated. During radiation therapy, people are likely to become extremely tired, especially in the later weeks of treatment. Rest is important, but doctors usually advise patients to try to stay as active as they can.

It is common to lose hair in the treated area and for the skin to become red, dry, tender, or itchy. There may also be permanent darkening or "bronzing" of the skin in the treated area.

When the chest and neck are treated, patients may have a dry, sore throat and trouble swallowing. Some patients may have tingling or numbness in their arms, legs, and lower back. Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. Often, changes in diet or medicine can ease these problems.

Radiation therapy also may cause a decrease in the number of white blood cells, cells that help protect the body against infection. If that happens, patients need to be careful to avoid possible sources of infection. The doctor monitors a patient's blood count during radiation therapy. In some cases, treatment may have to be postponed to allow blood counts to recover.

Although the side effects of radiation therapy can be difficult, they can usually be treated or controlled. It may also help to know that, in most cases, side effects are not permanent. However, patients may want to discuss with their doctor the possible long-term effects of radiation treatment on fertility and the increased chance of second cancers after treatment is over. The National Cancer Institute booklet "Radiation Therapy and You" has helpful information about radiation therapy and managing its side effects.

Bone Marrow Transplantation
Patients who have a bone marrow transplant face an increased risk of infection, bleeding, and other side effects from the large doses of chemotherapy and radiation they receive. In addition, graft-versus-host disease (GVHD) may occur in patients who receive bone marrow from a donor. In GVHD, the donated marrow attacks the patient's tissues (most often the liver, the skin, and the digestive tract). GVHD can range from mild to very severe. It can occur any time after the transplant (even years later). In most cases, GVHD can be treated effectively with the use of steriods and other immunosuppressant drugs.

Biological Therapy
The side effects caused by biological therapy vary with the specific type of treatment. These treatments may cause flu-like symptoms such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients also may bleed or bruise easily, get a skin rash, or retain fluid. These problems can be severe, but they usually go away after treatment stops.

Surgery
The side effects of surgery depend on the location of the tumor, the type of operation, the patient's general health, and other factors. Although patients are often uncomfortable during the first few days after surgery, the pain can usually be controlled with medicine. People can talk with their doctor or nurse about pain relief. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient.

Nutrition During Cancer Treatment
Eating well during cancer treatment means getting enough calories and protein to help prevent weight loss and regain strength. Good nutrition often helps people feel better and have more energy.

Some people with cancer find it hard to eat a balanced diet because they may lose their appetite. In addition, common side effects of treatment, such as nausea, vomiting, or mouth sores, can make eating difficult. Often, foods taste different. Also, people being treated for cancer may not feel like eating when they are uncomfortable or tired.

Doctors, nurses, and dietitians can offer advice on how to get enough calories and protein during cancer treatment. Patients and their families also may want to read the National Cancer Institute(USA) booklet Eating Hints for Cancer Patients, which contains many useful suggestions.

Recovery and Outlook
It is natural for anyone facing cancer to be concerned about what the future holds. Understanding the nature of cancer and what to expect can help patients and their loved ones plan treatment, anticipate lifestyle changes, and make quality of life and financial decisions.

Cancer patients frequently ask their doctors or search on their own for an answer to the question, "What is my prognosis?" Prognosis is a prediction of the future course and outcome of a disease and an indication of the likelihood of recovery. However, it is only an estimate. When doctors discuss a patient's prognosis, they are attempting to project what is likely to occur for that individual patient.

Sometimes patients use statistics to try to figure out their chances of being cured; however, statistics reflect the experience of a large group of patients and cannot be used to predict what will happen to a particular patient because no two patients are alike. The prognosis for a person with non-Hodgkin's lymphoma can be affected by many factors, particularly the type and stage of the cancer and the patient's age, general health, and response to treatment. The doctor who is most familiar with a patient's situation is in the best position to help interpret statistics and discuss that person's prognosis.

When doctors talk about surviving cancer, they may use the term remission rather than cure. Although many people with non-Hodgkin's lymphoma are successfully treated, doctors use the term remission because cancer can return. It is important to discuss the possibility of recurrence with the doctor.

Followup Care
People who have had non-Hodgkin's lymphoma should have regular followup examinations after their treatment is over. Followup care is an important part of the overall treatment plan, and people should not hesitate to discuss it with their health care provider. Regular followup care ensures that patients are carefully monitored, any changes in health are discussed, and new or recurrent cancer can be detected and treated as soon as possible. Between followup appointments, people who have had non-Hodgkin's lymphoma should report any health problems as soon as they appear.

Risk Factors Associated with Non-Hodgkin's Lymphoma
The incidence of non-Hodgkin's lymphoma has increased dramatically over the last couple of decades. This disease has gone from being relatively rare to being the fifth most common cancer in the United States. At this time, little is known about the reasons for this increase or about exactly what causes non-Hodgkin's lymphoma.

Doctors can seldom explain why one person gets non-Hodgkin's lymphoma and another does not. It is clear, however, that cancer is not caused by an injury, and is not contagious; no one can "catch" non-Hodgkin's lymphoma from another person.

By studying patterns of cancer in the population, researchers have found certain risk factors that are more common in people who get non-Hodgkin's lymphoma than in those who do not. However, most people with these risk factors do not get non-Hodgkin's lymphoma, and many who do get this disease have none of the known risk factors.

The following are some of the risk factors associated with this disease:

Age/Sex -- The likelihood of getting non-Hodgkin's lymphoma increases with age and is more common in men than in women.
Weakened Immune System (AIDS-related lymphoma) -- Non-Hodgkin's lymphoma is more common among people with inherited immune deficiencies, autoimmune diseases, or HIV/AIDS, and among people taking immunosuppressant drugs following organ transplants. (see Post-transplant lymphoproliferative disorder)
Viruses -- Human T-lymphotropic virus type I (HTLV-1) and Epstein-Barr virus are two infectious agents that increase the chance of developing non-Hodgkin's lymphoma.
Environment -- People who work extensively with or are otherwise exposed to certain chemicals, such as pesticides, solvents, or fertilizers, have a greater chance of developing non-Hodgkin's lymphoma.
People who are concerned about non-Hodgkin's lymphoma should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the person's age, medical history, and other factors.

Notable NHL patients
Notable persons treated for Non-Hodgkin's lymphoma include:

Jackie Kennedy Onassis, widow of former U.S. president John F. Kennedy
U.S. Senator Paul Tsongas
British soap opera star Anne Kirkbride
Velvet Underground guitar player Sterling Morrison
The former Shah Mohammed Reza Pahlevi of Iran (although this was probably CLL).
King Hussein of Jordan
U.S. Nobel Prize laureate Jack S. Kilby, inventor of the integrated circuit
Croatian basketball player, coach, and diplomat Krešimir Ćosić
Saku Koivu, NHL star, captain of the Montreal Canadiens.

