BLOOD CANCERS

HEMATOPOIESIS HEMATOPOIETIC STEM CELLS “Pluripotent Stem BLAST CELLS

Cells/ Hemocyblast” - Least differentiated cells
- Where all circulating blood cells arise from - Cannot function as mature cells
- Can proliferate and differentiate depends on - When matured, released to the peripheral
the body’s need circulation

LEUKEMIA - unregulated proliferation or accumulation of white blood cells (WBCs) in the bone marrow: The common
cancer that starts in the feature
tissue that forms blood. - There is also proliferation in the liver and spleen and invasion of other organs, such as the meninges,
lymph nodes, gums, and skin.
In a person with - commonly classified according to the stem cell line involved, either lymphoid or myeloid.
leukemia, the bone - classified as acute (abrupt onset) or chronic (evolves over months to years). Its cause is unknown. There is
marrow makes some evidence that genetic influence and viral pathogenesis may be involved.
abnormal white blood - Bone marrow damage from radiation exposure or chemicals such as benzene and alkylating agents can
cells. also cause leukemia
 The abnormal cells are
leukemia cells. CLINICAL MANIFESTATIONS: Cardinal signs and symptoms ASSESSMENT & DIAGNOSTIC FINDINGS
➢ leukemia cells - weakness and fatigue - Blood and bone marrow studies
don't die when - bleeding tendencies, petechiae confirm proliferation of WBCs
they should. - ecchymoses (leukocytes) in the bone marrow
➢ They may crowd - pain, headache
out normal white - vomiting, fever
blood cells, red - infection
blood cells, and ETIOLOGY: RISK FACTORS
platelets (makes it Genetic disorders Physical and chemical exposures
hard for normal - Down syndrome - Benzene Drugs: pipobroman
blood cells to do - Klinefelter syndrome - Pesticides, Cigarette smoking
their work) - Patau syndrome - Embalming fluids
- Ataxia telangiectasia - Herbicides
PH. CANCER SOCIETY - Shwachman syndrome
➢ 4.5 individuals per - Kostman syndrome
100,000 Filipinos - Neurofibromatosis Chemotherapy
will develop the - Fanconi anemia - Alkylating agents
disease - Li-Fraumeni syndrome - Topoisomerase-II inhibitors "A-T-A-T"
- Anthracyclines
lymphoid leukemia Radiation exposure - Taxanes
highest in Filipino - Nontherapeutic
children and those over - therapeutic radiation
70 years of age
➢ Survival rate of PATHOPHYSIOLOGY
Metro Manila
children with acute
lymphoid leukemia
is only 34%.

DOH
➢ “silent killer”
➢ among the top 5
killer-cancers in
the country
➢ September as
“Leukemia
Awareness
Month,” coinciding
with the “Blood
Cancer Awareness
1. clone of invasive cells may arise at any stage of cell 5. Leukemic Blasts infiltrate into bone
Month”
maturation and specialization in marrow; secrete factors which inhibit
o lymphoid normal hematopoiesis (formation of
PROGNOSIS
o Myeloid cellular components of the blood)
ALL: children 3-7 have
o pluripotential stage 6. Eventually infiltrate into other organs
highest chance to
2. The cause of this clonal development unknown in o Spleen
complete recovery
most cases; appears to involve the rearrangement o Liver
of sequence of bases on DNA molecules. - and therefore disrupting their regular
CLL: If affect B-cell, life
3. External and internal factors aid these changes. processes.
expectancy can be bet.
o ionizing radiation & chemicals 7. The blood becomes unable to carry out its
10-20 yrs (if tx begins
o chromosomal abnormalities functions; individual affected will experience
early); With affected T-
4. DNA changes will lead to a uncontrollable mitosis of o increased fatigue
cell (very low
cells which will give rise to cells that could o Infections
expectancy)
potentially be cancerous- some of which are o will bruise and bleed more easily
leukemic blasts (abnormal white blood cells) than they usually would’ve.
AML: If detected early,
SIGNS AND SYMPTOMS
20-40% survive for at
- Acute Leukemia: sx develop very quickly (within a few days or weeks )
least 60 mons
- Chronic Leukemia: can go unnoticed for years; usually found in a routine blood test
Anemia (a deficiency of red blood cells and Enlarged liver or spleen (leukemia cells build up in
CML: In early stage (98
hemoglobin) the liver or spleen)
mons); In intermediate
- shortness of breath - felt by swelling or discomfort in the abdomen.
stages (65 mons); Last
- Paleness - Loss 0f appetite
stage (42 mons)
- Palpitations (rapid heartbeat) - Losing weight without trying
- Weakness, tiredness - lower ribs usually cover these organs, but when
- Dizziness they are enlarged, the doctor can feel them
- Headaches
Leukopenia (A low white blood cell count)
- Weak immunity system: patient will have more
frequent or severe infections.
 Thrombocytopenia (a low blood platelet count) Rare symptoms
- Easy bleeding - Chloroma (granulocytic sarcoma): a tumour-
- Widespread bruising, purple patches under the like collection of leukemia cells under the skin
skin or in other parts of the body can occur
- Frequent nosebleeds
- Bleeding gums
- Red spots on the skin

