Hodgkin’s and Non-Hodgkin’s Lymphoma
The concept "lymphoma" unites more than 30 diseases, which are different in their clinical manifestations, course, and prognosis. There are two main types of lymphoma: Hodgkin's lymphoma (Hodgkin's disease) and non-Hodgkin's lymphoma. Despite similar clinical manifestations of both types, they differ at microscopic researches. While the Hodgkin's lymphoma originates from specific B-lymphocytes, non-Hodgkin's lymphoma occurs due to B- or T-lymphocytes. Hodgkin's disease has 5 subtypes, and non-Hodgkin's lymphoma is distinguished into 30 subtypes (Cheson & Leonard, 2008). Therefore, the exact diagnostics of a lymphoma subtype is rather important since subtypes react differently to diverse ways of treatment and have various prognoses. In this regard, it is necessary to perform the detailed analysis and compare the main features of a pathophysiology, clinical manifestations, medical management, and prognosis of a further course of both diseases for identification of the most effective methods of their treatment.
Hodgkin's lymphoma (the name was introduced by the WHO in 2001; also known as Hodgkin's disease) is a tumor disease of lymphatic system. People of all ages can get ill with Hodgkin's lymphoma. Moreover, men get sick more often than women. Until recently, it has been regarded that the incidence curve has two peaks: the first one occurs at the age of 15-40 years, and the second gradually accrues after 50 years (Leonard & Coleman, 2008). However, the use of immunophenotyping in the revision of the histological specimens in patients older than 50 years has shown that the second peak is either very insignificant or completely absent since the majority of histological preparations were carried to magnocellular non-Hodgkin lymphoma after the retrospective analysis (Cheson & Leonard, 2008).
Non-Hodgkin's lymphomas are a heterogeneous group of neoplastic diseases derived from cells of lymphoid (immune) system. The main points that determine the clinical features and prognosis of the disease include the stage of differentiation of cells that constitute the tumor and the nature of tumor growth within the process involved in the lymph node (Calandra et al., 2008). Achievements of immunology, cytogenetics, and molecular biology allow to define the specific subtypes of non-Hodgkin's lymphoma differing in a clinical course, response to therapy, and prognosis. Therefore, depending on non-Hodgkin's lymphoma subtype, prognosis can vary from safe (survival from 10 to 20 years) to extremely adverse (survival is less than one year) (Leonard & Coleman, 2008).
The cause of emergence of non-Hodgkin's lymphoma remains unknown. Risk factors common for all neoplastic diseases traditionally include the ionizing radiation, chemical carcinogens, and adverse conditions of environment. In some cases of lymphoma development, the interrelation between the influence of a virus and tumor growth is traced. Non-Hodgkin's lymphoma, which was earlier incurable, can now be cured, or the permanent remission is reached due to early detection and application of modern techniques (Hsu et al., 2008). However, unlike Non-Hodgkin's lymphoma, the reasons of Hodgkin's disease development are not established definitely. Exceptional cases of the Hodgkin's disease in one family are described; however, only separate cases of the family Hodgkin's lymphoma can be caused by heredity (Armitage, 2009).
Often during non-Hodgkin's lymphoma, various anomalies of the chromosomal apparatus of a cell (genetic material) are revealed. Most often, the tumor develops at the combination of several causal factors. Today, the amount of patients with AIDS suffering from the non-Hodgkin's lymphomas increases (Armitage, 2009). Often, tumor cells suppress the development of similar normal cells and cause the immunodeficiency. Patients with non-Hodgkin's disease usually have an increased susceptibility to infections of all kinds. Damage of marrow due to non-Hodgkin's lymphoma involves the development of insufficiency of marrowy blood formation with the decrease in all indicators of peripheral blood (Hsu et al., 2008).
In turn, during Hodgkin's lymphoma, both giant two- and multinuclear Reed-Sternberg cells and large mononuclear Hodgkin's cells are detected in the affected lymph node. Unlike non-Hodgkin's lymphoma, in this case, tumor cells constitute only a small part of the tumor, it is largely formed by the non-neoplastic polyclonal T-lymphocytes, plasma cells, histiocytes, and tissue eosinophils. This is due to the fact that Reed-Sternberg cells actively secrete numerous cytokin and chemotactic factors (Leonard & Coleman, 2008).
In the most cases, both Hodgkin's and non-Hodgkin's lymphomas have similar clinical manifestations. For example, most often, these diseases are followed by the emergence of a tumor in a lymph node or any other location. Usually, the tumor itself does not cause any subjective feelings in the patient and can be found at casual survey (Armitage, 2009). The common symptomatology consists of the weakness usual for neoplasia, increased fatigue, and decrease in body weight. The triad of signs combining the sweating, especially at night, unmotivated skin itch, and bad tolerance to stings of blood-sucking insects is rather pathognomonic for tumors of this kind. In some cases, the emergence of one or several symptoms from the specified triad can advance the development of the tumor for some years (Engert & Horning, 2010).