References:
"What You Need to Know About Non-Hodgkins Lymphoma". NIH Publication No. 99-1567. URL accessed on January 22, 2002.
The original version of this article was edited down from the source above. As a work of an agency of the U.S. Federal Government, this document is a public domain resource that can be used as source material for Wikipedia.
Please see the NIH Policies page for more information
"Non-Hodgkin's lymphoma Fact Sheet". Genentech, Inc.. URL accessed on April 25, 2005.
"Staging NHL". Cancer Research UK 2002. URL accessed on April 25, 2005.
From Wikipedia, the free encyclopedia.
>>http://en.wikipedia.org/wiki/Non-Hodgkins_lymphoma

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Clinicopathological features of gastric mucosa associated lymphoid tissue (MALT) lymphomas: high grade transformation and comparison with diffuse larg

2005-10-03T03:24:00.000-07:00

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Clinicopathological features of gastric mucosa associated lymphoid tissue (MALT) lymphomas: high grade transformation and comparison with diffuse large B cell lymphomas without MALT lymphoma features

Tadashi Yoshino1, Kunihiro Omonishi1, Keita Kobayashi1, Tomohiko Mannami1, Hiroyuki Okada2, Motowo Mizuno2, Ichiro Yamadori1, Eisaku Kondo1 and Tadaatsu Akagi1
1 Department of Pathology, Okayama University Medical School, 2-5-1 Shikata-cho, Okayama 700-8558, Japan
2 Department of Internal Medicine, Okayama University Medical School

Correspondence: Dr Yoshino email: yoshino@med.okayama-u.ac.jp

Accepted for publication August 9, 1999 .

Abstract
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Abstract
Introduction
Methods
Results
Discussion
References

Aims—To investigate the clinicopathological differences among gastric low grade MALT lymphomas (low MALT), large B cell lymphomas with low grade components (secondary high grade MALT lymphomas, high MALT), and diffuse large B cell lymphomas without low grade features (primary high grade MALT lymphomas, DLL).

Methods—Clinicopathological and morphological characters of 126 gastric lymphoma cases were studied: 82 cases of low MALT lymphoma including 40 that were surgically resected, 17 cases of high MALT lymphoma including 13 surgically resected, and 27 cases of DLL including 12 surgically resected.

Results—Age ranges were as follows: low MALT lymphoma, 34 to 85 years (mean 59.9); high MALT lymphoma, 53 to 88 years (mean 68.5); DLL, 29 to 83 years (mean 62.3). The average age for low and high MALT lymphomas was significantly different (p < 0.05), but there were no differences in other comparisons. There was a female predominance of low MALT lymphoma patients (female to male ratio, 47/35), while for high MALT patients the ratio was almost even (8/9), and for DLL patients there was a male predominance (11/16). Examination of surgically resected material showed that MALT lymphomas had a wider distribution in the gastric wall than DLL.

Conclusions—The findings suggest that at least some of the high grade gastric lymphomas, especially in patients younger than the fifth decade, do not originate from high grade transformation of low MALT lymphomas. It seems to take about one decade at least for high grade transformation of low MALT lymphomas.

Key Words: MALT lymphoma • stomach • transformation

Introduction
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Abstract
Introduction
Methods
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Discussion
References

Since Isaacson and Wright established the concept of the mucosa associated lymphoid tissue (MALT) lymphoma,1 it has been widely accepted as a distinct disease entity and is included in a new proposal of lymphoma classification.2 Aetiologically, gastric low grade MALT lymphoma (low MALT lymphoma) is closely associated with Helicobacter pylori gastritis.3–6 Low MALT lymphomas occasionally progress into high grade lymphomas (secondary or simultaneous high grade MALT lymphomas, high MALT lymphomas).7,8 High grade portions are composed of large lymphoma cells with frequent mitotic figures. High grade MALT lymphomas have been shown to be associated with p53 abnormalities9 and overexpression of BCL-6.10 In addition to these high grade MALT lymphomas, gastric lymphomas sometimes show the histology of conventional diffuse large B cell lymphoma without MALT lymphoma features (primary high grade MALT lymphomas, DLL). The histogenesis of these DLL tumours is not yet clear. In the present study, we characterise the clinicopathological features of gastric low and high grade MALT lymphomas and DLL, and suggest that at least some DLL do not originate from malignant progression of low grade MALT lymphomas.

Methods
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Introduction
Methods
Results
Discussion
References

CASES, DIAGNOSTIC CRITERIA, AND IMMUNOHISTOLOGY
We examined 126 cases of gastric lymphomas in our surgical pathology files; 65 of these were surgically resected. As it was recently reported that eradication of H pylori is effective treatment for gastric low grade MALT lymphomas,4–6 surgery is now rarely used as first line treatment. Thus most of the resected cases examined in our present study were treated over two years ago. Low grade MALT lymphomas were diagnosed on the basis of previously described criteria.11–13 We defined high grade MALT lymphomas as lymphomatous foci containing high grade as well as low grade components (fig 1). Histologically, the high grade component is similar to diffuse large B cell lymphomas. Diffuse large B cell lymphomas without low grade MALT lymphoma features are designated DLL. Eighty two cases were diagnosed as low grade MALT lymphoma, including 40 that were surgically resected; 17 cases were diagnosed as high grade MALT lymphomas, including 13 surgically resected; and 27 cases were diagnosed as DLL, including 12 surgically resected. In most cases with surgically resected material, over 20 blocks were made for histological examination.

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Figure 1 A case of high grade (simultaneous and secondary) gastric MALT lymphoma. (A) A low magnification view indicates that the low grade area (*) and the high grade area (**) are directly connected (haematoxylin and eosin, x20). (B) A high magnification view of a low grade MALT lymphoma area showing that the lymphoma cells are medium sized and centrocyte-like, forming a lymphoepithelial lesion (H&E, x322). (C) A high magnification view of a high grade MALT lymphoma area showing that large sized nucleated lymphoma cells proliferate diffusely (H&E, x322).

All cases were examined immunohistologically with anti-CD20, CD3, CD45, CD43, CD45RO, PCNA, cyclin D1, cytokeratin, Ig and Ig antibodies for diagnosis and characterisation. Cases in which frozen section were available were also examined with anti-CD5, 10, 19, and 22 antibodies. Immunohistochemical studies were carried out using the avidin-biotin peroxidase complex technique, as previously described.10
STATISTICAL ANALYSES
To compare the average ages and sexual differences of examined groups, we used the Student t test and the 2 test, respectively.

Results
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Introduction
Methods
Results
Discussion
References

CLINICAL CHARACTERISTICS
Patients with low MALT lymphoma were aged between 34 and 85 years (mean 59.9); those with high MALT lymphoma were between 53 and 88 (mean 68.5); and those with DLL were between 29 and 83 (mean 62.3) (table 1; fig 2). The average age of the patients with low and high MALT lymphomas was significantly different (t test, p < 0.05), but there was no difference in the other comparisons. Interestingly, the age distribution of DLL was much wider than that of MALT lymphomas and was composed of a large group with a normal distribution peaking in the sixties and an additional small group of younger patients aged less than 50.

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Table 1 Summary of the cases examined

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Figure 2 Age distribution of gastric lymphomas. Low MALT, low grade MALT lymphoma; high MALT, high grade MALT lymphoma; DLL, diffuse large B cell lymphoma without MALT lymphoma features.

As summarised in table 1, there was a predominance of female patients in the low MALT group (female to male ratio, 47/35), while the sex distribution was almost equal in the high MALT group (8/9). There was a male predominance among the DLL patients (female to male ratio, 11/16); this was particularly marked in the under-fifties, where the ratio was reduced to 1/4. These difference were not statistically significant, however.
MACROSCOPIC AND HISTOLOGICAL FEATURES
Macroscopically, low grade MALT lymphomas showed widespread lesions with multiple irregular shaped erosions or shallow ulcers in 55 cases (67%) (fig 3A), large ulcers in 10 cases (12%) (fig 3B), and swollen mucosal folds with or without multiple polyps in 17 cases (21%) (fig 3C). High grade MALT lymphomas often showed large ulcers similar to advanced gastric cancers, or protruded tumours, as well as multiple shallow ulcers. The macroscopic findings of DLL were similar to those of advanced gastric cancer except in two cases which showed multiple ulcers.