Other symptoms
- vomiting, confusion, loss of muscle control
- seizures
- Swollen Lymph nodes
- Fever or Chills
- Night Sweating
- Joint and bone pain - Leukemia Cutis: These are skin lesions that
occur in 25% of Chronic Lymphocytic Leukemia
DIAGNOSTIC TEST patients
Physical exam
- pale skin from anemia
- swelling of your lymph nodes, liver and spleen.
Blood tests
- abnormal levels of WBC or platelets, which may
suggest leukemia.
Bone marrow test
- remove a sample of bone marrow from
hipbone, sent to a laboratory to look for
leukemia cells
CLASSIFICATION
RATE OF PROGRESSION TYPE OF WBC INVOLVED
- Acute: rapidly developing; The cells divide rapidly so the - Lymphocytic L.: affects the
disease escalates very quickly. Aggressive treatment is lymphoid cells. SX: swollen lymph
required. nodes in the neck, armpits and
- Chronic: mature blood cells that divide and replicate more groin.
slowly; could initially function like a normal WBC; could - Myelogenous L.: affects myeloid
remain undiagnosed for years cells, (immature WBC)
4 MAIN TYPES
Acute lymphocytic L.(ALL) –most common type of Chronic lymphocytic L. (CLL)
affecting young children - Many people with the condition will not have
- still does affect adults any symptoms for years
- the affected adults usually have a worse - tend to be harder to manage than acute ones.
prognosis than children

Acute myelogenous L. (AML): most common type of Chronic myelogenous L. (CML): mostly adults.
acute leukemia in adults - slow-moving subtype.
- rapidly developing condition. - can alter its progression and suddenly become
- Can quickly spread to different parts of the body an acute, rapidly-progressing condition
like spleen, liver and brain
TREATMENT (3 STEPS)
Induction Therapy: Consolidation Therapy: Maintenance Therapy:
4-6 weeks Killing off the remaining leukemia cells or Preventing any remaining
Killing of leukemia cells the aberrant cells. If these cells are not leukemia cells from growing or
in the blood and bone killed, they could re-grow and could cause a from coming back
marrow relapse
- low doses of chemo
- chemotherapy. - chemotherapy - IV treatment (infusion of
- stem cell transplant (replacement of liquid substances directly
damaged bone marrow cells with into a vein)
healthy ones).
CHEMOTHERAPY
Alkylating Agents- Busulfan (Myleran): Nursing Care:
MOA: Non-cell-specific - Monitor complete blood count (CBC) regularly
- interfere with DNA structure by adding an alkyl - Assess for signs of infection, bleeding, anemia
group to it, preventing cell division. - Administer antiemetics as prescribed to
Common Side Effects: manage nausea and vomiting
- Nausea and vomiting - Encourage fluid intake to prevent dehydration
- Bone marrow suppression (risk of infection, - Monitor respiratory function
anemia, bleeding) - report any signs of pulmonary toxicity.
- Pulmonary toxicity
- Skin reactions
 Anthracyclines - Doxorubicin (Adriamycin): Nursing Care:
MOA: Non-cell-specific - Monitor cardiac function regularly.
- inhibit DNA and RNA synthesis by intercalating - Administer antiemetics and supportive care
into the DNA strands and disrupting the DNA for nausea and vomiting.
structure. - Monitor CBC and assess for signs of infection,
Common Side Effects: bleeding, and anemia.
- Cardiotoxicity - Provide emotional support and education on
- Nausea and vomiting potential side effects.
- Bone marrow suppression - Encourage good oral hygiene to prevent oral
- Alopecia (hair loss) mucositis.
- Red-orange discoloration of urine and sweat - Advise the patient about the discoloration of
urine and sweat.

Antimetabolites - Fludarabine (Fludara): Nursing Care:

MOA: Cell-specific (S-phase) - Monitor CBC regularly for myelosuppression.
- interfere with the DNA synthesis process by - Administer antiemetics and manage diarrhea.
substituting normal metabolites, inhibiting DNA - Provide adequate hydration to prevent
replication. dehydration.
Common Side Effects: - Assess for signs of infection and bleeding.
- Myelosuppression - Educate the patient on proper hygiene to
- Nausea and vomiting prevent infection.
- Diarrhea - Monitor and manage fatigue.
- Fatigue

Corticosteroids - Prednisone: Nursing Care:

MOA: Non-cell-specific - Monitor for signs of infection.
- anti-inflammatory and immunosuppressive - Monitor blood glucose levels regularly.
effects. - Provide emotional support for mood changes.
Common Side Effects: - Educate the patient on the importance of
- Immunocompromised state infection prevention.
- Increased risk of infection - Encourage a well-balanced diet.
- Hyperglycemia
- Mood changes

Plant Alkaloids - Vincristine (Oncovin): Nursing Care:

MOA: M-phase specific - Monitor for signs of peripheral neuropathy.
- disrupt the mitotic spindle, preventing cell - Administer stool softeners and laxatives to
division. prevent constipation.
Common Side Effects: - Monitor CBC for myelosuppression.
- Peripheral neuropathy - Provide emotional support and education on
- Constipation potential side effects.
- Myelosuppression - Encourage good oral hygiene to prevent oral
- Alopecia (hair loss) mucositis.
STEM CELL/ BONE MARROW TRANSPLANT
- Bone Marrow: Spongy tissue; produces WBC, RBC, Platelets
- Act of replacing, via infusion, a faulty bone marrow with one that’s available to produce healthy blood cells
- Achieved by using “Stem Cells” from pt or from suitable donor
- Stem cells: undifferentiated cells that have the ability to develop and mature into any type of cell
- Prior to infusing stem cells, chemo/ radiation is used to destroy the old & unhealthy leukemia cells and
bone marrow → Process: 5-7 days
- After this, Stem cells are introduced and infused through a tube connected to a major vein in the chest
- Stem cells enter bloodstream & find their way to marrow and jump start the production of healthy blood
cells
NURSING PROCESS
Assessment Planning and Goals
- Identify range of s/s reported by patient in nursing history and - absence of complications
physical examination. and pain,
- Assess results of blood studies, and report alterations of WBCs, - attainment and
absolute neutrophil count (ANC), hematocrit, platelet, creatinine maintenance of adequate
and electrolyte levels, hepatic function tests, and culture results. nutrition
Collaborative Problems/Potential Complications - activity tolerance
- Infection - ability to provide self- care
- Bleeding/disseminated intravascular coagulation (DIC) and to cope with the
- Renal dysfunction diagnosis and prognosis
- Tumor lysis syndrome - positive body image, and
- Nutritional depletion an understanding of the
- Mucositis disease process and its
- Depression and anxiety treatment.
 NURSING DIAGNOSES
- Risk for infection and bleeding - Risk for excess fluid volume related to renal
- Risk for impaired skin integrity related to toxic dysfunction, hypoproteinemia, need for
effects of chemotherapy, alteration in nutrition, multiple intravenous (IV) medications and blood
and impaired mobility products
- Impaired gas exchange - Diarrhea due to altered GI flora, mucosal
- Impaired mucous membranes from changes in denudation, prolonged use of broad-spectrum
epithelial lining of the gastrointestinal (GI) tract antibiotics
from chemotherapy or antimicrobial - Risk for deficient fluid volume related to
medications potential for diarrhea, bleeding, infection, and
- Imbalanced nutrition: less than body increased metabolic rate
requirements related to hypermetabolic state, - Self-care deficits related to fatigue, malaise, and
anorexia, mucositis, pain, and nausea - Acute protective isolation
pain and discomfort related to mucositis, - Anxiety due to knowledge deficit and uncertain
leukocytic infiltration of systemic tissues, fever, future
and infection - Disturbed body image related to change in
- Hyperthermia related to tumor lysis and appearance, function, and roles - Grieving
infection related to anticipatory loss and altered role
- Fatigue and activity intolerance related to functioning - Risk for spiritual distress - Deficient
anemia, infection, and deconditioning knowledge of disease process, treatment,
- Impaired physical mobility due to anemia, complication management, and self-care
malaise, discomfort, and protective isolation measures
PLANNING AND IMPLEMENTATION
- Assist in bone marrow biopsy - Plan acts to prevent fatigue
o Apply pressure on site for 5 mins - Provide measures for uninterrupted rest and sleep
or until bleeding stops - Assist in maintaining good personal hygiene, oral
- Freq. asses for bleeding up to 4 hrs after hygiene (saline sol)
the procedure - Lubricate lips with water soluble lubricants q 2 hrs
- Reverse isolation
NURSING INTERVENTIONS
Preventing or Managing Bleeding Preventing Infection
- Assess for thrombocytopenia, - Infection: major cause of death in leukemia
granulocytopenia, and anemia. patients.
- Report any increase in petechiae, melena, - Assess temperature elevation, flushed
hematuria, or nosebleeds. appearance, chills, tachycardia, and
- Avoid trauma and injections; use small-gauge appearance of white patches in the mouth.
needles when analgesics are administered - Observe for redness, swelling, heat, or pain in
parenterally, and apply pressure after injections eyes, ears, throat, skin, joints, abdomen, and
to avoid bleeding. rectal and perineal areas.
- Use acetaminophen instead of aspirin for - Assess for cough and changes in character or
analgesia. color of sputum.
- Give prescribed hormone therapy to prevent - Give frequent oral hygiene.
menses. - Wear sterile gloves to start infusions.
