Lymph

Type of Immunity

Sistem limfatik terdiri dari :o Pembuluh limfatik yang membantu

mengembalikan cairan jaringan ke sistem sirkulasi.

o Nodus dan nodul limfe yang berupa massa jaringan limfatik yang berbeda dalam ukuran dan lokasinya.

o Limpa (spleen) yang berperan dalam proses fagositosis patogen serta memproduksi leukosit dan antibodi.

o Kelenjar timus yang berfungsi pada permulaam masa anak dan akan menurun saat menjelang dewasa.

o Nodus limfatik membentuk kelompok yang berhubungan dengan pembuluh limfe untuk menghancurkan material asing.

o Kelompok nodul limfatik terletak paa daerah cervikal, axilla dan inguinal.

Pembuluh Limfe (LYMPH VESSELS)

o Sistem pumbuluh limfe mulai dari kapiler limfe yang terdapat di beberapa jaringan.

o Kapiler limfe sangat permiabel dan berfungsi mengumpulkan cairan jaringan dan protein.

o Contoh : Lacteals are specialized lymph capillaries in the villi of the small intestine; they absorb the fat-soluble end products of digestion, such as fatty acids and vitamins A, D, E, and K.

o Kapiler limfe merupakan bagian dari pembuluh limfe yang besar ang mempunyai struktur seperti vena. Mempunyai mekanisme venous return (The smooth muscle layer of the larger lymph vessels constricts, and the one-way valves prevent backflow of lymph).

o Pembuluh limfe pada ekstremitas (kaki) : skeletal muscle pump.

Sistem Limfe

lymph system is responsible for the following:

• Cleansing the cellular environment• Returning proteins and tissue fluids

to the blood (drainage)• Providing a pathway for the

absorption of fats and fat-soluble vitamins into the bloodstream.

• Defending the body against disease.

Lymph

• Lymph is a virtually colorless fluid similar to blood plasma in composition that carries harmful substances from tissues to lymph nodes to be filtered.

Lymph• Lymph nodes come in many variations of the jelly bean size

mentioned above but a standard nod eis about one inch long and the size of a bean.

• When a human is born, they have about 600-700 lymph nodes. As we age, the number of lymph nodes decreases to about 100.

• They are covered in a capsule and are divided into the cortex and medulla. The cortex holds the lymphocytes known as B-cells which produce antibodies that circulate.

• The rest of the cortex contains T-cells that circulate the lymphatic system searching and destroying pathogens.

• The medulla is where a  macrophage, another type of leukocyte, attach the the fibers of the node. Lymph node are what filter lymph.

• Kanker atau tumor ganas adalah pertumbuhan sel/jaringan yang tidak terkendali, terus bertumbuh/bertambah, immortal (tidak dapat mati). Sel kanker dapat menyusup ke jaringan sekitar dan dapat membentuk anak sebar (Riskesdas, 2013).

Riskesdas, 2013

LYMPHOMA

• Hodgkin’s disease, a neoplastic disorder, is characterized by painless, progressive enlargement of the lymph nodes, spleen, and other lymphoid tissue (Sommer et al, 2007).

• The enlargement is caused by a proliferation of lymphocytes, histiocytes, eosinophils.

• Malignant lymphoma, or NHL, is a heterogeneous grouping of several disease types that range from the aggressive, rapidly fatal diffuse histiocytic lymphoma to the indolent nodular varieties

LYMPHOMA

• Malignant lymphoma, also called lymphosarcoma or non-Hodgkin’s lymphoma (NHL), is a diffuse group of neoplastic diseases that are characterized by rampant proliferation of lymphocytes (Sommer, Johnson, Beery, 2007).

• Malignant lymphoma, or NHL, is a heterogeneous grouping of several disease types that range from the aggressive, rapidly fatal diffuse histiocytic lymphoma to the indolent nodular varieties.

LYMPHOMA• NHLs adalah keganasan (kanker) yang

berasal dari sistem kelenjar getah bening dan biasanya menyebar ke seluruh tubuh. Beberapa jenis limfoma NHL berkembang sangat lambat (medicastore.com).

• more than 60,000 new cases of lymphoma that are diagnosed each year in the United States, approximately 55,000 of them will be NHL. In the past 30 years, the incidence of NHL has increased by more than 80%, making it one of the largest increases of any cancer.