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Figure 3 Macroscopic findings of low grade gastric MALT lymphomas. (A) Endoscopic pictures showing irregular shaped shallow ulcers (arrowheads). (B) A resected stomach showing a large scarring ulcer. Lymphoma cells were found on the edge of the ulcer. (C) Cut surface of the stomach with multiple polypoid lesions. The inset panel is the endoscopic view of the same case.

Depth, spread, and lymph nodal metastases were examined in surgically resected material. In 77% of high grade MALT lymphomas and 83% of DLL, lymphoma cells invaded the muscle layer or more deeply. In contrast, 83% of low grade MALT lymphomas were confined to the mucosal and submucosal layers (fig 4). The distribution of the lymphomas was investigated by subdividing the stomach into three portions: C (the upper third), M (the middle third), and A (the lower third). MALT lymphomas tended to have multiple lesions and 52% were distributed in more than one portion. In contrast, 78% of DLL were confined to a single area (fig 5). The gastric greater curvature was involved in 79% of all MALT lymphomas, but in only 17% of DLL. Stump involvement in resected stomachs was detected in five cases of MALT lymphoma (one high grade and four low grade cases), but not in DLL.

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Figure 4 Depth of the gastric walls involved with lymphoma cells; m, mucosa; sm, submucosa; mp, muscularis propria; s, subserosa and serosa. Low MALT, low grade MALT lymphoma; high MALT, high grade MALT lymphoma; DLL, diffuse large B cell lymphoma without MALT lymphoma features.

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Figure 5 Regional distribution of gastric lymphomas. C, upper third; M, middle third; A, lower third. CM, MA, and CMA represent C + M, M + A, and the whole area, respectively. DLL, diffuse large B cell lymphoma without MALT lymphoma features. MALT lymphomas include both low grade and high grade lymphomas.

The correlation between the depth of the lesions and lymph node dissemination is summarised in table 2. Lymph nodal resection was performed in 60 cases. Lymph node metastases were found in only one of 34 cases (3%) that involved only the mucosal or submucosal layers. In contrast, lymph node metastases were often observed in lymphomas invading down to the muscle layer (45%) or deeper (73%), irrespective of histological type.

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Table 2 Relation between depth of the gastric wall involved with lymphoma and lymph node dissemination

Discussion
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Methods
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References

The pathogenesis of primary and secondary high grade gastric lymphomas, and the differences between them, are interesting issues. Some investigators have categorised gastric DLL among the MALT lymphomas,14–16 but others have regarded them as being separate from high grade MALT lymphomas.17 Chan et al have recently reported that DLL are associated with abnormalities of chromosome 12, but these changes were found less often in high grade MALT lymphomas.18 Ott et al also recently pointed out that gains of chromosome 7 and 12 tend to be associated with DLL, and gains of chromosome 18 are more closely related to high grade MALT lymphomas, though a statistical difference could not be shown.19 These findings may indicate that DLL and high grade MALT lymphomas have a different pathogenesis.
We focused on the clinicopathological features and differences between low and high grade MALT lymphomas and DLL. Our data indicate that low grade MALT lymphomas have a female preponderance, like MALT lymphomas at other sites,11 but DLL appears to have a slight male preponderance (table 1), though the differences did not achieve statistical significance. The regional distribution of low grade and high grade MALT lymphomas was much wider than that of DLL (figs 4 and 5). The stump invasion of lymphoma cells was detected only in MALT lymphomas. This finding is probably correlated with the wider distribution of MALT lymphomas. Lymph node metastasis was obviously dependent on the depth of the lesions, and there was a clear borderline between the submucosa and the muscle layers proper (table 2).These findings should be useful for image analyses of gastric lymphoma cases.

The mean age of patients with high grade MALT lymphoma was 8.6 years older than that of patients with low grade MALT lymphoma, and this difference was statistically significant (table 1, fig 2). There is at present no information about the time course of malignant transformation from low MALT lymphoma into high MALT lymphoma—that is, secondary high grade MALT lymphoma. Though this information could be obtained from prospective studies, the opportunities for such studies are limited. As our cases were consecutive, the age differences found may well be related to the rate of progression, which is another important result.

As shown in fig 2, the age distribution curve of low grade MALT lymphoma is normally distributed, with a peak age in the sixties. In the high grade MALT lymphoma group, the number of cases gradually increased from the fifties to the seventies. The age distribution curve of the DLL group was quite different, being much more widely distributed over the age range, and the shape of the curve suggested that the patients formed a mixed population, with a normally distributed older age group and a separate, smaller group of younger patients. Interestingly, there appeared to be a male predominance in patients younger than 50 years old. The differences in the clinicopathological features in our series suggest that some at least of the DLL cases do not originate from transformation of low grade MALT lymphomas, especially in the younger age group. This information may prove useful in the clinical management of gastric lymphomas.

Acknowledgments

We thank Ms Yoshiko Sakamoto, Mr Ryouichi Domatsu, Ms Hiromi Nakamura, and Ms Mie Kosaka for technical assistance, and Ms Yoshiko Narasaki for secretarial work. This work was supported, in part, by a grant-in-aid for scientific research from the Ministry of Education, Science, Sports, and Culture of Japan. Presented in part at the 6th International Conference on Malignant Lymphoma at Lugano, Switzerland, June 5–8, 1997, and at the Non-Hodkin's Lymphoma Classification Project meeting at Omaha, September 8–10, 1997.

References
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Abstract
Introduction
Methods
Results
Discussion
References