- Manage hemorrhage with bed rest and - Provide daily IV site care
transfuse red blood cells and platelets as - observe for signs of infection.
ordered - Ensure normal elimination
- avoid rectal thermometers, enemas, and rectal
Managing Mucositis trauma; avoid vaginal tampons.
- Assess the oral mucosa thoroughly; identify and - Avoid catheterization unless essential.
describe lesions; note color and moisture - Practice scrupulous asepsis if catheterization is
(remove dentures first). necessary.
- Assist patient with oral hygiene with soft-
bristled toothbrush. Improving Nutritional Intake
- Avoid drying agents, such as lemon–glycerin - Give frequent oral hygiene (before and after
swabs and commercial mouthwashes (use meals) to promote appetite; with oral
saline or saline and baking soda). anesthetics, caution patient to prevent self-
- Emphasize the importance of oral rinse injury and to chew carefully.
medications to prevent yeast infections. - Maintain nutrition with palatable, small,
- Instruct patient to cleanse the perirectal area frequent feedings of soft nonirritating foods;
after each bowel movement; monitor provide nutritional supplements, as prescribed.
frequency of stools, and stop stool softener - Record daily body weight, as well as intake and
with loose stool output, to monitor fluid status.
- Perform calorie counts and other more formal
nutritional assessments.
- Provide parenteral nutrition, if required.
 Easing Pain and Discomfort Decreasing Fatigue and Deconditioning
- Administer acetaminophen rather than aspirin - Assist in choosing activity priorities; help patient
for analgesia. balance activity and rest; suggest a stationary
- Sponge patient with cool water for fever; avoid bicycle and sitting up in chair.
cold water or ice packs; frequently change - Assist patient in using a high-efficiency
bedclothes; provide gentle back and shoulder particulate air (HEPA) filter mask to ambulate
massage. Provide oral hygiene (for stomatitis), outside room.
and assist the patient with use of patient- - Arrange for physical therapy when indicated.
controlled analgesia (PCA) for pain.
- Use creative strategies to permit uninterrupted
sleep (a few hours) Maintaining Fluid and Electrolyte Balance
- Assist the patient when awake to balance rest - Measure intake and output accurately; weigh
and activity to prevent deconditioning. the patient daily.
- Listen actively to patients enduring pain. - Assess for signs of fluid overload or dehydration.
- Monitor laboratory tests (electrolytes, blood
Improving Self-Care urea nitrogen [BUN], creatinine, and
- Encourage the patient to do as much as hematocrit), and replace blood, fluids, and
possible. electrolyte components as ordered and
- Listen empathetically to the patient. indicated.
- Assist patient to resume more self-care during
recovery from treatment. Encouraging Spiritual Well-Being
- Assess the patient’s spiritual and religious
Managing Anxiety and Grief practices, and offer relevant services.
- Provide emotional support, and discuss the - Assist the patient to maintain realistic hope
impact of uncertain future. over the course of the illness (initially for a
- Assess how much information patient wants to cure, in later stages for a quiet, dignified
have regarding the illness, its treatment, and death).
potential complications; reassess at intervals.
- Assist patient to identify the source of grief, and
encourage patient to allow time to adjust to the
major life changes rendered by the illness.
- Arrange to have communication with nurses
across care settings to reassure patient that he
or she has not been abandoned
Promoting Home- and Community-Based Care
Teaching Patients Self-Care Terminal Care
- Ensure that patients and their families - Respect the patient’s choices about treatment,
have a clear understanding of disease including measures to prolong life and other end-of-life
and complications (risk for infection and measures.
bleeding). - Advance directives, including living wills, provide
- Teach family members about home care patients with some measure of control during terminal
while patient is still in the hospital, illness.
particularly vascular access device - Support families and coordinate home care services to
management if applicable. alleviate anxiety about managing the patient’s care in
the home.
Continuing Care - Provide respite for the caregivers and patient with
- Maintain communication between the hospice volunteers.
patient and nurses across care settings. - Give the patient and caregivers assistance to cope with
- Provide specific instructions regarding changes in their roles and responsibilities (ie,
when and how to seek care from the anticipatory grieving).
physician - Provide information on hospital-based hospice
programs for patients to receive palliative care in the
hospital when care at home is no longer possible

