There are a number of early treatment and disease effects which may arise in the person affected by NHL which require prompt assessment and interventions.
Acute tumour lysis syndrome (TLS) is characterised by metabolic changes resulting from the body's inability to process the large volume of intracellular components released with rapid tumour cell destruction.3 The metabolic changes can result in cardiac arrhythmias, seizures, loss of muscle control, acute renal failure and even death.3
The risk is highest in individuals where the following are present:34, 35
- tumours with high growth fractions
- dehydration/ poor urinary output prior to cytotoxic treatment
- bulky abdominal disease (greater than 8-10cm)
- extensive lymph node involvement on diagnosis and prior to treatment
- high white blood cell count
- elevated potassium, phosphorus and uric acid prior to treatment
- elevated lactate dehydrogenase prior to treatment.
The development of TLS is frequently associated with commencement of treatment and is usually observed within 12 – 72 hours.3 It may also be precipitated by corticosteroids, ionizing radiation, hormonal therapy, and biological response modifiers. Management of TLS includes prevention and prompt correction of fluid and electrolyte imbalances.34, 35
Large mediastinal masses may cause severe airways obstruction at presentation.15
Cardiac tamponade requires prompt initiation of specific therapy together with pericardial paracentesis.15
Superior vena cava obstruction, although not uncommon in individuals with NHL, is not usually life threatening.15
Massive abdominal involvement which is commonly associated with ascites, is usually due to Burkitt's lymphoma, and may be responsible for:15
- perforation and/or obstruction of bowel (including intussusception)
- gastrointestinal haemorrhage
- obstruction of ureters, inferior vena cava and lymphatics.
Neurological emergencies associated with NHL may include paraplegia, cranial nerve palsies, meningeal disease and intracerebral tumour. Primary central nervous system lymphoma (PCNSL) is a rare, extranodal form of NHL. Individuals may present with neurological changes. Treatment includes high dose methotrexate requiring specific nursing interventions and evaluation to ensure safety and decrease drug toxicity.36
Access Oncological Emergencies and Paraneoplastic Syndromes (you will need to set up a free account) for further information about:
- Tumour lysis syndrome (page 6)
- Spinal cord compression (page 3)
- Superior vena cava obstruction (page 1).
For each of the following conditions, explain the pathophysiology of the condition in relation to NHL and the signs and symptoms which may be associated with their occurrence:
- Cardiac tamponade
- Bowel perforation
Outline nursing and medical assessment, monitoring and interventions associated with administration of high dose methotrexate to prevent and manage toxicities.
M ☑ F ☐
Stage III Diffuse Large B-cell lymphoma
Enlarged mediastinal mass present on chest x-ray
PET scan indicates positive supraclavicular and mediastinal lymph nodes
Bone marrow aspirate and trephine reveals 74% blasts.
Arthur reports ongoing fatigue, reduced appetite, nausea, and shortness of breath on exertion.
Identify common side effects of CHOP-R regimen, and for each drug:
- Outline a plan for prevention and management of each of these effects
- Discuss nursing considerations associated with the drug administration.
Discuss the pre-treatment information and support that Arthur should receive.
- Provide examples of a range of evidence based strategies for delivering, tailoring and reinforcing information and providing support.
- Outline key information to be conveyed.
- Identify resources which may facilitate information and supportive care provision.
Outline the prognostic and management implications of the pathology results in Arthur's health history.
Discuss significant results which may indicate TLS in Arthur's case.
- Summarise the likely medical management associated with increased risk of TLS in Arthur's case.
- Outline the nursing assessment required and implications associated with caring for Arthur when at risk of and affected by TLS.
Outline the nursing interventions to manage current symptoms Arthur is experiencing:
- Reduced appetite
- Shortness of breath on exertion.