Isaacson PG, Wright D. Malignant lymphoma of mucosa-associated lymphoid tissue. Cancer 1983;52:1410–16.[Medline]
Harris NL, Jaffe ES, Stein H, et al. A revised European–American classification of lymphoid neoplasms: a proposal from the international lymphoma study group. Blood 1994;84:1361–92.[Free Full Text]
Wotherspoon AC, Ortiz HC, Falzon MR, et al. Helicobacter pylori-associated gastritis and primary B-cell gastric lymphoma. Lancet 1991;338:1175–6.[Medline]
Wotherspoon AC, Doglioni C, Diss TC, et al. Regression of primary low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue type after eradication of Helicobacter pylori. Lancet 1993;342:575–7.[Medline]
Roggero E, Zucca E, Pinotti G, et al. Eradication of Helicobacter pylori infection in primary low-grade gastric lymphoma of mucosa-associated lymphoid tissue. Ann Intern Med 1995;122:767–9.[Abstract/Free Full Text]
Bayerdorffer E, Neubauer A, Rudolph B, et al. Regression of primary gastric lymphoma of mucosa-associated lymphoid tissue type after cure of Helicobacter pylori infection. MALT Lymphoma Study Group. Lancet 1995;345:1591–4.[Medline]
Isaacson PG. Recent developments in our understanding of gastric lymphomas. Am J Surg Pathol 1996;20(suppl 1):S1–7[Medline]
Montalban C, Manzanal A, Castrillo JM, et al. Low grade gastric B-cell MALT lymphoma progressing into high grade lymphoma. Clonal identity of the two stages of the tumour, unusual bone involvement and leukemic dissemination. Histopathology 1995;27:89–91.[Medline]
Du M, Peng H, Singh N, et al. The accumulation of p53 abnormalities is associated with progression of mucosa-associated lymphoid tissue lymphoma. Blood 1995;86:4587–93.[Abstract/Free Full Text]
Omonishi K, Yoshino T, Sakuma I, et al. BCL-6 protein is identified in high-grade but not low-grade mucosa-associated lymphoid tissue (MALT) lymphomas of the stomach. Mod Pathol 1998;11:181–5.[Medline]
Isaacson P, Norton A. Extranodal lymphomas. New York: Churchill Livingstone, 1994.
Ortiz HC, Wright DH. The morphological spectrum of monocytoid B-cell lymphoma and its relationship to lymphomas of mucosa-associated lymphoid tissue. Histopathology 1992;21:555–61.[Medline]
Isaacson PG, Wotherspoon AC, Diss T, et al. Follicular colonization in B-cell lymphoma of mucosa-associated lymphoid tissue. Am J Surg Pathol 1991;15:819–28.[Medline]
Taal G, Boot H, van Heerde P, et al. Primary non-Hodgkin's lymphomas of the stomach: endoscopic pattern and prognosis in low versus high grade malignancy in relation to the MALT concept. Gut 1996;39:556–61.[Abstract]
Krol AD, Hermans J, Kramer MH, et al. Gastric lymphomas compared with lymph node lymphomas in a population-based registry differ in stage distribution and dissemination pattern but not in patient survival. Cancer 1997;79:390–7.[Medline]
Nakamura S, Yao T, Aoyagi K, et al. Helicobacter pylori and primary gastric lymphoma. A histopathologic and immunohistochemical analysis of 237 patients. Cancer 1997;79:3–11.[Medline]
Cogliatti SB, Schmid U, Schumacher U, et al. Primary B-cell gastric lymphoma: a clinicopathological study of 145 patients. Gastroenterology 1991;101:1159–70.[Medline]
Chan W-Y, Wong N, Chan AB-W, et al. Consistent copy number gain in chromosome 12 in primary diffuse large cell lymphomas of the stomach. Am J Pathol 1998;152:11–16.[Abstract]
Ott G, Kalla J, Steinhoff A, et al. Trisomy 3 is not a common feature in malignant lymphomas of mucosa-associated lymphoid tissue type. Am J Pathol 1998;153:689–94.[Abstract/Free Full Text]
>>http://jcp.bmjjournals.com/cgi/content/full/53/3/187?maxtoshow=&HITS=&hits=&RESULTFORMAT=&fulltext=Lymphoma&andorexactfulltext=and&searchid=1128335037852_178&stored_search=&FIRSTINDEX=0&resourcetype=1

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Among B cell non-Hodgkin's lymphomas, MALT lymphomas express a unique antibody repertoire with frequent rheumatoid factor reactivity

2005-10-03T03:19:00.000-07:00

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Among B cell non-Hodgkin's lymphomas, MALT lymphomas express a unique antibody repertoire with frequent rheumatoid factor reactivity

Richard J. Bende1, Wilhelmina M. Aarts1, Robert G. Riedl1, Daphne de Jong2, Steven T. Pals1, and Carel J.M. van Noesel1
1 Department of Pathology, Academic Medical Center
2 Department of Pathology, Netherlands Cancer Institute, 1105 AZ Amsterdam, Netherlands

CORRESPONDENCE Carel J.M. van Noesel: c.j.vannoesel@amc.uva.nl

We analyzed the structure of antigen receptors of a comprehensive panel of mature B non-Hodgkin's lymphomas (B-NHLs) by comparing, at the amino acid level, their immunoglobulin (Ig)VH-CDR3s with CDR3 sequences present in GenBank. Follicular lymphomas, diffuse large B cell lymphomas, Burkitt's lymphomas, and myelomas expressed a CDR3 repertoire comparable to that of normal B cells. Mantle cell lymphomas and B cell chronic lymphocytic leukemias (B-CLLs) expressed clearly restricted albeit different CDR3 repertoires. Lymphomas of mucosa-associated lymphoid tissues (MALTs) were unique as 8 out of 45 (18%) of gastric- and 13 out of 32 (41%) of salivary gland-MALT lymphomas expressed B cell antigen receptors with strong CDR3 homology to rheumatoid factors (RFs). Of note, the RF-CDR3 homology without exception included N-region–encoded residues in the hypermutated IgVH genes, indicating that they were stringently selected for reactivity with auto-IgG. By in vitro binding studies with 10 MALT lymphoma–derived antibodies, we showed that seven of these cases, of which four with RF-CDR3 homology, indeed possessed strong RF reactivity. Of one MALT lymphoma, functional proof for selection of subclones with high RF affinity was obtained. Interestingly, RF-CDR3 homology and t(11;18) appeared to be mutually exclusive features and RF-CDR3 homology was not encountered in any of the 19 pulmonary MALT lymphomas studied.

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Abbreviations used: Ag, antigen; B-CLL, B cell chronic lymphocytic leukemia; B-NHL, B non-Hodgkin's lymphoma; BCR, B cell antigen receptor; BL, Burkitt's lymphoma; D, diversity; DLBCL, diffuse large B cell lymphoma; FL, follicular lymphoma; FR, framework region; GC, germinal center; HCV, hepatitis C virus; HID, healthy immunized donor; ICV, intraclonal sequence variation; J, joining; LIDA lymphoma- idiotype-derived Ab; MALT, mucosa-associated lymphoid tissue; MCL, mantle cell lymphoma; MZBCL, marginal zone B cell lymphoma; RF, rheumatoid factor; V, variable.
>>http://www.jem.org/cgi/content/abstract/201/8/1229?maxtoshow=&HITS=&hits=&RESULTFORMAT=&fulltext=Lymphoma&andorexactfulltext=and&searchid=1128334506381_5848&stored_search=&FIRSTINDEX=0&resourcetype=1

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Lymphoma

2005-10-03T03:18:00.000-07:00

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Lymphoma

Lymphoma is a general term for malignancies of lymphocytes or, more rarely, of histiocytes. Collectively, these cell types form the reticuloendothelial system and circulate in the vessels of the lymphatic system. Traditionally, Lymphoma is classified as Hodgkin's disease, discovered by Thomas Hodgkin in 1832, and non-Hodgkin's lymphoma (all other types of lymphoma). Modern classifications of lymphoma have moved away from this artificial division.

Classification
The Working Formulation, published in 1982, is primarily descriptive but remains the most widely used classification of non-Hodgkin lymphoma today.