EVALUATION: EXPECTED PATIENT OUTCOME

- Shows no evidence of infection - Experiences less fatigue and increases activity
- Experiences no bleeding - Maintains fluid and electrolyte balance
- Exhibits intact oral mucous membranes - Participates in self-care
- Attains optimal level of nutrition - Copes with anxiety and grief
- Reports satisfaction with pain and discomfort - Experiences absence of complications
levels
 Chronic Myeloid ➢ 3 Stages: chronic, transformation, accelerated or blast crisis
Leukemia ➢ Marrow expands into cavities of the long bones, and cells are formed in the liver and spleen, with resultant
painful enlargement problems. Infection and bleeding are rare until the disease transforms to the acute
affected cells carry out phase.
some of their normal CLINICAL MANIFESTATIONS PHARMACOLOGIC THERAPY
functions initially, - Many patients are asymptomatic, - Oral formulation of a tyrosine kinase inhibitor, imatinib
making it difficult to and leukocytosis is detected by a mesylate (Gleevec).
detect CBC count performed for some - In those instances where imatinib (at conventional doses)
other reason. does not elicit a molecular remission, or when that remission
progression of this - Leukocyte count commonly is not maintained, other treatment options may be
disease is slow and exceeds 100,000/mm . considered: The dosage of imatinib can be increased (with
symptoms show up only - Patients with extremely high increased toxicity), another inhibitor of BCR-ABL can be used
in the later stages. leukocyte counts may be some- (eg, dasatinib [Sprycel]), or allogeneic transplant can be
what SOB or slightly confused used.
because of leukostasis. - Bone marrow transplant and peripheral blood stem cell
117 mons: highest - Splenomegaly with tenderness transplantation are additional treatment strategies.
survival recorded and hepatomegaly are common. - In the acute form of CML (blast crisis), treatment may
- Some patients have insidious resemble induction therapy for acute leukemia, using the
uncommon before 20 symptoms: malaise, anorexia, same medications as for AML or ALL.
yo, but the incidence weight loss. - Oral chemotherapeutic agents,
increases with age - transforming phase o hydroxyurea or busulfan (Myleran)
(mean age is 67 years). o bone pain o leukapheresis (leukocyte count greater than
o fever, weight loss 300,000/mm3)
o anemia o anthracycline chemotherapeutic agent (eg,
o thrombocytopenia daunomycin [Cerubidine]) for purely palliative
approach (rare)
Acute Myeloid L. Assessment Methods Med Management
more severe form - Bone marrow specimen (excess of immature blast - The objective is to achieve complete
characterized by faster cells) remission, typically with chemotherapy
progression of the - Complete blood cell (CBC) count (decreased (induction therapy), which in some
disease; common type platelet count and erythrocyte count) instances results in remissions lasting a year
among adults. Diagnosis or longer.
- Peripheral Blood Smears Treatment
Age : 40 – 60 y/o - Bone Marrow Aspiration - Induction chemo: 7+3 regimen; Must be
(Common in adult); - Immunophenotyping hypocellular aplastic marrow
Men than women Cytogenic analysis o Cytarabine for 7 days +
CLINICAL FEATURES Daunorubicin for 3 days
defect in the - Anemia, Neutropenia. Thrombocytopenia o Idarubicin - Bone marrow is
hematopoietic stem cell - Bone pain is less seen but more of pain in soft examined after 14 days of
that differentiates into tissues treatment
all myeloid cells: - Gingival bleeding 4 weeks prior to onset of other o Cytarabine for CNS disease
monocytes, signs & symptoms - Post remission: High dose cytarabine
granulocytes - Most signs and symptoms evolve from insufficient (HIDAC)
(neutrophils, basophils, production of normal blood cells: Chemotherapy: recommended treatment
eosinophils), o Fever and infection result from method.
erythrocytes, and neutropenia - Cytarabine (Cytosar, Ara-C) & daunorubicin
platelets. o Weakness, fatigue from anemia (Cerubidine)
o bleeding tendencies from - Mitoxantrone (Novantrone) or idarubicin
7 different subgroups thrombocytopenia. Major hemorrhage (Idamycin)
based on cytogenetics, occurs with a platelet count of less than - Sometimes etoposide (VP-16, VePesid) is
histology, morphology 10,000/mm added
(appearance) of the - The most common sites of bleeding: GI, pulmonary, - Consolidation therapy (postremission
blasts. intracranial. therapy with chemotherapy agents)
- Proliferation of leukemic cells within organs leads to
All age groups are a variety of additional symptoms: pain from an Supportive Care
affected; incidence rises enlarged liver or spleen, hyperplasia of the gums, - Administration of blood products
with age and peaks at and bone pain from expansion of marrow. - Prompt treatment of infections
67 years of age. - onset without warning; symptoms develop over - Granulocyte colony-stimulating factor (G-
weeks or over months. CSF [filgrastim]) or granulocyte-macrophage
most common - Peripheral blood shows decreased erythrocyte and colony-stimulating factor (GM- CSF
nonlymphocytic platelet counts. [sargramostim]) to decrease neutropenia
leukemia. - The leukocyte count is low, normal, or high; the - Antimicrobial therapy & transfusions as
percentage of normal cells is usually vastly needed
Death usually occurs decreased. - Occasionally, hydroxyurea (Hydrea): briefly
secondary to infection Risk Factors to control the increase of blast cells
or hemorrhage - Genetic disorder: Down syndrome (trisomy 21) - Bone Marrow Transplantation: tissue match
- Smoking; Post-chemotherapy can be obtained. The transplantation
- Chemical exposure (Pesticides, Benzenes); procedure follows destruction of the
Radiation leukemic marrow by chemotherapy
 Chronic Lymphocytic RISK FACTORS Treatment
Leukemia (CLL) - Genetic predisposition CHEMO
common cancer of older - 25% asymptomatic 1. Fludarabine: Nucleoside Analogues
adulthood; Ave. age of - Enlarged abdominal lymph nodes - MOA: interferes with the synthesis of DNA and RNA.
diagnosis is 72 years. - Infection (death) It is converted into its active form inside cells and
then inhibits DNA polymerase, leading to DNA chain
high incidence rate CLINICAL FEATURES termination and ultimately disrupting cell division.
among people aged - Asymptomatic (early stages) - Cell Specificity: commonly used in the treatment of
more than 60. - Abnormal bruising (occurs late in the hematological malignancies, particularly chronic
disease) lymphocytic leukemia (CLL). It affects rapidly dividing
Men are more likely to - Enlarged lymph nodes, liver, or spleen cells, including cancer cells.
be affected - Excessive sweating, night sweats - Side Effects:
- Fatigue; Fever; ecurrent infections o Hematological: myelosuppression, anemia,
Progression: slow - Many cases are asymptomatic. neutropenia, thrombocytopenia.
- Lymphocytosis is always present. o GI: nausea, vomiting, diarrhea.
slow increase in white - Erythrocyte and platelet counts may be o Immunological:  susceptibility to
blood cells (B lympho) normal or decreased. infections.
