Introduction
Extant literature demonstrates that lymphomas are a diverse group of lymphoproliferative malignancies with differing patterns of epidemiologic prevalence, etiology, behavior, as well as responses to clinical management (Hochberg et al., 2009). The purpose of the current paper is to critically compare and contrast the pathophysiology, clinical manifestations, management, and prognosis of the two main types of lymphomas namely Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL).
In background information, it is important to mention that HL was discovered in 1832 by Thomas Hodgkin as a progressive, malignant infection arising from lymphoid tissue and characterized by two distinct features, namely (1) replacement of normal lymphoid tissue with collections of abnormal cells, and (2) presence of distinctive binucleate Reed-Sternberg cell (Cole & Dunne, 2004). HL, according to these authors, mostly affects young adults between 15 and 34, as well as patients over 50 years. On its part, NHL represents the fourth most frequent cancer diagnosed in young children and adolescents 15 to 25 years, not to mention that it is normally subdivided into three distinct histologic subtypes, namely “…(1) lymphoblastic lymphoma, (2) mature B-cell NHL, including Burkitt lymphoma [and] diffuse large B-cell lymphoma, and (3) anaplastic large cell lymphoma” (Mann et al., 2007, p. 443).
Pathophysiology
HL and NHL are uniquely related to lymphocytes, which are a type of white blood cell originating from the bone marrow and largely found in the blood, the lymphatic system, and body tissues. There are two variants, T lymphocytes, and B lymphocytes, with each playing its individual distinctive and fundamental function in the body’s immune system (Cole & Dunne, 2004). According to these authors, HL “…occurs when a normal lymphocyte undergoes uncontrolled production and transforms into an abnormal malignant cell” (p. 46). The authors further posit that HL is typified by the presence of a unique binucleate Reed-Sternberg cell, which is considered to be the malignant component in the disease and is thought to originate from a B lymphocyte. The lymphoma cells in HL are known to principally affect the lymph nodes, but they do have the capacity to penetrate tissue and other body organs, obliterating their normal constitution as well as penetrating lymphatic tissue and the bone marrow.
Similar to HL, a majority of NHL cases are derived from the B lymphocytes, with only a few coming from malignant transformation of the T lymphocytes (Schrieuer & Huhn, 2003). Scientists believe that the various subtypes of NHL (described in background information) are primarily derived from a multiplicity of corresponding cells at varied hierarchical levels/phases of hemopoietic and lymphoid cell development (Mann et al., 2007). Available literature demonstrates that “…similar to most human cancers, the genetic lesions involved in non-Hodgkin lymphoma include activation of proto-oncogenes and disruption of tumor suppressor genes” (Evans & Hancock, 2003, p. 139). By contrast with HL, chromosomal translocations represent the primary means of proto-oncogene activation in many variants of NHL, with available literature demonstrating that these translocations are typified by reappearance within an explicit clinicopathological category of NHL and are clonally represented in each tumor (Evans & Hancock, 2003).
Clinical Manifestations
Patients suffering from HL present with an enlarged painless lymph node and, in most cases, the cervical nodes are the first to be involved (60-70 percent of cases), followed by axillary nodes (10-15 percent of cases), and inguinal nodes (6-12 percent of cases) (Cole & Dunne, 2004). As further postulated by these authors, HL “…normally follows a predictable course, with the disease progressing from one group of lymph nodes to adjacent groups in an organized contiguous manner” (p. 47). Although the clinical presentation of HL often depends on the location of the lymph node affected, many patients characteristically present with enlarged liver or spleen due to infiltration by lymphoma cells, fatigue, sustained weight loss, night sweats, pruritis, as well as irregular fevers usually linked to the night sweats (Cole & Dunne, 2004).
Similar to HL, presentation of NHL to a large extent depends on-site/location of involvement, but also on other factors including the natural history of the lymphoma as well as the presence or absence of B symptoms (sustained weight loss by more than 10 percent of the total body weight, night sweats, and fever). For some subtypes of NHL, particularly indolent lymphomas, patients usually “…present with peripheral lymphadenopathy, which generally waxes and wanes over time and is usually asymptomatic unless it causes compression, for instance of the ureter, orbit, or spinal cord” (Evans & Hancock, 2003, p. 141). With aggressive lymphomas, however, rapid tumor growth is experienced (lumps can emerge almost anywhere and virtually affect any tissue or organ, including extranodal sites such as the gastrointestinal tract, head, neck, and skin), and victims might quickly become seriously ill. Some patients with either HL or NHL have presented with symptoms only (e.g., weight loss, bone pain, breathlessness; recurrent infection; night sweats, exhaustion), but without necessarily demonstrating a mass or tumor that is easy to biopsy (Evans & Hancock, 2003).
Nursing/Medical Management
A point of convergence in the management of both HL and NHL arises from the fact that all patients with, or who potentially have, lymphoma should have their treatment and management strategies discussed by a qualified team constituted by multidisciplinary professionals (Cole & Dunne, 2004; Evans & Hancock, 2003). It is generally felt that the involvement of a multidisciplinary team of professionals, along with informed consent to take part in the ongoing clinical trials for HL and NHL, is critical for the patient’s own most favorable treatment option and the contribution to evidence-based practice for future improvements in care. Additionally, according to these authors, the importance of staging is emphasized once a diagnosis for either HL or NHL is confirmed because medical professionals use the staging system to decide treatment options, management, and prognosis.