Low Grade
Malignant Lymphoma, small lymphocytic (chronic lymphocytic leukemikaka)
Malignant Lymphoma, follicular, predominantly small cleaved cell
Malignant Lymphoma, follicular, mixed (small cleaved and large cell)
Intermediate Grade
Malignant Lymphoma, follicular, predominantly large cell
Malignant Lymphoma, diffuse, small cleaved cells
Malignant Lymphoma, diffuse, mixed (small and large cells)
Malignant Lymphoma, diffuse large cells
High Grade
Malignant Lymphoma, large cell, immunoblastic
Malignant Lymphoma, lymphoblastic
Malignant Lymphoma, small non-cleaved cells (Burkitt's lymphoma)
Miscellaneous
Composite
Mycosis fungoides
Histiocytic
Extramedullary plasmacytoma
Unclassifiable
The WHO Classification is the latest classification of lymphoma, published by the World Health Organization in 2001. This classification attempts to classify lymphomas by cell type, i.e. the normal cell type that most closely resembles the tumour. They are classified in three large groups: the B cell tumours, the T cell and natural killer cell tumours, Hodgkin lymphoma, and other minor groups:

Mature B Cell Neoplasms
Chronic lymphocytic leukemia/small lymphocytic lymphoma
B-cell prolymphocytic leukaemia
Lymphoplasmacytic lymphoma/Waldenström macroglobulinemia
Splenic marginal zone lymphoma
Plasma cell neoplasms
Plasma cell myeloma
Plasmacytoma
Monoclonal immunoglobulin deposition diseases
Heavy chain diseases
Extranodal marginal zone B cell lymphoma (MALT lymphoma)
Nodal marginal zone B cell lymphoma
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B cell lymphoma
Mediastinal (thymic) large B cell lymphoma
Intravascular large B cell lymphoma
Primary effusion lymphoma
Burkitt lymphoma/leukemia
lymphomatoid granulomatosis
Mature T cell and Natural Killer (NK) Cell Neoplasms
T cell prolymphocytic leukemia
T cell large granular lymphocytic leukemia
Agressive NK cell leukemia
Adult T cell leukemia/lymphoma
Extranodal NK/T cell lymphoma, nasal type
Enteropathy-type T cell lymphoma
Hepatosplenic T cell lymphoma
Blastic NK cell lymphoma
Mycosis fungoides/Sezary syndrome
Primary cutaneous CD30-positive T cell lymphoproliferative disorders
Primary cutaneous anaplastic large cell lymphoma
Lymphomatoid papulosis
Angioimmunoblastic T cell lymphoma
Peripheral T cell lymphoma, unspecified
Anaplastic large cell lymphoma
Hodgkin Lymphoma
Nodular lymphocyte-predominant Hodgkin lymphoma
Classical Hodgkin lymphoma
Nodular sclerosis
Mixed cellularity
Lymphocyte-rich
Lymphocyte depleted
Immnuodeficiency-Associated Lymphoproliferative Disorders
Associated with a primary immune disorder
Associated with the Human Immunodeficiency Virus (HIV)
Post-transplant
Associated with Methotrexate therapy
Histiocytic and Dendritic Cell Neoplasms
Histiocytic sarcoma
Langerhans cell histiocytosis
Langerhans cell sarcoma
Interdigitating dendritic cell sarcoma/tumour
Follicular dendritic cell sarcoma/tumour
Dendritic cell sarcoma, unspecified

Prevalence
According to the U.S. National Institutes of Health, lymphomas account for about five percent of all cases of cancer in the United States, and Hodgkin's disease in particular accounts for less than one percent of all cases of cancer in the United States.
From Wikipedia, the free encyclopedia.
>>http://en.wikipedia.org/wiki/Lymphoma

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Looking at lymphoma and leukemia

2005-10-03T03:17:00.000-07:00

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Looking at lymphoma and leukemia
BARBARA ROGERS CRNP, AOCN, MN

Abstract
Learn the signs and symptoms of these liquid tumors and how to help patients manage them.

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LYMPHOMA AND LEUKEMIA, two blood-related cancers, can produce similar signs and symptoms. Both may follow a chronic or very aggressive course. The terms lymphoma and leukemia encompass multiple diseases, each posing unique challenges for patients—and for you, the nurse caring for them.

According to American Cancer Society statistics, lymphoma will account for 5% of all cancer diagnoses in 2005; leukemia will account for almost 3%. In this article, I'll discuss each disorder in detail and take a close look at current treatment protocols and nursing interventions.

LYMPHOMA: MALIGNANT LYMPHOCYTES
A lymphoma is a neoplastic disease in which lymphocytes undergo malignant change and produce tumors in lymphoid tissue. Sharing the common characteristic of lymphadenopathy, various lymphomas are classified as Hodgkin's disease and non-Hodgkin's lymphoma (NHL). Enlarged lymph nodes are a hallmark of both types; the patient also may experience fatigue, weight loss, fever, or night sweats. Some patients complain of severe itching, possibly caused by cytokines from the malignant cells.

Biopsy of an enlarged lymph node establishes the diagnosis. When biopsy shows the presence of Reed-Sternberg cells, distinctive giant cells with one or two large nuclei, the diagnosis is Hodgkin's disease. The diagnosis is NHL when biopsy shows infiltration of malignant B cells or T cells in the lymph system.

Once diagnosed with Hodgkin's disease or NHL, the patient undergoes further diagnostic tests to stage the disease. (See Staging Hodgkin's and non-Hodgkin's lymphoma for details.) Lymphoma is further identified as “A” (no symptoms) or “B” (the patient has such signs and symptoms as fever, chills, night sweats, and weight loss).

Tests performed to stage lymphoma include chest X-ray and computed tomography (CT) scans of the head and neck, chest, abdomen, and pelvis. Positron emission tomography (PET) of the entire body may help the clinician identify hypermetabolic areas that suggest malignancy and assist staging.

The patient's blood work will probably include a complete blood cell (CBC) count to assess for anemia, a sedimentation rate, and a beta-2 microglobulin level. He may also have a bone marrow biopsy to stage the disease. Lactate dehydrogenase levels are nonspecific markers that may be used to determine prognosis in NHL.

Treating Hodgkin's disease
Spread through the lymphatic system, Hodgkin's disease accounts for about 12% of lymphomas. Its etiology is unknown, but reduced immunity and infection with certain viral diseases have been implicated. The overall survival rate 10 years after diagnosis of Hodgkin's disease is 77%.

Hodgkin's disease is treated with radiation therapy, chemotherapy, or both.

Radiation therapy is a common treatment choice for patients with stage IA or IIA nonbulky (less than 9 cm) Hodgkin's disease. More than 95% of these patients achieve complete remission, and 90% survive beyond 20 years.

Chemotherapy is appropriate for anyone with more advanced stage IIIB or IV disease, bulky disease (involving a large part of the chest and mediastinum), four or more sites of involvement, or extranodal disease. The standard regimen, known as ABVD, includes A driamycin (doxorubicin), b leomycin, v inblastine, and d acarbazine. A patient who achieves a partial response with chemotherapy may have a complete response after undergoing radiation therapy to sites of residual disease.

From 20% to 30% of patients with Hodgkin's disease never achieve complete remission (all signs and symptoms eliminated) or partial remission (cancer shrinking but not disappearing). Another 20% to 30% achieve complete remission, then have a relapse. If your patient requires a second round of therapy, the duration of his response to initial therapy helps determine what he'll receive next.

If Hodgkin's disease recurs within 12 months of initial therapy, the patient is more likely to have a poor outcome. Someone with a relapse more than 12 months after initial therapy can generally be treated successfully with combination chemotherapy. A patient who has a relapse after receiving radiation therapy alone has a 50% to 80% likelihood of long-term disease-free survival if he receives chemotherapy with ABVD for the recurrence. In someone who relapses after responding to chemotherapy, the clinician will consider high-dose therapy with autologous bone marrow or peripheral blood stem cell support.

The downside of therapy
Adverse reactions to chemotherapy for Hodgkin's disease and other malignancies depend on the regimen. (See Managing problems associated with chemotherapy for specific recommendations.) Therapy with ABVD may cause infertility, especially in males, although this is a smaller risk than with earlier regimens such as MOPP ( m echlorethamine, O ncovin [vincristine], p rocarbazine, and p rednisone). Chemotherapy also can cause sperm abnormalities and birth defects, so talk with your patient about the need to prevent pregnancy and the option of banking sperm or ova before starting treatment. Oncologists generally recommend that women avoid pregnancy for 2 years and men use contraception for 6 months after treatment.