- Lymphadenopathy (enlargement of lymph o Neurological: headache, dizziness.
Accumulation of nodes), which is sometimes severe and o Others: fever, chills, fatigue.
incompetent painful, and splenomegaly may be noted. 2. Chlorambucil, Cyclophosphamide (Cytoxan):
lymphocytes - “B symptoms”: - MOA:
o fevers, sweats (especially night) o Chlorambucil: Alkylating agent that forms
Majority are B cells o unintentional weight loss covalent bonds with DNA, preventing cell
o Infections are common. replication.
Eventually causes the - Anergy (decreased or absent reaction to o Cyclophosphamide: Alkylating agent that
bone marrow to fail skin sensitivity tests) reveals the defect in undergoes metabolic activation to produce
cellular immunity. alkylating intermediates, which cross-link
classified into 3-4 stages - Later stages: anemia &thrombocytopenia DNA strands, preventing cell division.
(two classification may develop. - Cell Specificity: These drugs affect both rapidly
systems are in use). In dividing cancer cells and normal cells. Their impact is
the early stage, an TREATMENTS OTHER more pronounced on cells with higher mitotic activity.
elevated lymphocyte - RT: For painfully enlarged lymph nodes - Side Effects:
count is seen; it can - Stem cell transplantation o Hematological: myelosuppression, anemia,
exceed 100,000/mm. o Autologous leukopenia.
o Allogenic o GI: nausea, vomiting, diarrhea.
The disease is usually o Renal toxicity (cyclophosphamide).
diagnosed during MEDICAL MANAGEMENT o Neurological effects (rare).
physical examination or - The chemotherapy agents o Increased risk of infection.
treatment for another o fludarabine (Fludara) & o Long-term use may be associated with
disease. cyclophosphamide (Cytoxan) secondary malignancies.
o often given in combination with
the monoclonal antibody 3. Rituximab (Rituxan):
rituximab (Rituxan). - MOA: monoclonal antibody that targets the CD20
- The monoclonal antibody alemtuzumab antigen on the surface of B cells. It triggers immune
(Campath) is often used in combination responses leading to B-cell lysis and elimination.
with other chemotherapeutic agents - Cell Specificity specifically targets B cells, including
when the disease is refractory to both normal B cells and B-cell lymphomas.
fludarabine, the patient has very poor - Side Effects:
prognostic markers, or it is necessary to o Infusion-related reactions (fever, chills)
eradicate residual disease after initial during the first administration.
treatment o Immunological reactions: increased risk of
- Prophylactic use of antiviral agents and infections.
antibiotics (eg, o Hematological effects: neutropenia.
trimethoprim/sulfamethoxazole [Bactrim, o Cardiovascular effects.
Septra]) for patients receiving o Hepatitis B reactivation.
alemtuzumab (at significant risk for o Progressive multifocal leukoencephalopathy
infection). (PML) in rare cases.
- IV immunoglobulin may prevent
recurrent bacterial infections in selected
patients.
Acute Lymphocytic CLINICAL MANIFESTATIONS
Leukemia - Immature lymphocytes proliferate in marrow - Manifestations of leukemic cell infiltration into
most common form of and impede development of normal myeloid other organs are more common with ALL than
cancer in children cells. with other forms of leukemia and include pain
- Normal hematopoiesis is inhibited: reduced from an enlarged liver or spleen and bone pain.
¼ of all cancers in numbers of leukocytes, erythrocytes, - CNS: frequently a site for leukemic cells;
children belong to this platelets. headache and vomiting because of meningeal
type. - Leukocyte counts: low or high but always involvement.
include immature cells - Other extranodal sites: testes and breasts
 high incidence rate
among adults, older RISK FACTORS TREATMENT
than 45 years of age. - Age (bimodal = 2-4y/o & 50y/o & above) Induction Chemo
- Radiation ➢ Vincristine, corticosteroid and
Chemotherapy is the - Post-chemotherapy anthracycline
established treatment - Chemical exposure (benzene)
method for this disease - Virus (HIV, EBV) CNS treatment
- Genetics ➢ Cranial irradiation
Most common cancer in - ➢ Intrathecal chemo with
children CLINICAL FEATURES methotrexate or cytarabine
➢ 1st peak: 2- 4 y/o - Anemia, Neutropenia, Thrombocytopenia
➢ 2nd peak: 50 y/o - Bone Pain- in children Stem cell transplant
- CNS involvement: rare – CN 3, 4, 6, 7 ➢ Offered only to high risk ALL
a patient with acute - Hepatomegaly & lymphadenopathy
lymphocytic leukemia Splenomegaly Post remission Therapy
could survive for 4 ➢ Consolidation/ Intensification
months at the most. DIAGNOSTIC TEST o Chemo
However, thanks to Peripheral Blood Smear o Stem cell transplant:
modern treatment ➢ WBC: >100,000/mm3 Offered only to high risk
methods, about 80% of ➢ Neutrophil: low, despite increased WBC ALL
the affected children ➢ Platelet: <50, 000/mm3 ➢ Maintenance Therapy
are completely cured. o Lower-dose treatment
Adults have been seen Bone marrow aspiration for 2-3 years
to have a 40% chance of ➢ Lymphoblasts comprise at least 20% o 6-MP Mercaptopurine:
complete cure ➢ Smears to assess cell morphology daily
o Methotrexate (oral):
early detection and Lumbar puncture weekly
treatment: factor that ➢ Leukemic cells in the CSF o Vincristine and
can lengthen life Prednisone: monthly
expectancy or increase MEDICAL MANAGEMENT
the likelihood of the - Because ALL frequently invades the central - Once a patient is in remission, intensification
disease going into nervous system, preventive cranial irradiation therapy (consolidation) ensues.
remission or intrathecal chemotherapy (eg, - In the adult with ALL, allogeneic transplant may
methotrexate) or both is also a key part of the be used for intensification therapy.
treatment plan - For those for whom transplant is not an option
- Corticosteroids and vinca alkaloids are an (or is reserved for relapse), a prolonged
integral part of the initial induction therapy. maintenance phase ensues
Typically, an anthracycline is included, o L lower doses of medications are given
sometimes with asparaginase (Elspar). for up to 3 years.
ABOUT THE CHEMO DRUGS
Vincristine: vinca alkaloid that disrupts microtubule Corticosteroids (e.g., prednisone, dexamethasone):
formation during mitosis. It inhibits the assembly of anti-inflammatory and immunosuppressive effects.
microtubules, leading to cell cycle arrest in They induce apoptosis (programmed cell death) in
metaphase and ultimately preventing cell division. lymphoid cells and inhibit various aspects of the
- Cell Specificity: Vincristine affects rapidly immune response.
dividing cells, particularly those in the M phase - Cell Specificity: used in the treatment of various
of the cell cycle. hematologic malignancies
- Side Effects: - Side Effects:
o Peripheral neuropathy (tingling, o Increased risk of infections.
numbness in the extremities). o Hyperglycemia (elevated blood sugar
o Constipation. levels).
o Jaw pain. o Osteoporosis.
o Hair loss. o Mood changes.
o Rarely, severe neurotoxicity. o Weight gain.
o Increased appetite