• This increase is unexpected and is only partially explained by earlier detection because of improved diagnostic techniques or human immunodeficiency virus (HIV)–associated lymphomas.

Penyebab• Penyebab NHL belum diketahui, tetapi

beberapa bukti menunjukkan adanya hubungan dengan virus. Perkembangan penyakit berkaitan dengan infeksi karena HTLV-1 (human T-cell Lymphotropic Virus tipe I), yang fungsinya menyerupai HIV.

• exposures to viruses and immunosuppression,

• organ transplantation, • a history of cancer treated with radiation, • acquired immune deficiencies, • autoimmune disorders are considered risk

factors (Sommer, Johnson, Beery, 2007)

Gejala

• Pembesaran kelenjar getah bening, pembesaran pada tonsil dapat mengganggu proses menelan, pembesaran kelenjar getah bening pada dada atau perut dapat menekan berbagai organ dan menyebabkan :

• gangguan pernafasan, • sembelit, • nyeri perut, • pembengkaan tungkai, • penyebaran pada darah menyebabkan leukemia, • penyebaran ke sumsum tulang , saluran cerna, kulit,

sehingga menyebabkan anemia, ruam kulit, • gejalan neurologis (kelemahan dan sensasi abnorma)l

Gejala

• Biasanya yang membesar kelenjar getah bening bagian dalam yang menyebabkan :• Pengumpulan cairan di sekitar

paru sehingga timbul sesak• Penyumbatan kelenjar getah

bening sehingga terjadi penumpukan cairan

• Penekanan usus sehinggan menyebabkan anoreksia dan muntah

Gejala Penyebab Kemungkinan Timbul Gejala

Gangguan pernafasan

Pembesaran kelenjar getah bening di dada

20-30%

Pembengkakan wajahAnoreksiaSembelitNyeri perutkembung

Pembesaran kelenjar getah bening di perut

30-405

Pembengkakan tungkai

Penyumbatan pembuluh getah bening di lipatan paha

10%

Penurunan BBDiareMalabsorpsi

Penyebaran limfoma ke usus halus

10%

Pengumpulan cairan di sekitar paru (efusi pleura)

Penyumbatan pembuluh getah bening di dada

20-30%

Kehitaman dan menebal di kulit yang terasa gatal

Penyebaran limfoma ke kulit 10-20%

DemamKeringat malam hari

Penyebaran limfoma ke seluruh tubuh

50-60%

Anemia Perdarahan ke dalam saluran pencernaanPenghancuran SDM oleh limpa yang membesar dan terlalu aktifPenghancuran SDM oleh antibodi abnormal (anemia hemolitik)Penghancuran sumsum tulang karena penyebaran limfomaketidakmampuan sumsum tulang untuk menghasilkan SDM akibat obat atau terapi radiasi

30% bisa sampai 100%

Mudah infeksi Penyebaran ke sumsum tulang dan kelenjar getah bening, menyebabkan berkurangnya pembentukan antibodi

20-30%

KOMPLIKASI

• hypercalcemia, • increased uric acid levels, • meningitis, • anemia,• as tumors grow, they may compress

the vital organs and cause organ dysfunction; problems from organ compression include complications such as increased intracranial pressure.

Tekanan Intra Kranial (ICP)

• The skull is a fixed compartment containing approximately :• 80% brain tissue, • 10% cerebrospinal fluid (CSF), • 10% blood volume. • an increase in brain size, blood volume,

or CSF must be accompanied by an equal decrease in 1 of these components or an elevation in ICP will occur.

TIK

• The Monro-Kellie doctrine states that the skull is a rigid compartment containing three components: brain, blood, and cerebrospinal fluid. If an increase in one component is not accompanied by a decrease in one or both of the other components, the result is increased intracranial pressure

ICP

• Elevated ICP leads to a decrease in cerebral perfusion pressure (CPP) and decreased flow, resulting in cerebral ischemia.

• Intracranial pressure values consistently greater than 40 mm Hg represent lifethreatening intracranial hypertension because of the risk for brain herniation.