Teach your patient that receiving radiation or chemotherapy for Hodgkin's disease increases the risk of another type of lymphoma, so he'll continue to need monitoring after he finishes treatment. After 5 disease-free years, however, his risk becomes close to normal. Radiation therapy also increases the risk of developing a solid malignancy, such as a breast or lung tumor, or thyroid disease if the radiation field during treatment included these regions.

Non-Hodgkin's lymphoma: Aggressive or indolent
Scientists don't understand how NHL begins, but they do know that the incidence has increased about 7% annually over the past 20 years, primarily in older adults. Spread through the bloodstream, NHL is classified as aggressive or indolent.

Aggressive NHL is fast growing, so patients typically are sicker at diagnosis. Because the disease is discovered in the early stages, a cure is more likely. Aggressive NHL is divided into intermediate and high grades; although treated differently, both are curable.

Indolent NHL is slow growing and poses more of a challenge to cure. Also known as low-grade NHL, the disease progresses slowly, so it's typically widely disseminated before being discovered. Even after treatment, most patients with indolent NHL have relapses.

What causes NHL is unclear, but factors that increase risk are long-term immunosuppressant therapy, bone marrow transplantation, inherited immune defects, rheumatoid arthritis, and previous treatment for Hodgkin's disease. Lymphoma related to human immunodeficiency virus (HIV), now recognized as a separate entity, is treated differently than other types of NHL.

Treatment options for NHL
A patient with NHL may receive radiation, chemotherapy, or both, depending on the disease grade and stage. Monoclonal antibodies such as rituximab (Rituxan) may be used to enhance the effects of chemotherapy. For someone with recurrent NHL, stem cell transplantation may be an option.

Combating aggressive NHL.
The standard treatment for intermediate-grade NHL has been CHOP chemotherapy ( c yclophosphamide, h ydroxydaunomycin, O ncovin [vincristine], and p rednisone), producing a cure in about 40% of patients treated. Recent data show that 60% of patients who also receive rituximab have long-term survival without relapse, so adding rituximab to the regimen (CHOP-R) has become the standard of care. The patient may receive radiation therapy too if he has only a partial response to chemotherapy or to prevent recurrence at sites of previous bulky disease.

Typically, a patient with high-grade NHL requires combination chemotherapy, but radiation also plays a role in combating this disease. Studies suggest that receiving fewer chemotherapy treatments and radiation can be equally effective and less toxic than more courses of chemotherapy alone. Someone with clinical stage I high-grade NHL has a greater than 80% chance of cure with radiation to either the involved field or an extended field.

Figure. Maturity matters
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Combating indolent NHL.
If your patient has localized low-grade NHL, radiation therapy alone offers a 60% to 80% chance of 10-year survival and possibly a full cure. However, in disseminated low-grade NHL, early intervention doesn't appear to prolong survival, so “watch and wait” is an acceptable approach. The reason to delay is that the patient may remain stable for years without treatments that could cause adverse reactions and decrease quality of life.

If your patient chooses to watch and wait, the practitioner will monitor him and prescribe therapy if adenopathy and disease-related symptoms increase or if he develops organ compromise or bone marrow suppression. Multiple chemotherapy options are available if he wants a more aggressive approach.

When treatment for low-grade NHL is necessary, numerous options include single or combination alkylating agents and the addition of an anthracycline (an anticancer antibiotic such as doxorubicin), radiation therapy, or biologic agents (such as monoclonal antibodies). The choice depends on the extent of disease, the patient's signs and symptoms, and major organ dysfunction due to other medical conditions. Because biologic agents produce a slower response, the patient may need chemotherapy for significant symptoms. Adding biologic agents to various chemotherapy regimens may enhance the response.

Generally, a shorter initial response to chemotherapy means shorter survival. After subsequent treatments, each remission is typically shorter and of less quality than the preceding one. Although the histologic features of disease at relapse are typically the same as at diagnosis, the disease could transform into a more aggressive type.

High-dose chemotherapy with autologous stem cell transplantation (ASCT) is a treatment option for someone with a recurrence. Considered a bone marrow “rescue,” ASCT is a standard approach to treating patients with relapsed disease who previously responded to chemotherapy. Allogeneic bone marrow transplant may be an option for someone with more resistant disease.

LEUKEMIA: CANCER IN THE MARROW
A malignancy of bone marrow cells, leukemia occurs when cells arising from stem cells lose the ability to differentiate into white blood cells (WBCs), red blood cells (RBCs), and platelets. (See Maturity matters .) Instead, one type of abnormal WBC prevails and normal cell line development declines.

Acute and chronic leukemias are classified as lymphocytic or myelogenous according to the predominant cell type. Biphenotypic leukemia is a name given to acute leukemia with both lymphocytic and myelogenous features.

No single factor has been pinpointed as a cause of leukemia, although genetics, drugs, and environmental and occupational exposures have been implicated. In most cases, signs of leukemia are evident in CBC count results, but a bone marrow biopsy is necessary for a definitive diagnosis.

Acute leukemias progress rapidly and are characterized by ineffective, immature cells in the bone marrow crowding out and preventing development of normal cells. Acute myelogenous leukemia (AML) accounts for most acute leukemias in adults; acute lymphocytic leukemia (ALL) is more common in children.

Some initial signs and symptoms of acute leukemia are nonspecific. Rising numbers of immature cells can affect all the blood cell lines—RBCs, WBCs, and platelets—so signs and symptoms are related to anemia, neutropenia, and thrombocytopenia. These include pallor, headache, fatigue, malaise, loss of appetite, weight loss, tachycardia, shortness of breath, petechiae, ecchymoses, and splenomegaly.

Bleeding or easy bruising after minor trauma, a characteristic sign of leukemia, stems from thrombocytopenia. Bone tenderness of the long bones, ribs, and sternum also may occur as leukemic cells expand the intramedullary space or invade the periosteum.

Chronic leukemias progress more slowly and rarely affect people under age 20. Allowing development of more normal cells, chronic leukemia may not affect the patient's health as severely until the advanced stages. Chronic myelogenous leukemia (CML) typically strikes between ages 40 and 50, with slightly more men affected than women. Chronic lymphocytic leukemia (CLL) typically develops after age 40 and is most common in older men.

Recognizing and treating leukemia
Now let's look at each leukemia type in detail.

Acute myelogenous leukemia.
Stem cells destined to develop in the myelogenous line of cells normally mature into neutrophils, monocytes, eosinophils, RBCs, and platelets. But when these cells overwhelmingly commit to one type—most commonly neutrophils—AML develops. Bone marrow biopsy is necessary to make the diagnosis.

Several clinical characteristics of AML influence prognosis. Factors in the patient's favor are age under 60 years, spontaneous rather than secondary leukemia, a WBC count less than 10,000/mm 3 , and the achievement of complete remission with one cycle of chemotherapy.

Treatment for AML consists of induction and maintenance therapy.