Anthracyclines (e.g., doxorubicin):

intercalate with DNA and inhibit Side Effects:
topoisomerase II, leading to DNA strand o Cardiotoxicity (particularly with cumulative
breaks. This disrupts DNA replication and doses): congestive heart failure.
transcription, ultimately inducing apoptosis. o Myelosuppression (decreased blood cell
production).
- Cell Specificity: Anthracyclines target o Nausea and vomiting.
both rapidly dividing cancer cells and o Hair loss.
normal cells. They are widely used in the o Mucositis (inflammation of the mucous
treatment of various cancers, including membranes).
breast cancer, lymphomas, and leukemias. o Risk of secondary leukemia with long-term
use.
 Chronic Myelogenous CLINICAL FEATURES DIAGNOSIS
Leukemia Chronic phase (months or years) - Bone marrow biopsy
- blood and bone marrow contains 10% blast - Blood and bone marrow testing for the presence of
Uncommon in people cells the Philadelphia chromosome
under 20 years of age; - few or no symptoms during this time (Cytogenetic analysis)
incidence rises with age - Usual Sx: fatigue, night sweats, pallor, o FISH (Flourescence in situ hybridization):
dyspnea, splenomegaly presence of gene sequence known as BCR-
Usually associated with - Most people are diagnosed during this ABL 1 confirms the diagnosis
an abnormal stage, when they are having blood tests o PCR- polymerase chain reaction: sensitive
chromosome called the done for other reasons. blood test which also measures leukemic
Philadelphia Accelerated phase cancer cells
chromosome (hallmark) - Leukemia cells grow more quickly, about 10- TREATMENT
19 percent are blast cells - Busulfan, Hydroxyurea
- Usually clients who are treated but disease - Imatinib (Gleevec)
still progresses o First treatment for nearly everyone with
- Common Sx: fever (without infection), CML
bone pain, and a swollen spleen. o Taken by mouth
Blast phase: Terminal phase o Eliminates production of malignant clone
- Aggressive - Allogenic stem cell transplant: Only known cure for
- Resembles ALL or AML CML (Allogenic Bone marrow transplant)
Hodgkin’s Lymphoma CLINICAL FEATURES PREVENTION/ SCREEENING/ DETECTION
- Lymphadenopathy: painless; Neck, Check up for persistent:
cancer of lymph tissue above the clavicle, elbow, under the - Fatigue
found in the lymph arms or near the groin - Weight loss
nodes, spleen, liver, - Fever - Night sweats
bone marrow - Persistent fatigue - Fever
- Night sweats DAIGNOSIS AND STAGING
Reed-Sternberg cells: - Weight loss - History and Physical exam
found in lymph fluid - Pruritus - Chest X-ray
- identify under the RISK FACTOR - CT scan: Chest, abdomen, pelvis
microscope due to - Age: 1st peak – 20-30s - Lymphangiogram
the fact that they - 2nd peak: 50s & up - PET scan
are so large and - Family History - Gallium-67 scan: Widely used in nuclear medicine as a
often contain more - Male tumor-imaging agent by gamma-emission scintigraphy
than one nucleus - Epstein Barr Virus - Lab – CBC, LDH & Liver and Renal function test
- Binucleated or METASTASIS - Bone marrow biopsy: lymphoma cells
multinucleated - Spreads from 1 lymph node to - Percutaneous needle biopsy
cells another - Staging laparotomy: Rarely done today because NHL is
- Large malformed - Retroperitoneal node considered systemic
cells with 2 nuclei - Liver - Immunophenotyping: identify cells, based on the types of
- Distinguishes - Lungs antigens or markers on the surface of the cell
Hodgkins and Non- - Spleen
hodgkins - Bone Marrow