Another point of similarity for the two diseases is grounded on the fact that their mainstays of treatment have always been chemotherapy or radiotherapy. Still, it can be argued that modern science is evaluating ways through which monoclonal antibodies (e.g., Rituximab) can be used in the treatment of both HL and NHL to circumvent the serious side effect of toxicity related to chemotherapy and radiotherapy (Cole & Dunne, 2004; Evans & Hancock, 2003).
In management, patients suffering from either of the two diseases need to be afforded social support to strengthen their coping strategies but also assist them to develop a positive attitude to life and a proactive desire to fight the disease (Cole & Dunne, 2004; Evans & Hancock, 2003). The needed social support, according to these authors, can be derived from family members, friends, as well as healthcare professionals.
Readily available information about the diseases should be afforded to the patients, including the reasons for adopting a particular treatment regimen, because such exposure not only enhances control and reduces anxiety, but also enables patients to make informed decisions relating to their treatment. However, according to Cole & Dunne (2004), the release of information to patients should be done “…in a balanced way that is concise, easy to understand and recognizes that information needs may change throughout the cancer journey” (p. 49). Social support and access to information may also be obtained from other sources, such as relevant internet sites, social workers, cancer support groups, and other governmental or non-governmental agencies.
Most patients suffering from either HL or NHL present with the main symptom of lymphadenopathy. It should be the task of nursing professionals to evaluate the function of the surrounding tissue and organs, as well as observe for vital symptoms of lymphoedema. Nursing professionals designated with the task of managing the two diseases must also take time to educate patients about the side-effects of various treatment strategies such as chemotherapy and radiotherapy, along with the management of their side effects in case they appear (Cole & Dunne, 2004; Evans & Hancock, 2003).
There exist points of divergences regarding the way the two diseases are treated and managed. While the mode of treatment for HL depends on the stage of the disease, hence the significance of accurate classification and staging (Cole & Dunne, 2004), treatment for NHL is to a large extent influenced by factors such as the tumor type and extent, patient’s performance status, and previous medical history (Evans & Hancock, 2003). Additionally, although both diseases have benefitted from modern advanced treatment regimens, HL uses doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) regimen (Cole & Dunne, 2004), while NHL uses doxorubicin, cyclophosphamide, vindesine, and bleomycin (ACVB) regimen (Evans & Hancock, 2003). According, to Cole & Dunne (2004), the ABVD has been found to possess more anti-tumor activities than previous treatment options such as the MOPP, not mentioning that it is less likely to occasion sterility or secondary leukemia.
Prognosis
The clinical prognostic aspects for the two diseases under discussion are mainly a surrogate for the disease bulk, with available literature showing that factors that have commonly been established as being linked to a poor prognosis of the two diseases include (1) age older than 60 years, (2) poor patient performance status, (3) exhibition of symptoms related to the B lymphocyte, (4) disseminated stage, (5) a tumor/mass of more than 10 centimeters in diameter or widening of the mediastinum by more than one third, (6) three or more extranodal locations exhibiting the disease, (7) bone marrow or liver involvement, (8) concentration in serum of lactate dehydrogenase beyond ordinary limits, and (9) transformation from earlier low-grade histology (Cole & Dunne, 2004; Evans & Hancock, 2003). Consequently, it can be argued that all of the above aspects independently contribute to the prognosis of both HL and NHL, but the major ones, as postulated by these authors, include age, stage of progression/development, number of extranodal sites/locations, performance status, as well as the concentration of lactate dehydrogenase.
Conclusion
Not only has the present paper discussed important information regarding the pathophysiology, clinical manifestations, management, and prognosis of HL and NHL, but it has brought forward some striking similarities shared by the two diseases, as well as some points of divergences that make them unique. The information contained in this paper has important implications for practice not only for the medical and nursing professionals but also for the patients themselves. Perhaps some of the most salient issues that can contribute immensely to the effective treatment and management of the diseases are that the medical professionals and the nurses must work in collaboration and cooperation with patients and that the diseases require a multifaceted and multidisciplinary approach for successful management.
References
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Evans, L.S., & Hancock, B.W. (2003). Non-Hodgkin lymphoma. Lancet, 362(9378), 139-146.
Hochberg. J., Waxman, I.M., Kelly, K.M., Morris, E., & Cairo, M.S. (2009). Adolescent non-Hodgkin lymphoma and Hodgkin lymphoma: State of the science. British Journal of Hematology, 144(1), 24-40.
Mann, G., Attarbaschi, A., Burkhardt, B., Niggli, F., Klapper, W., Ludwig, W.D…Reiter, A. (2007). Clinical characteristics and treatment outcome of infants with non-Hodgkin lymphoma. British Journal of Hematology, 139(3), 443-449.
Schrieuer, F., & Huhn, D. (2003). New directions in the diagnosis and treatment of chronic lymphocytic leukemia. Drugs, 63(10), 953-969.