Diagnosis

• Biopsi• CT scan

BIOPSY• Fine needle aspiration (FNA) or core needle

biopsy: In an FNA biopsy, the doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from an enlarged lymph node or a tumor mass. For a core needle biopsy, the doctor uses a larger needle to remove a slightly larger piece of tissue (http://www.cancer.org/cancer/non-hodgkinlymphoma/detailedguide/non-hodgkin-lymphoma-diagnosis.

• Bone marrow aspiration and biopsy: These procedures are often done after lymphoma has been diagnosed to help determine if it has reached the bone marrow. The 2 tests are often done at the same time. The samples are usually taken from the back of the pelvic (hip) bone, although in some cases they may be taken from the sternum (breast bone) or other bones.

Computed Tomography (CT) Scan

• The CT scan is an x-ray test that produces detailed, cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body.

• Unlike a regular x-ray, CT scans can show the detail in soft tissues (such as internal organs). This scan can help tell if any lymph nodes or organs in your body are enlarged. CT scans are useful for looking for lymphoma in the abdomen, pelvis, chest, head, and neck.

Spectrum of histopathologic diagnosis of lymph node biopsies: A descriptive study from a tertiary care center in South India over 5½

years Arun Roy, Rakhee Kar, Debdatta Basu, Bhawana Ashok Badhe

Year : 2013 | Volume : 56 | Issue : 2 | Page : 103-108 http://www.ijpmonline.org

Abstract • Aims: Lymphadenopathy is a common clinical problem and biopsies

undertaken to determine the cause of nodal enlargement may be neoplastic or non-neoplastic. The former are mainly lymphohematogenous malignancies and metastases while the causes of non-neoplastic lymphadenopathy are varied. This study was undertaken to determine the histopathological spectrum of lymphadenectomies.

• Materials and Methods: This was a descriptive cross-sectional study wherein 1010 cases of histologically diagnosed peripheral lymph node biopsies in the Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry from January 2007 to June 2012 were reviewed. Surgical resection specimens with lymph node dissection were excluded from the study.

• Results: Neoplastic lesions were more common comprising 53% (535 cases) and included 32.1% (324 cases) of non-Hodgkin lymphoma, 12.4% (125 cases) of Hodgkin lymphoma and 8.5% (86 cases) of metastatic lesions. The non-neoplastic lesions were 47% (475 cases), which included 21.6% (218 cases) of non-specific reactive lymphoid hyperplasia, 6.8% (69 cases) of other reactive or specific lymphoid hyperplasia, 18% (182 cases) of tuberculous lymphadenitis, 0.6% (6 cases) of other granulomatous lesions.

• Conclusions: Lymph node biopsy plays an important role in establishing the cause of lymphadenopathy. Among the biopsied nodes, lymphomas were the most common (44.5%) followed by non-specific reactive hyperplasia (21.6%), tuberculous lymphadenitis (18%) and metastasis (8.5%)

Pengobatan

• Radiasi• Surgery• Kemoterapi• Stem Cells Transplant

Radiotherapy

Kemoterapi

• Vincristine• Cyclophosphamide• Doxorubicin• Metrotreksat• Prednison

Vincristine

• Vincristine merupakan salah satu kemoterapi yang digunakan pada keganasan hematologi dan tumor solid karena mekanisme kerjanya, aktivitas antikankernya, dan dapat dikombinasikan dengan kemoterapi lain.

• Vincristine menyebabkan depolimerisasi mikrotubulus, metaphase arrest, dan apoptosis sel yang sedang menjalani mitosis.

• Mekanisme kerja: mencegah polimerisasi tubulin menjadi mikrotubulus.

• Cepat terdistribusi ke jaringan, dimetabolisme luas di hati, ekskresi terutama melalui saluran empedu.

Vincristine

• Indikasi:• Leukemia akut, limfoma Hodgkin dan non-

Hodgkin, neuroblastoma, rabdomiosarkoma, osteosarkoma, sarkoma Ewing, fungoides mikosis, tumor Wilms, kanker payudara, kanker serviks, kanker paru.

• Efek Samping:• Neurotoksik, konstipasi, ileus paralitik,

alopesia, mielosupresi, mual-muntah, diare, stomatitis.

