Burkitt lymphoma

BURKITT LYMPHOMA
PRESENTED BY,
HINA RODGE
30/06/2020 BURKITT LYMPHOMA 1

Objectives
• GENERAL OBJECTIVE: At the end of the class, the
students will be able to gain in-depth knowledge regarding
Burkitt Lymphoma, appreciate and develop positive
attitude and practice this knowledge in theory as well as
clinical settings.

Specific objectives
At the end of the class, the students will be able to:-
1. Define Burkitt Lymphoma.
2. Explain the types of Burkitt Lymphoma
3. Enlist the etiology of Burkitt Lymphoma.
4. Discuss the Pathophysiology of Burkitt Lymphoma
5. Enumerate the clinical manifestation of Burkitt Lymphoma
6. Explain the stages of Burkitt Lymphoma

Conti…..
7. Explain the diagnostic evaluation of Burkitt Lymphoma
8. Discuss the medical management of Burkitt Lymphoma.
9. Explain the nursing management of Burkitt Lymphoma
10. Explain the prognosis for Burkitt Lymphoma.
11. Explain the prevention of Burkitt Lymphoma.

Introduction
Lymphomas are the heterogeneous group of lymphoproliferative
malignancies resulting from clonal expansion of tumour cells
derived from B, T or NK cells.

• A majority of them are derived from B lymphocytes.
• Lymphomas are primary tumours of lymph cells called
lymphocytes, a type of WBCs.
• Lymphomas is the third most common cancer in children.

Two broad classification of lymphoma:
• Hodgkin lymphoma (HL): also known as Hodgkin disease
(HD) which is named after Dr. Thomas Hodgkin who first
described it.
• Non-Hodgkin lymphoma (NHL): NHL tends to occurs in
younger children, whereas HL is more likely to affects older
children and teens.

• The WHO classification of NHLs is based on
1. B-cell malignancies
2. T- cell malignancies

Three Classification of NHL:
1. B-cell NHL: it originated from B-cells. Burkitt
lymphoma/leukemia and diffuse large B-cell lymphoma
2. Lymphoblastic lymphoma: It develops from T cells and
usually starts from thymus (thymus contains T lymphocytes).
It is rarely seen in tonsil too.

3. Large cell lymphoma: Large cell lymphomas arise from
mature T and B cells and develop in any part of the body where
lymphocytes are there.
• Two main subtypes of large cell lymphoma are:
• 1. Anaplastic Large cell lymphoma: it usually develops from
mature T cells. It usually lymph nodes in the neck or other areas
and may be found in the skin, lungs, bone, digestive tract or
other organs.

• 2. Diffuse large B-cell lymphoma: it starts in B cells. Also
called primary mediastinal B-cell lymphoma.
• These lymphomas sometimes grow as large masses in the
mediastinum.

Burkitt Lymphoma
• Burkitt lymphoma is a form of non-Hodgkin's lymphoma. It is
highly aggressive form of lymphoma resulting from
translocation from chromosome 8 to chromosome 14.
• It is named after Denis Parsons Burkitt, the Irish surgeon who
first described the disease in 1958 while working in equatorial
Africa.

Definition:
• Brukitt lymphoma is also as small noncleaved cell lymphoma, it
is a Non-Hodgkin Lymphoma of the high grade exclusively B-
cell origin.
• The disease may jaw, central nervous system, bowel, kidneys,
ovaries or other organs.
• It also called Burkitt leukemia when it presents as tumour cells
in bone marrow and the bloodstream.

• Often grows first in the lymph tissue of the head and neck
including the tonsils or in the abdomen.
• Grows rapidly and can spread to many parts of the body
including to the spinal fluid and bone marrow.

Types of Burkitt Lymphoma
• According to World Health Organization classification, there are
three types of Burkitt lymphoma:
Endemic
Sporadic
Immunodeficiency associated
1
2
3

Endemic Burkitt lymphoma
• Endemic (African) form: the most common form, found
mainly in central Africa, where it is associated with the Epstein
Barr virus (EBV).
• It is most common in children.
• This form often manifests as enlargement of the jaw or facial
bones
• Endemic Burkitt lymphoma primarily affects African children
ages 4 to 7 and is twice as common in boys.

Sporadic Burkitt lymphoma
• Sporadic (non-African) form: Sporadic Burkitt lymphoma
occurs worldwide.
• Globally, it accounts for 1% to 2% of adult lymphoma cases.
• In the U.S. and Western Europe, it accounts for up to 40% of
pediatric lymphoma cases.
• That often develops in the abdomen with bone marrow
involvement. The kidneys, ovaries, breasts or other organs may
also be involved.
• This form commonly affects children and young adults.