* Induction chemotherapy usually consists of cytosine arabinoside and an anthracycline. The goal of induction therapy is to attain complete remission by eliminating leukemic cells from the bone marrow.
* Postinduction therapy (consolidation) is necessary to prevent relapse after remission. However, the optimal regimen hasn't yet been determined. From 25% to 35% of patients have a long-term remission after postinduction chemotherapy. Therapy with high-dose cytarabine has improved the duration of first remission in most young patients with AML.
The options for consolidation therapy are more standard-dose chemotherapy or a transplant of the patient's own stem cells (autologous) or stem cells from a human-leukocyte-antigen (HLA) matched sibling or unrelated donor (allogeneic). Whether ASCT improves the rate of long-term remission is unclear. Allogeneic transplants from HLA-matched donors have produced a cure in 50% to 60% of patients in consolidation therapy. The regimen that precedes allogeneic transplant is so harsh that this option is usually reserved for patients younger than 55 years, who are more likely to survive the adverse effects of treatment.

Acute lymphocytic leukemia.
Rapidly developing immature lymphocytes crowding out normal cells indicate ALL. In adults with ALL, the Philadelphia chromosome, the hallmark of CML, is the most common chromosome abnormality detected. Cytogenic testing on the bone marrow specimen identifies this marker.

Poor prognostic factors for ALL include a high WBC count (25,000/mm 3 or greater) at presentation, presence of the Philadelphia chromosome, age over 50 years, and slow first remission (longer than 4 weeks).

The primary goal of ALL therapy is complete remission with restoration of normal hematopoiesis.

* Induction chemotherapy is administered in two phases. The first consists of daunorubicin, vincristine, and prednisone with L-asparaginase. The second phase, administered soon after the first, includes cyclophosphamide, cytarabine, and 6-mercaptopurine and prophylaxis with intrathecal methotrexate or cytosine arabinoside.
* Maintenance therapy must follow induction to prevent relapse. Several alternating regimens may be used for up to 36 months. The patient's risk factors determine the duration of treatment.
Chronic myelogenous leukemia
Characterized by the presence of the Philadelphia chromosome and development of too many neutrophils, CML consists of three clinical phases:

* The chronic phase follows an indolent course during which the patient may have mild symptoms and respond to standard treatments. The percentage of blasts in bone marrow is usually less than 10%.
* The accelerated phase is characterized by spleen enlargement and progressive signs and symptoms, such as intermittent fevers, night sweats, and unexplained weight loss. The typical patient doesn't respond to treatment as readily, and his bone marrow contains 10% to 30% blasts and promyelocytes. The accelerated phase typically lasts 6 to 12 months.
* The blast phase indicates a transformation to a very aggressive acute leukemia. The bone marrow contains more than 30% blasts, and promyelocytes and blasts commonly spread to other tissues and organs. Most patients die when CML reaches this phase.
The kinase inhibitor imatinib (Gleevec) is the current treatment of choice for CML. Most effective at inducing remission in the early stages, it's also well tolerated. Trials are under way to combine imatinib with other agents to enhance the response rate and duration.

Other agents used to treat patients with CML include interferon alpha, which has been shown to reduce growth and division of leukemia cells in 55% to 60% of treated patients. Because interferon alpha causes major adverse reactions, it's no longer the drug of choice to combat CML. Another agent, hydroxyurea, may prolong the chronic phase of CML but hasn't been shown to affect cell growth and development.

Stem cell transplant from a compatible donor achieves long-term survival in many patients, but the risk of dying during the first 100 days is 20%. This intervention is most successful early in the chronic phase of CML.

Chronic lymphocytic leukemia
The course of CLL depends on the disease stage. Median survival ranges from less than 19 months for patients with advanced disease to more than 10 years for those with early-stage disease.

An indolent disease characterized by lymphocytosis, lymphadenopathy, and hepatosplenomegaly, CLL eventually poses a risk of death from recurrent bacterial and viral infections as the disease advances.

Treatment of CLL with standard chemotherapy can produce remissions but can't cure the disease. Because CLL isn't curable and therapy may cause harsh adverse reactions, treatment is usually delayed until the patient develops signs and symptoms. The options include the alkylating agent chlorambucil with or without prednisone, the antimetabolite fludarabine, and combined chemotherapy such as CVP (cyclophosphamide/vincristine/prednisolone). Rituximab is frequently combined with chemotherapy to enhance the response. The patient also may receive radiation therapy to sites of bulky lymphadenopathy.

Skilled care, teaching, emotional support
Anyone with lymphoma or leukemia requires skilled nursing care to cope with the diagnosis and to minimize adverse reactions to treatment. Remind your patient that most adverse effects of therapy can be managed and that many people continue working during treatment. To help him manage immediate and long-term problems, teach him about the following effects of his illness and therapy.

* Emotional issues. Encourage him to discuss his feelings; provide reassurance and support when he does. Teach him relaxation techniques and encourage him to seek help through a support group or counselor. If he's taking prednisone, advise him to take it with breakfast or lunch to prevent insomnia and to notify the oncologist/hematologist if he has mood changes, which can occur with prednisone therapy.
* Infection. Teach him about infection risk. Review the signs and symptoms and tell him to contact the oncologist/hematologist if he develops signs of infection.
* Hair loss and skin changes. Tell the patient about the potential for hair loss and explain that his hair will probably grow back after he finishes therapy. Encourage him to purchase a wig or hat before his first chemotherapy infusion. Tell him that his skin may dry and become more sensitive to sunlight so he may need to apply sunblock and wear protective clothing in the sunshine. He may also notice changes in his nails.
* Fatigue. Encourage your patient to pace his activities, rest frequently, and get help with activities of daily living.
* Reproductive issues. Discuss the potential for chemotherapy-induced sterility. For a male, review the need to prevent pregnancy in his partner because chromosome damage to sperm can negatively affect the fetus. Discuss sperm banking and provide resource information if he chooses this option. Teach a female patient that treatment can cause menstrual changes and menopause-like symptoms and make her susceptible to vaginal infections.
* Stomatitis. Encourage your patient to see a dentist before starting chemotherapy. Teach him to rinse his mouth with a solution of salt and baking soda in water to prevent infection and advise him to avoid drinking alcohol. Tell him to call the oncologist/hematologist if he develops mouth sores.
* Bladder and bowel changes. Advise your patient to drink plenty of fluids and to void frequently to prevent cystitis. Teach him to check his urine for blood and to call his health care provider if he develops frequency or discomfort with urination. Teach him to include fiber in his diet and encourage him to use a laxative if he can't move his bowels every 2 days. Tell him to call his health care provider if he develops diarrhea. Monitor his response to antidiarrheal medication and assess him for dehydration.
* Gastric irritation. If your patient takes prednisone, tell him to take it with food or milk. If he reports midepigastric distress, ask the oncologist/hematologist to prescribe medication to prevent gastrointestinal irritation.
Keeping current
By keeping current on the various treatments for lymphomas and leukemias, you can prepare your patient for treatment, answer his questions, and help him manage problems caused by his disease or therapy.

Barbara Rogers is a nurse practitioner in adult hematology/oncology at Fox Chase Cancer Center in Philadelphia, Pa.

The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

SELECTED WEB SITES
Gilda's Club http://www.gildasclub.org

National Marrow Donor Program http://www.marrow.org/index.html

Planet Cancer: Support for Young Adults with Cancer http://www.planetcancer.org

The Leukemia & Lymphoma Society http://www.leukemia-lymphoma.org/hm_lls

Last accessed on June 2, 2005.

Staging Hodgkin's and non-Hodgkin's lymphoma
Stage I
Involvement of a single lymph node or localized involvement:
Stage II
Involvement of two or more lymph node regions on the same side of the diaphragm:
Stage III
Involvement of several lymph node regions on both sides of the diaphragm:
Stage IV
Involvement of extralymphatic tissue, such as the bone marrow

Managing problems associated with chemotherapy
Follow these guidelines to help your patient overcome adverse reactions.