Difference bet. Hodgkin

to nonhodgkin
- (-) Reed-Sternberg
cell: non-
Hodgkin’s.
- (+) Reed-
Sternberg:
Hodgkin’s
lymphoma
 TREATMENT
STAGE 1 or 2 STAGE 3 or 4
- RT, Chemo or both - Presence of B symptoms or bulky disease
- treated according to stage and prognosis ABVD
o Improved compliance due to IV
- Chemo regimen: MOPP- usually for older than administration
75 y/o o Less cumulative myelotoxicity
o Mechlorethamine o Lower risk of secondary malignancy o
o vincristine/ Oncovin Lower rate of infertility
o procarbazine
o prednisone RELAPSED/ RECURRENT
- ABVD- Primary choice - BEAM- the most common high dose regimen
o Doxorubicin - B-Carmustine, etoposide, cytarabine, melphalan
o Bleomycin - Bone marrow or peripheral blood stem cells are
o Vinblastine removed before therapy
o dacarbazine
- Dose-escalated BEACOPP PROGNOSIS
o Bleomycin - Treated stage I or II: 20 year survival is 70-80%
o Etoposide - Stage III or IV treated with ABVD: remission
o doxorubicin/ Adriamycin, after chemo with a rate of 89%
o cyclophosphamide - Most common complications
o vincristine o Malignancy
o procarbazine o ischemic heart disease
o prednisone - Common secondary malignancies
o Lung CA
o AML
o NHL
o thyroid CA, breast CA
Non- Hodgkins RISK FACTORS CLASSIFICATION
Lymphoma Immunodeficiency Indolent (Low grade)
- AIDS, Immunosuppression - Slow growing; median age of 50-60 y/o
Malignancies that arise - Ataxia-telangiectasia: Recessive, complex, - Follicular lymphoma
from proliferation of B multisystem disorder; progressive neurologic - Cutaneous T-cell lymphoma
or T Lymphocytes impairment, variable immunodeficiency - Lymphoplasmacytic lymphoma
Wiscott-Aldrich syndrome - Marginal zone B-cell lymphoma
Morphologically and - With variable expression, but commonly - MALT lymphoma
clinically different from includes immunoglobulin M (IgM) deficiency - Small-cell lymphocytic lymphoma
HD Autoimmune disorders Aggressive (High grade)
- RA - fast growing
Diagnosed at more - SLE - Diffuse large B-cell lymphoma
advanced stage - Hashimoto’s disease - Anaplastic large-cell lymphoma
Infectious Agents - Burkitt lymphoma
- EBV, Herpes, H. Pylori, Hep C - Lymphoblastic lymphoma
Environmental factors - Mantle cell lymphoma
- Carcinogen exposures - Peripheral T-cell lymphoma
 CLINICAL FEATURES DIGNOSIS
- Generalized lymphadenopathy - Labs
- Bone marrow involvement - CXR, CT of thorax, abdomen, pelvis and head
- Coughing or SOB: if the cancer affects the - PET scan
thymus gland or lymph nodes in the chest - Gallium 67 scan
- Abdominal pain or swelling - MRI
- Bone scans
METASTASIS
- Follicular- bone marrow
- Diffuse- CNS, bone and GI tract
TREATMENT
Indolent/ low grade NHL Aggressive Lymphoma
- RT- field or total nodal radiation - Chemotherapy
- Chemo- no improved survival shown - CHOP
o CVP- cyclophosphamide, vincristine, - RT
prednisone
o CHOP- cyclophosphamide, Highly aggressive lymphoma
doxorubicin, vincristine, prednisone - CNS prophylaxis (methotrexate)
o Interferon - Hyper CVAD – Cyclophosphamide, mesna,
o Nucleosides Analogues: fludarabine vincristine, doxyrubicin, decadron
and cladribine
NURSING MANAGEMENT
LYMPHADENOPATHY Myelosuppression
- Can cause pain and dysfunction due - Monitor complete blood counts (CBC) regularly to assess
to compression levels of RBC, WBC, and platelets.
- Can obstruct venous blood flow - Assess for signs and symptoms of anemia (e.g., fatigue,
- Assess the function of the pallor), neutropenia (e.g., fever, infection), and
surrounding organs and tissues and thrombocytopenia (e.g., bruising, bleeding).
the presence of lymphedema - Administer prophylactic antibiotics or granulocyte colony-
- Encourage mobility of the affected stimulating factor (G-CSF) if prescribed.
lymph - Educate patients on bleeding precautions.
- Use a soft toothbrush and avoid activities that may cause
CNS involvement injury.
- Can cause Altered mental status, - Monitor for signs of bleeding, such as petechiae and
seizures ecchymosis

-
MULTIPLE MYELOMA RISK FACTORS
Cancer that forms in a - Chromosomal abnormalities
type of WBC called - 70 y/o and above
plasma cell which helps - Male
fight infection by making - Black-American Race
antibodies that - Family history
recognizes and attacks - Occupational exposure to ionizing radiation
foreign antigens. - Pesticides, oil-related, farming chemicals, Wood, leather

Cancerous plasma cells CLINICAL FEATURES

accumulate in bone - Bone pain: in humerus, scapula, spine; osteoporosis
marrow and crowd out - Hypercalcemia: loss of appetite, constipation; feeling sleepy or
normal healthy cells. confused
- Kidney problems
No cure, but can live in - Anemia (weakness, pale skin, SOB, dizziness)
10-20 years - Infections
- Low platelet count = bleeding, bruising

S/S DIAGNOSIS
- Frequent infections - Serum and urine electrophoretic & immunologic studies
- Weakness due to anemia o Elevations in immunoglobulin = tall, narrow
- Bone pain (back, ribs, and hips) based monoclonal spike (M-spike): all the exact
- Kidney problems same hallmark
- Excessive thirst o 24-hr urine – reveals Bence Jones Protein
- Nausea and vomiting - Laboratory studies
- Shortness of breath o  creatinine
- Frequent urination o low albumin
o calcium
o anemia
- Bone marrow biopsy
- MRI, X-rays
 Disease Related Complications
Hypercalcemia Bone Disease
- hydration using isotonic saline - Fixations (intermedullary rods, vertebroplasty)
- Diuretics - IV bisphosphonates, Zoledronic acid,
- Corticosteroids Pamidronate
- biphosphonates (prevent the loss of bone - Active lifestyle, Exercise
mass) - Prompt and timely meds (e.g. round-the-clock
o Side effects: thirst, bone pain, analgesics
polyuria - Report unrelieved pain
o Increased fluids and fiber
- Stool softener Renal Failure
- Privacy for bowel elimination - Hyperuricemia – Allopurinol ( fluids while
taking)
Hyper viscosity - Azotemia
- oronasal bleeding, blurred vision, CHF o Hemodialysis, plasmapheresis (Each
- Analgesics session 60-90 mins)
- Assess for numbness, tingling, loss of balance o Obtain daily/weekly weight
Progressive dysuria, constipation o Monitor I&O
- Plasmapheresis, Corticosteroids, Radiation
Infections
Anemia - Gram (+) i.e. S. pneumoniae, S. Aureus, H.
- fatigue, dyspnea, headache influenzae
- Hgb < 10g/dl - Prompt administration of antibiotics and
- Packed RBC trans round-the clock analgesics
- Colony-stimulating factors (epoetin alfa) - Hydration and nutrition
- Teach about side effects of transfusion
- Report promptly for adverse reactions
TREATMENT
Chemotherapy: Combination chemotherapy Radiation
- MP: melphalan + prednisone - for chemo-resistant
- VBCMP: vincristine + melphalan + carmustine + - Relieves bone pain
cyclophosphamide + prednisone - Treat spinal cord compression
- VBAP: vincristine + melphalan + carmustine + - Improves quality of life but does not enhanced
doxorubicin + prednisone + doxorubicin + survival
prednisone
- VAD – vincristine