Cyclophosphamide• Farmakologi:• Mekanisme kerja: berikatan silang terhadap DNA

sehingga menghambat proliferasi.• Mengalami biotransformasi di hati menjadi bentuk

aktif, ekskresi terutama melalui ginjal.• Bioavailabilitas sediaan tablet 75%.

• Indikasi:Kanker payudara, kanker paru, kanker ovarium, limfogranulomatosis, limfosarkoma, sarkoma sel retikulum, leukemia, multipel mieloma.

• Peringatan dan Perhatian:Hati-hati pada pasien mielosupresi, infiltrasi sel kanker ke sumsum tulang, radioterapi, pernah mendapat obat sitotoksik, gangguan fungsi hati, ginjal.

• Efek Samping:Sistitis hemoragik steril, alopesia, mual muntah, mielosupresi, amenorrhea, gangguan fungsi hati, hiperpigmentasi, ulserasi oral.

Doxorubicin

• Farmakologi:• Mekanisme kerja: menghambat enzim topoisomerase II

sehingga menghambat proses pembelahan sel dan pembentukan DNA.

• Bersihan plasma cepat, ekskresi terutama melalui empedu.

• Indikasi:Leukemia akut, tumor Wilm, neuroblastoma, sarkoma jaringan lunak dan tulang, kanker payudara, kanker ovarium, kanker kandung kemih (sel transisional), kanker tiroid, kanker paru, kanker lambung, limfoma Hodgkin & non-Hodgkin.

• Peringatan dan Perhatian :• Perlu pemantauan hematologi, fungsi hati, dan jantung.• Dapat menyebabkan perubahan warna urin.

• Efek Samping:Mielosupresi, gangguan fungsi jantung, alopesia, hiperpigmentasi, mual-muntah, stomatitis, flebosklerosis.

Asuhan Keperawatan

• Pengkajian• A family history of NHL as well as

other cancers increases one’s risk of developing disease, but the amount of increased risk and the mechanism by which it occurs remain unclear. There also appear to be sporadic forms of the disease, but little information is available on phenotypic differences.

• The peak incidence of NHL occurs later than with Hodgkin’s disease, which is more common in men than in women and is a disease of the middle years. About 25% of cases develop in patients between ages 50 and 59. Maximal risk is between the ages 60 and 69. Small lymphocytic lymphomas occur in the elderly.

• Lymphoblastic lymphoma has a predilection for males younger than age 20. Follicular lymphomas are uncommon in the young and occur mainly in midadult life. Burkitt’s lymphoma occurs in children and young adults. Whites have a higher risk than African Americans and Asian Americans

History

• Note any history of infection with HIV, acquired immunodeficiency syndrome (AIDS), organ transplant, congenital immunodeficiency, autioimmune diseases, or other treatment with immunosuppressive drugs.

• Patients often have complaints of painless enlarged lymph nodes (commonly in the neck, mediastinum, or chest wall), fevers, night sweats, weight loss, weakness, and malaise. Because nodes and extranodal sites are more likely to be involved in NHL, the patient may also report vague abdominal distress (bleeding, bowel obstruction, cramping, ascites), symptoms of spinal cord compression, or back pain.

• Cough, dyspnea, and chest pain occur about 20% of the time and are indicative of lung involvement.

Physical Examination

• Carefully inspect all the locations for lymph nodes and the abdomen for signs of hepatosplenomegaly and ascites.

• Skin lesions that look like nodules or papules with a tendency to ulcerate appear in about 20% of cases.

• When palpating lymph node chains, examine the submental, infraclavicular, epitrochlear, iliac, femoral, and popliteal nodes.

• Involved nodes are characteristically painless, firm, and rubbery in consistency; they are in contrast to the rock-hard nodes of carcinoma because they are freely movable and of varying size.

• Palpate the liver or spleen, which may be enlarged. The patient may also have weight loss and fever.

Psychological

• The diagnosis of cancer is devastating at any time of life. Because the disease is most common in the older adult, the patient may be planning retirement. The diagnosis of NHL throws all retirement plans into disarray and may lead to feelings of loss, grief, and anger.

Primary Nursing Diagnosis

• Risk for infection related to impaired primary and secondary defenses

Refference

• http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2013;volume=56;issue=2;spage=103;epage=108;aulast=Roy