However, unlike Hodgkin's lymphoma, clinical manifestations of the effect on the organ supplement the picture of the Hodgkin's disease. For example, extranodal lesions are localized in the lung tissue, causing respiratory failure, pneumonia, lymphogranuloma in lungs and pleura, and pleural effusion. Besides, intrathoracic lymph nodes may increase, which is manifested by a compression of the superior vena cava, causing edema, hyperemia, and dilated veins of the upper half of the body. The increased lymph nodes of belly and pelvic areas lead to the expressed hypostasis of hips, shins, and scrotum (Hsu et al., 2008). Moreover, the ocular fundus can be affected, which is manifested by a specific infiltration by the Reed-Steinberg cells. In addition, herpetic lesions can be observed (Stoppler, 2014).
Nursing and Medical Management
The methods of treatment and nursing are almost similar for both kinds of lymphomas. Modern therapy of lymphomas is based on the exact verification of a tumor sub-type. The simplified diagnostics of lymphoma, which does not allow an accurate diagnosis and forms only a "group" diagnosis (for example, "lymphoma of high malignity degree") impairs significantly the possibility of assisting the patient. Depending on the nosological diagnosis and the stage of the disease, treatment of lymphoma of both types is based on the application of programs of chemotherapy and radiation therapy (Engert & Horning, 2010).
Cyclophosphamide, vincristine, prednisone (according to the CHOP program), and some other preparations are often used as cytostatic agents (Stoppler, 2014). In the absence of the disease leukemization, there is a good opportunity for intensive chemotherapy with the subsequent transplantation of the autologous marrow prepared for the patient before the intensive treatment started. In addition to autologous transplantation, the allogenic bone marrow transplantation is used for the treatment of both Hodgkin's and non-Hodgkin's lymphomas under appropriate conditions (Armitage, 2009).
The choice of treatment method of refractory forms of Hodgkin's and non-Hodgkin's disease and early recurrence (within one year after the end of radiation therapy) includes high-dose polychemotherapy with mobilization of stem cells of blood or marrow and their subsequent autotransplantation or transplantation of the allogeneic bone marrow (Stoppler, 2014). The treatment of late recurrence (one year after the complete remission) is conducted according to the scheme by means of which it succeeded to reach the full remission earlier. Monochemotherapy represents a palliative treatment for the older weakened patients and is also employed in cases when the possibility of polychemotherapy can be considered exhausting (Cheson & Leonard, 2008).
Control monitoring is conducted once every three months in the first year after the completion of the therapy, once every six months in the second year, and once every following year thereafter. Monitoring of indicators of general and biochemical blood tests is done once every three months. The X-ray analysis of a thorax is conducted once a year within 10 years. The physical therapy, insolations, and pregnancy in the first two years after the end of the therapy are contraindicated to the patients (Cheson & Leonard, 2008). The modern treatment of Hodgkin's and non-Hodgkin's lymphomas, which is based on the exact morphological diagnosis allowing to prolong and keep life of the patients, demands harmonious work of many experts as well as the attraction of knowledge-intensive and resource-intensive technologies and, finally, depends on the economic policy of the state in the field of health care (Calandra et al., 2008).
Without special treatment, prognosis of Hodgkin's and non-Hodgkin's lymphomas is absolutely poor. The individual prognosis of Hodgkin's lymphoma is defined by the stage of the disease and is rather optimistic for patients with I and II stages. However, at higher stages of the disease, the adequate therapy also allows to achieve quite good results (Engert & Horning, 2010). In its turn, during non-Hodgkin's lymphoma, the individual forecast depends on a sub-type of the lymphoma and the possibility of conducting the adequate treatment. The paradox is that the modern methods of treatment can provide long-term survival and cure for patients with high-grade lymphoma, while they have practically no influence on the course of low-grade lymphomas. Today, there is no effective prevention of lymphomas. However, general recommendations are to avoid the contact with the potentially mutagenic factors (Calandra et al., 2008).
Taking into account all the information mentioned above, it should be noted that lymphoma is a collective name for cancer of the lymphoid tissue, characterized by enlarged lymph nodes and the presence of tumor-like formations. There are two types of lymphoma: Hodgkin's and non-Hodgkin's lymphoma. The former has five subtypes, while the latter comprises thirty subtypes. Diseases can be attributed to one or another type only after the histological examination of a tissue sample obtained by biopsy. If the Reed-Sternberg cells, which are specific to Hodgkin's disease, were not found during the microscopic examination, the disease belongs to the group of non-Hodgkin's lymphomas. However, the main parameters of both types of lymphomas are very similar to each other and have minor differences. The treatment for both types of lymphomas is also based on the same methods. It is complex and directed at the control or suppression of leukemic process (radiation therapy, polychemotherapy), treatment of infectious complications of the disease (antibiotics and antibacterial preparations), and treatment of autoimmune complications. However, in any case, the treatment of Hodgkin's and non-Hodgkin's diseases demands the investment of forces of qualified specialists and high technologies, which can be provided only in the country with well-developed economical and healthcare infrastructures.