Myelosuppression
* Monitor complete blood cell count before each treatment.
* Administer packed red blood cells (RBCs) as ordered.
* Administer growth factors as prescribed: granulocyte colony-stimulating factor, to decrease duration of nadir and epoetin alfa (Procrit) or darbepoetin alfa (Aranesp) to increase RBC production.
* Assess the patient for signs and symptoms of infection. Educate him about decreased absolute neutrophil count and infection risk.
* Monitor temperature daily. Call the oncologist/hematologist if the patient's oral temperature exceeds 100.5°F (38°C).
Pulmonary toxicity
* Obtain baseline pulmonary function tests.
* Assess the patient's pulmonary status before each infusion.
* Teach him to report cough, dyspnea, or shortness of breath.
* Hold bleomycin if he reports any symptoms of altered pulmonary status.
Cardiac toxicity
* Make sure that the patient undergoes a MUGA (multiple-gated acquisition) scan or an echocardiogram to determine adequate left ventricular ejection fraction before his first chemotherapy dose.
* Teach him to report shortness of breath or palpitations.
* Monitor his total doxorubicin dose.
* Perform ongoing assessments for signs and symptoms of heart failure, including dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and fatigue.
Nausea and vomiting
* Administer antiemetics before administering chemotherapy.
* Assess the patient's level of nausea and vomiting with each treatment and modify his antiemetic regimen as indicated.
* Teach him how to use his prescribed antiemetic to prevent or treat delayed nausea and vomiting.
Extravasation
* Assess your patient's veins before and during each chemotherapy infusion.
* Teach him about the benefits of a central venous access device if peripheral access is poor.
* Assess blood return frequently during administration of vesicants such as doxorubicin, vinblastine, and dacarbazine.
* Treat extravasation promptly, according to facility policy.
Hypersensitivity reactions
* Assess your patient's baseline vital signs. Bleomycin in particular can cause fever.
* Administer premedications such as acetaminophen and steroids before therapy and have emergency equipment readily available in case of anaphylactic or anaphylactoid reaction.
* Teach him to promptly report any unusual symptoms such as dizziness, itching, or pain.
* Monitor his vital signs throughout the infusion. Increase the infusion rate every 30 minutes only if his vital signs remain stable and he doesn't develop signs of an adverse reaction.
* Stop the infusion if he develops a reaction.
Neuropathy
* Assess him for sensory and perceptual changes before each treatment.
* Notify the oncologist of any changes (peripheral, gastrointestinal) that develop after he receives vinca alkaloids.
Pain at injection site: ABVD
* Administer dacarbazine in 100 to 250 ml of I.V. fluid and infuse slowly over 1 hour.
* Apply heat or ice above the injection site.
Flulike syndrome
* Premedicate with acetaminophen.
* Encourage the patient to drink plenty of fluids.
Hyperglycemia
* Monitor his serum glucose level.
* Increase monitoring frequency if he has diabetes. The prescriber may need to modify his antihyperglycemic therapy.
SELECTED REFERENCES
American Cancer Society: Cancer Facts & Figures. Atlanta, Ga., American Cancer Society, 2005.

Cheson B. Hodgkin's disease and the non-Hodgkin's lymphomas. In R Lenhard, et al., The American Cancer Society's Clinical Oncology . Atlanta, Ga., American Cancer Society, 2001.

Harris N, et al. World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues: Report of the clinical advisory committee meeting-Arlie House, Virginia. Journal of Clinical Oncology. 17(12):3835–3849, November 1999.

Lowenberg B, et al. Acute myelogenous leukemia. The New England Journal of Medicine . 341(14):1051–1062, September 30, 1999.

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Looking at lymphoma and leukemia
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Nursing2005
July 2005
Volume 35 Number 7

© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(7), July 2005, p 56–63
Looking at lymphoma and leukemia
[ARTICLE]
ROGERS, BARBARA CRNP, AOCN, MN

>>>http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=591039

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Turning Helplessness Into Hope

2005-10-03T03:10:00.000-07:00

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Turning Helplessness Into Hope
Doctor transforms personal cancer battle into fight for lymphoma patients.

By William Hawley, MD
President of the Lymphoma Research Foundation
As chief of cardiac surgery at INTEGRIS Baptist Medical Center in Oklahoma, I knew I should see a physician when I started noticing some small bumps on my scalp in September 1995. But I was just too busy with my own surgical practice and kept putting it off for “some day. ”

Some day came when a nodule appeared on my face. A biopsy, followed by a more careful exam, revealed an enlarged lymph node that gave the final diagnosis of lymphoma. I reviewed the biopsy slides with a pathology colleague who was very kind and sympathetic, but the blow of receiving a cancer diagnosis was overwhelming, despite my extensive experience helping patients in similar situations.

I suffered a complication from the biopsy site, which led to a severe infection. I was very ill, frightened and felt like I was facing my own immediate mortality. That was eight years ago.

After the initial shock from the diagnosis wore off, I did what most cancer patients do—I got busy learning all I could about the disease. The course of treatment prescribed was “watch and wait”—a strange concept for a surgeon to grasp since my idea of treatment usually involved something much more definitive.

My physician at Dana-Farber Cancer Institute suggested I meet one of his lymphoma patients, who had lived seven years so far with a “watch and wait.” After talking with his patient, Doug Lawless, I realized the importance of meeting others facing the same challenges.

Doug was a great help to me and I will never forget his words of encouragement. He had continued to practice law and adjusted to living with a widespread, incurable malignancy. Though he did eventually require chemotherapy, he continues to enjoy a long-term remission. We have become true friends and partners in a tough game.

After more than 30 years as a surgeon, I took leave from my practice so I could work as a full-time advocate for patients with hematologic malignancies, despite advice from several lymphoma specialists that I could, and possibly should, continue with my surgical practice. I now devote myself entirely to advocacy for lymphoma patients. My family and friends tease that I am the busiest unpaid physician in the country!

I became involved with the Lymphoma Research Foundation (LRF)—the nation’s largest lymphoma-focused nonprofit organization. LRF has a program that matches newly diagnosed patients with others facing the same type of disease (there are more than 30 different types of lymphoma).

Participating in this patient-to-patient program led to my speaking and counseling patients across the country through LRF’s Lymphoma Support Network. It was a chance for me to offer other patients the emotional support and encouragement I so badly needed when first diagnosed.

While I had long encouraged my patients to be their own best advocates with respect to their treatment and care, as a patient I realized the importance of a different type of advocacy—one that would lead me straight to Capitol Hill.

In June 2003, I testified before the U.S. Senate Defense Appropriations Subcommittee to request $25 million in funding for a national blood cancer research initiative. I’ve also participated in the annual Blood Cancer Advocacy Days, which provide patients and their families a chance to meet face-to-face with lawmakers to advocate for more blood cancer funding.

I am now president of LRF and plan to keep visiting Capitol Hill to urge Congress to pass initiatives that will help speed better treatments and eventually cures for the nearly 500,000 Americans suffering from lymphoma.
Would I choose this life with cancer if I had a choice? Perhaps. I believe it has made me a better physician, a better friend and a better husband and father. And through advocacy, I’ve learned that I do not have to live with a feeling of helplessness—because there is hope.

For more information about the Lymphoma Research Foundation, visit www.lymphoma.org or call 800-235-6848.
>>>http://curetoday.com/backissues/v3n3/departments/advocacy/index.html

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