NURS 212: Week 15 - Malignant Disorders of WBCs

• Malignant Disorders of WBCs


  • Leukemia
  • Lymphoma
• Types of Leukemia


  • Acute lymphocytic (ALL)
  • Acute myelogenous (AML)
  • Chronic lymphocytic (CLL)
  • Chronic myelogenous (CML)
• Leukemia - circulating tumors that are disseminated from the beginning of the disease process; primarily involve blood and bone marrow
• Lymphoma - tends to localize in lymph tissues; is often disseminated to other sites at diagnosis
• Diagnosis of Hematologic Neoplasms


  • Evaluation of peripheral blood sample is a key aspect of diagnosis
  • Definitive diagnosis is usually made after bone marrow aspiration or lymph node biopsy
• Leukemia


  Cancer of bone marrow stem cells, usually WBCs (either lymphocytes or myeloid cells)
• Leukemia


  • Clonal disorders: A single progenitor cell undergoes malignant transformation
  • Diffuse "overcrowding" of bone marrow with WBC precursors
  • Uncontrolled proliferation of leukocytes crowding out RBC/platelet stem cells
  • WBCs spill out of bone marrow into circulating blood
  • Infiltrate into liver, spleen, lymph nodes
  • Systemic disease
• Risk Factors for Leukemia


  • Smoking
  • Ionizing radiation
  • Viral infections: HIV, Hep C, HTLV-1
  • Genetic factors
  • Philadelphia chromosome (90% in CML)
  • Abnormal chromosomes reported in 40-50% of patients with acute leukemia
  • Bone marrow damage from radiation (Chernobyl) and bone marrow depression drugs like chloramphenicol, benzenes or prior exposure to antineoplastic drugs (alkylating agents) like cytoxan
• Types of Leukemia


  • Acute Myelogenous Leukemia (AML)
  • Chronic Myelogenous Leukemia (CML)
  • Acute Lymphocytic Leukemia (ALL)
  • Chronic Lymphocytic Leukemia (CLL)
• Leukemia


  • Philadelphia Chromosome
  • More Common in Children
  • Common pathophysiology is blast cells cause overcrowding in the bone marrow and other cell lines cease to function: Pancytopenia, ↓ Hct/Hgb and platelets
  • Labs: ↑WBC, ↓RBC, ↓Platelets
  • Labs: ↑WBCs T cells, B cells, ↓RBCs ↓platelets
• Characteristics of Leukemias


  • Acute Lymphocytic Leukemia (ALL) most often in children (ages 3-7)
  • Chronic Lymphocytic Leukemia (CLL) most often in adults (rare if <45 years)
  • Acute Myelocytic Leukemia (AML) - 50% of cases >60 years of age - Strongest link to toxins
  • Chronic Myelocytic Leukemia (CML) - Philadelphia chromosome is marker in 90% of cases (translocation between chromosome 9 and 22)
• Multiple Myeloma


  A B cell cancer characterized by the proliferation of malignant plasma cells that infiltrate the bone marrow and aggregated into tumor masses throughout the skeletal system
• Multiple Myeloma


  • Slow proliferation of malignant cells with tumor cell masses in the bone marrow, usually not in the peripheral blood
  • As the number of myeloma cells increases, fewer RBC, WBC, and platelets are produced
  • Peak incidence between 65 and 70 years
• Multiple Myeloma Pathophysiology


  • Malignant cells arise from one clone of B cells that produce abnormally large amounts of one class of immunolglobulin (Usually IgG, occasionally IgA), but the clonal antibodies are usually defective
  • Multiple mutations in different pathways alter the plasma cell
  • Changes in chromosome number, translocations, mutations in proto-oncogenes (RAS)
• Multiple Myeloma Clinical manifestations

  • ↑ Calcium levels, renal failure (proteinuria), anemia, and bone lesions
  • Pain – destruction of bone tissue and fractures
  • Vertebral fx –spinal cord compression
  • Amyloidosis may occur (antibody proteins build up in tissues)
  • Fatigue, purple spots on the skin, enlarged tongue, diarrhea, edema, and numbness or tingling in the legs and feet
  • Calcium and bone lesions from infiltration of the bone by malignant plasma cells and stimulation of osteoclasts to reabsorb bone
• Diagnosis and Tx of Multiple Myeloma


  • Symptoms, lab tests, and bone marrow biopsy
  • Biomarkers of antibody components, elevated calcium, renal failure, anemia, and bone lesions
  • Tx: Chemotherapy, radiation, plasmapheresis (exchange) and stem cell transplant
  • Prognosis is poor (5-year survival for all stages is 45.1%)
• Lymphoma


