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malignancies include the leukemias, lymphomas, and multiple myeloma. The malignant cells can occur in the blood stream, bone marrow, spleen, lymph nodes, and thymus, and, in some cases, they can invade bone itself.

Leukemia

The leukemias are malignancies of white blood cells, most commonly

granulocytes (neutrophils or polymorphonuclear leukocytes) and lymphocytes. These malignant cells first occupy the bone marrow, replacing normal cells, then spill into the blood stream.

Because the malignant cells first occupy the bone marrow, they can

occlude the space occupied by normal bone marrow cells. As a result,

patients can have anemia, thrombocytopenia, and leukopenia. Often,

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Table 5-13. Types of Leukemia

Type

Cells Involved

Age Range (yrs)

Acure lymphocytic leukemia

Lymphocytes

3-7

Acute non lymphocytic leukemia

Stem cells

15-40

Chronic myelogenous leukemia

Granulocytes

25-60

Chronic lymphocytic leukemia

Lymphocytes

50+

the clinical manifestations of leukemia are fatigue, easy bruising, and

infections. (Refer to Chapter 6 for hemarologic information.)

Leukemia is classified as acute or chronic, depending on the maturity of the malignant cell. Acute leukemia is from a more immature white blood cell; disease progtession tends to be tapid. Chronic leukemias are from more mature cells; disease progression is usually slower. Acute leukemias tend to occur in children and young adults.

Chronic leukemia tends to occur in older adults. Types of leukemia,

cells affected, and common age ranges are listed in Table 5-13.

Lymphomas

Lymphomas are malignancies of lymphocytic cells and lymph tissues.

Unlike leukemic cells that occupy bone marrow and spill into the

blood stream, lymphomas occupy lymph tissue (lymph nodes and

spleen). Occupation of the lymph nodes usually causes painless

enlargement, often the first sign of lymphoma.

The most common type of lymphoma is Hodgkin's lymphoma. The

other most common types of lymphoma are non-Hodgkin's (malignant

or lymphosarcoma) and Burkitt's lymphomas. Butkitt's lymphoma is a

solid tumor of B-cell origin, endemic in Africa.I,? Characteristics of

Hodgkin's and non-Hodgkin's lymphomas can be found in Table 5-14.

Table 5-14. Characteristics of Hodgkin's and Non-Hodgkin's Lymphomas

Non-Hodgkin's

Hodgkin's Lymphoma

Lymphoma

Nodal involvemenr

Usually involves single

Usually involves more

node site

than one sire

Spread

Usually orderly

Nonorderly

Extranodal involvement

Uncommon

Common

ONCOLOGY

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Table 5-15. Sr3gcs of Lymphoma, Ann Arbor Classification

Stage

Distribution of Disease

I

Single lymph node region or single extralymphatic organ or site involved

II

Two or more lymph node regions on the same side of the diaphragm

involved or involvement of limited continuous extralympharic organ

III

Lymph node regions on both sides of the diaphragm, limited contig-

uous exrralympharic organ involvement, or both

IV

Multiple, disseminated involvement of one or more extra lymphatic

organs, with or without lymphatic involvement

Source: Adapred from Carbone PP. Kaplan HS, Musshoff K, er 31. Report of rhe Conlfllirtcc on Hodgkin') Disease Sraging Classificarion. Cancer Res 1971 ;31 (11): 1860--1861.

For lymphoma, the TNM system has generally been replaced by

the Ann Arbor Classification. This classification is based on the number and location of lymph nodes involved. The Ann Arbor Classification can be found in Table 5-15.

Prognosis

If left untreated, all leukemias and lymphomas are fatal. Malignant

cells can infiltrate all major blood vessels and organs, causing occlusion and infarction. Infiltration into the musculoskeletal structures can result in joinr hemorrhage, rheumarologic-rype symptoms, and

synovitis. Infiltration of neurologic tissues can result in nerve palsies,

encephalopathy, headache, vomiting, blurred vision, and auditory

problems.' In addition, the decreased number of normal immunologic

cells leaves the patient highly susceptible to infection.

Treatme1lt

Leukemias are treated with chemotherapy, radiarion, hormone therapy, and bone martow transplantation. Lymphoma is treated with chemotherapy, irradiation, or both. Some of the slower-growing leukemias are left untreated, especially if the patient is elderly.3 Bone marrow transplantation is discussed in Chapter 12.

Clinical Tip

Platelet counts and hematocrit should be assessed to determine a safe level of activity or exercise. See Bone Marrow

Transplant in Chapter 12 for specific guidelines.