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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.