Immunodeficiency-associated
• This variant of Burkitt lymphoma is most common in people
with HIV/AIDS.
• It accounts for 30% to 40% of Non-Hodgkin lymphoma in HIV
patients and may be an AIDS-defining disease.
• It also can occur in people with congenital conditions that cause
immune deficiency and in organ transplant patients who take
immunosuppressive drugs.

Causes of Burkitt lymphoma

Idiopathic
Epstein-Barr Virus (EBV)
Malaria
Chromosomal abnormalities: translocation of C myc-
gene
HIV Infection
Oncogenes

Pathophysiology of Burkitt
Lymphoma

Due to causes (EBV, Malaria, HIV etc.)
Enhanced B cell activation and proliferation
Germinal centre expansion

C-MYC gene t(8:14, 2:8, 8:22)
EBV gene products MYC gene mutation
Burkitt Lymphoma

Translocation of c-MYC-gene (8:14, 2:8,
8:22)
MYC-gene mutation
Burkitt Lymphoma

CLINICALMANIFESTATION OF
BURKITT LYMPHOMA

Swollen, painless lymph nodes in neck, armpit or groin
abdominal pain, swelling
Earliest sign is the loosening of child’s molar or premolar.
Intra-abdominal tumours, especially retroperitoneal lymph nodes
or ovaries.
Extradural lesion causing spinal cord compression and
paraplegia.

Enlargement of the parotid glands, breasts (usually both), testis,
thyroid and kidneys (all are uncommon).
Proptosis (bulging eyes)
Weight loss
Loss of appetite
fatigue
Unexplained fever
Night sweats

STAGING OF NON-HODGKIN
LYMPHOMA

Staging

Diagnostic Evaluation of Burkitt
Lymphoma

History collection
Physical Examination
Complete Blood Cell Count (CBC) Count
Serum Chemistry: LDH (Lactate Dehydrogenase) is a tumour
marker to monitor response to treatment relapse.
Uric Acid is a measure of tumour lysis.
Computed tomographic (CT) imaging of the chest, abdomen,
and pelvis
Chest X-ray

Testing for HIV disease
CSF Examination for finding brain metastasis
Cellular fluid cytology
PET or gallium scan
Bone marrow biopsy
Cellular Biopsy

MANAGEMENT OF BURKITT
LYMPHOMA

Medical Management
Intensive intravenous chemotherapy :
Commonly drugs used are:
• Cyclophosphamide
• Vincristine
• Prednisone
• Doxorubicin

Chemotherapy Drugs
• Cyclophosphamide
 Medication used as chemotherapy and to suppress the immune
system.
Indication:
• Lymphoma
• multiple myeloma
• Leukemia

• ovarian cancer
• breast cancer
• small cell lung cancer
• neuroblastoma, and
• sarcoma.
Side effect:
• Nausea
• Vomiting

• Loss of appetite
• Stomach pain or upset
• Diarrhoea
• Alopecia
• Skin rash
Contraindication:
• Severe hypersensitivity

Vincristine
• Antineoplastic drug
• Indication:
• acute lymphocytic leukemia,
• acute myeloid leukemia,
• Hodgkin's disease
• Neuroblastoma and
• small cell lung cancer among others.

• Non-Hodgkin Malignant Lymphomas
• Side effects:
• Peripheral neuropathy
• Paresthesia
• Sensory loss
• Acute uric acid nephropathy
• Amenorrhea
• Hypertension
• Hypotension
• Nausea

• Vomiting
• Constipation
• Myelosuppression
• Leukopenia
• Gait changes
• Jaw pain
• Aspermia
• Alopecia

• Contraindication:
Pregnancy
Breastfeeding
Administration of live vaccines to immunocompromised
patients should be avoided
Radiation therapy

Doxorubicin
• Antineoplastic drug
• Indication:
Leukemia
Hodgkin lymphoma
Cancer of the bladder, breast, stomach, lung, ovaries
Multiple Myeloma
• Side effect:
 nausea and vomiting

Diarrhea
Loss of appetite
Weakness
Missed menstrual periods
Darkening skin or nails
Eye redness or puffy eyelids.
Low white blood cell count (neutropenia, leukopenia)
Anemia

• Contraindication:
• Hypersensitivity.
• Active infection.
• Severe hepatic impairment
• Cardiomyopathy, congestive heart failure (CHF), impaired
cardiac function

Prednisone
• it is corticosteroid drug.
• Used to treat arthritis, blood disorders, breathing problems,
severe allergies, skin diseases, cancer, eye problems, and
immune system disorders.
• Side effect: Nausea, vomiting, loss of appetite, heartburn,
trouble sleeping, increased sweating, or acne may occur.
• Contraindication: hypersensitivity, diabetes, active, untreated
tuberculosis, chronic heart failure, seizure etc.