  Defined as a group of malignant neoplasms that affect the lymphatic system
• Types of Lymphoma

  • Hodgkin's Lymphoma (or disease) (15% of all lymphomas)
  • Non-Hodgkin's lymphomas are a broad group of neoplastic disorders that affect the lymphatic system and include all lymphomas except Hodgkin's Disease
• Hodgkin's Lymphoma


  • Malignant disorder of lymph nodes characterized by presence of Reed-Sternberg cells (though to be malignant B lymphocyte)
  • High rates of cure (83% 5 year survival rate)
• Non-Hodgkin's Lymphoma

  • No Reed-Sternberg cells
  • Cure rates vary, better with low grade than high grade lymphoma
• Treatments for Hodgkin's Lymphoma

  • Chemotherapy
  • Radiation
  • Antibody treatments for some
• Types of Non-Hodgkin's Lymphoma

  • High Grade – grow more quickly, need treatment
  • Low Grade- grow more slowly, may not need treatment
• Non-Hodgkin's Lymphoma


  • Risk Factors: Infection with certain viruses, Genetic predisposition, Exposure to occupational toxins
  • High cure rate 90-95% in early stages
  • First sign usually painless swollen lymph node in neck
  • 5 year survival rate: 59%
• Hodgkin's Disease (HD) Pathogenesis

  • Presence of Reed Sternberg cell, a distinctive giant tumor cell believed to be derived from the macrophage-monocyte line replace normal cell structure in lymph node
  • Grow in predictable manner – originates in one lymph node- metastasizes typically along contiguous lymphatic pathways
  • Eventually infiltrates other tissues, liver, spleen, lungs, bone marrow and ureters
  • Incidence (bimodal) rises sharply after 10 years of age, peaks in 20s, drops until age 50 and increases again; younger age group affects males and females equally; after age 50 > in men
• Symptoms of Hodgkin's Disease

  • Painless and progressive enlargement of a single node or group of nodes
  • May have fever, night sweats, pruritis, weight loss and malaise
  • Most commonly starts above the diaphragm, cervical nodes most common
  • If subdiaphragmatic, then inguinal nodes most common
  • Spleen involved in about 1/3 of cases
• Common and Uncommon sites for involvement of lymph nodes for Hodgkin's
• Staging and Treatment of Hodgkin's Lymphoma

  • Accurate staging is essential as treatment is based on staging
  • Based on number of lymph nodes areas involved, one or both sides of diaphragm, disseminated disease to bone marrow or liver
  • Tx: radiation and chemotherapy
  • Effectiveness is related to the age of the individual and dissemination of disease
• Non Hodgkin's Lymphoma


  • A progressive expansion of clonal B cells, T cells, or NK cells
  • Genetic mutations result from translocations creating oncogenes
• Risk Factors for Non Hodgkin's Lymphoma

  • Environment family history
  • Exposure to a variety of mutagenic chemicals
  • Irradiation
  • Infection with certain cancer-related viruses
  • Immune suppression drugs
• Non Hodgkin's Lymphoma found in individuals >50 years old
• Non Hodgkin's Lymphoma reclassified into the B cell, T cell and NK cell neoplasms
• Non Hodgkin's Lymphoma


  • Can start in one lymph node area but more likely multicentric in origin and can originate in any lymphoid tissue
  • Cervical, axillary, inguinal and femoral chains are the most commonly affected sites
  • Unpredictable in spread (noncontiguous)
  • Similar symptoms as Hodgkin's (painless lymph node enlargement, fever, night sweats and weight loss
  • Most present with advanced disease (stage III or IV)
• Non Hodgkin's Lymphoma


  • No Reed-Sternberg cells
  • Older adults and males are affected at higher rates
  • Overall 5-year survival rate is about 50%
  • Tx: Radiation in early stage, chemotherapy for more disseminated disease which can lead to anemia, thrombocytopenia and leukopenia
• lymph nodes are small masses of tissue scattered throughout the body where white blood cells filter out foreign substances
• the spleen is the largest lymphoid organ, located on the left side of the abdomen
• the thymus gland is an important part of the immune system that produces T cells
• bone marrow is the soft, spongy material found inside bones where stem cells develop into red and white blood cells
• The bone marrow produces red blood cells, platelets, and some immune cells.
• leukocytosis is when there is an increase in the number of white blood cells circulating in the bloodstream
• Lymphatic vessels carry fluid called lymph from tissues back to the circulatory system.