Surgical Management
Surgery: surgery only for abdominal emergency
Radiation Therapy
Radiation therapy: radiation therapy for superior vena cava
(SVC) obstruction or paraspinal compression

Complication
Tumour-related complications
SVC syndrome
Spinal cord compression
Pleural and Pericardial effusion
Airway/pharyngeal obstruction

Cont..
Metabolic complications
Tumour lysis
Syndrome of inappropriate antidiuretic hormone secretion
(SIADH)
Hypo/Hyperglycaemia

Cont..
Gastrointestinal complication
Bleeding and obstruction
Haematological complications
Bone marrow infiltration
Pancytopenia

Nursing Management
• Nursing management focuses on managing the problems
lymphoma and side effect of chemotherapy.
Prevention from infections:
 Following measures must be taken to prevent infection:
Broad spectrum antibiotics are used prophylactically.
When child is in hospital, universal precautions are used along
with isolation, barrier nursing, strict handwashing and aseptic
technique.

• Fever is an sign of infection, so if fever occurs blood, urine,
stool and nasopharyngeal cultures are done to identify the cause
and site of infection.
• An adequate protein and calorie intake provides the child with
better host defences against infection and increases tolerance to
chemotherapy.

• Management of side effects of chemotherapy
• Nausea and vomiting:
• for mild to moderate vomiting antiemetic like promethazine,
chlorpromazine etc. are used
• Metaclopramide is administered for severe vomiting
• Antiemetics should be given before chemotherapy is started (30
minutes too 1 hour before chemotherapy) and then regularly at
two hours interval up to 24 hours.

• Anorexia
• Loss of appetite occurs because of chemotherapy and radiation
therapy to:
• Give small frequent feeds to the child according to her likes.
• Give and easily digestible food to the child.
• Serve the food in an attractive manner.

• Mucosal ulceration
 As a side effect of chemotherapy, the mucosa of gastrointestinal
tract becomes ulcerated. Oral ulcer develop which make eating
extremely uncomfortable so:
Give bland, moist and soft diet to the child.
Use soft tooth brush or cotton tipped applicator and mouth wash
to clean the child’s mouth.
Frequent mouth wash may be provided with normal saline.

 local anaesthetics like lidocaine can be used to anesthetize oral
ulcers, before the child eats food.
Liberal fluid intake is encouraged.
Nasogastric feeds may be started in case of severe ulceration in
mouth.

• Neuropathy
Vincristine and Vinblastin can cause various neurotoxic effects
leading to foot drop, weakness and numbness of extremities and
reduce bowel movements. So :
Use foot rest to prevent foot drop in the bed ridden children.
The children used to suffers from constipation. Regular bowel
movement should be ensured by using stool softeners and
laxatives. Also fluid intake must be increased.

• Haemorrhagic cystitis:
The drug Cyclophosphamide leads to hemorrhagic cystitis. It can
be prevented by:
Liberal fluid intake.
Motivate child to void immediately on feeling the urge to
urinate.
Administer chemotherapy drugs in the morning, to allow for
sufficient intake of ral fluids and frequent voiding or urination.

• Alopecia
Hair loss occur because of chemotherapy
Inform the parents and child about this side effect earlier.
Encourage the parents to purchase a wig for child before hair
fall occurs.
Child’s hair should be cut short and she/he should be made to
wear surgical cap to collect fallen hair.
Parents and child should be reassured that hair will grow again
after the treatment stops.

• Mood changes:
Shortly after starting steroid therapy, children experience mood
changes which range from feeling of well-being and euphoria to
depression and irritability. Parents should be made aware of
these behaviour changes

• Parental support and guidance:
Nurses should continually guide, support and help parents to
adjust to this disease condition.
Parents should encouraged to express their feeling, fear, grief
and concerns.
Provide emotional support to the parents continuously.

Prognosis for Burkitt Lymphoma
• Burkitt lymphoma is fatal if left untreated. In children,
prompt intensive chemotherapy usually cures Burkitt
lymphoma, leading to long-term survival rates of 60%
to 90%. In adult patients, results are more variable.
Overall, prompt treatment is associated with long-term
survival rates of 70% to 80%.

Prevention:
• Most of the cancers can be prevented up to an extent if
precautions are taken. NHL has no risk factors that can
be prevented; hence, preventing NHL is not easy. The
best way to reduce the risk for NHL is to improve
immune system, as one of the major risk factors is the
weakened immune system.

• Prevent HIV infection in the children through
education of parents and children e.g. treating the
pregnant women with HIV with anti-HIV drugs and
advising HIV positive mother not to breastfeed their
baby.
• NHL can also develop as a consequences of the
treating other cancers with chemotherapy,
immunosuppressive drugs and radiation therapy.

• Caution may be taken while treating children with
cancers and find better ways to treat children with
cancers for not raising the risk for NHL.

Burkitt lymphoma

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