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Non-Hodgkin's Lymphoma

Topic Overview

What is non-Hodgkin's lymphoma?

Lymphoma is cancer that begins in the lymph system in white blood cells called lymphocytes. When these cells become abnormal, they don’t protect the body from infection or disease. They also grow without control and may form lumps of tissue called tumors.

Lymphomas are either Hodgkin’s lymphomas or non-Hodgkin’s lymphomas. Hodgkin’s lymphomas have a type of cell called Reed-Sternberg cells. Lymphomas without these cells are non-Hodgkin’s lymphomas. This topic is about non-Hodgkin’s lymphoma (NHL).

NHL can start almost anywhere in the body. It may start in a single lymph node, a group of lymph nodes, or an organ such as the spleen. Or it can spread to almost any part of the body, including the liver and bone marrow.

There are many types of NHL. Sometimes they are grouped as:

  • Slow-growing lymphomas, which spread slowly and cause few symptoms. These may also be called indolent or low-grade lymphomas.
  • Fast-growing lymphomas, which spread quickly and cause severe symptoms. These may also be called aggressive lymphomas and may be classified as intermediate-grade or high-grade.

Treatment can cure some people and may allow others to live for years. How long you live depends on the type of NHL you have and the stage of your disease (how far it has progressed).

What causes non-Hodgkin's lymphoma?

The cause of NHL is not known. The abnormal cell changes may be triggered by an infection or exposure to something in the environment. Or it may be linked to gene changes (mutations). NHL is not contagious.

What are the symptoms?

Symptoms of NHL include:

  • A painless swelling of the lymph nodes in the neck, underarm, or groin. This is the most common symptom.
  • Fever not caused by another health problem.
  • Night sweats.
  • Extreme fatigue.
  • Weight loss you can't explain.
  • Pain in the belly or back.

How is non-Hodgkin's lymphoma diagnosed?

Your doctor will do a physical exam and ask you questions about your health. The exam includes checking the size of your lymph nodes in your neck, underarm, and groin.

Your doctor will take a piece of body tissue (biopsy) to diagnose NHL. The tissue usually is taken from a lymph node. You may have other tests to find out what kind of NHL you have.

How is it treated?

Your treatment depends on the type of lymphoma you have, the stage of the disease, your age, and your general health. You may not need treatment until you have symptoms. NHL is usually treated with chemotherapy. Sometimes radiation or radiation with chemotherapy may be used. Or you may have targeted therapy with monoclonal antibodies.

If treatment doesn't work, or if NHL comes back after initial treatment, you may have chemotherapy along with a stem cell transplant.

Frequently Asked Questions

Learning about non-Hodgkin's lymphoma:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Living with non-Hodgkin's lymphoma:

Cause

Experts don't know what causes non-Hodgkin's lymphoma (NHL).

When a person has non-Hodgkin's lymphoma, abnormal rapid cell growth occurs. This abnormal growth may need a "trigger" to start, such as an infection or exposure to something in your environment. There is also a link between NHL and problems with the immune system.

NHL is not contagious and is not caused by injury.

Symptoms

Symptoms of non-Hodgkin's lymphoma (NHL) include:

  • A painless swelling of the lymph nodes in the neck, underarm, or groin. This is the most common symptom.
  • Unexplained fever.
  • Night sweats.
  • Feeling very tired.
  • Unexplained weight loss.
  • Itchy skin.
  • Reddened patches on the skin.
  • A cough or shortness of breath.
  • Pain in the belly or back.

What Happens

In non-Hodgkin's lymphoma (NHL), white blood cells called lymphocytes divide and grow without order or control. The abnormal lymphocytes usually are either B-cell or T-cell lymphocytes. But most cases of NHL involve B-cell lymphocytes.

Lymph tissue is present in many areas of the body, so NHL can start almost anywhere in the body. It may occur in a single lymph node, a group of lymph nodes, or an organ. And it can spread to almost any part of the body, including the liver, bone marrow, and spleen.

NHL may be classified as:

  • Slow-growing lymphomas, which spread slowly and cause few symptoms. These may also be called indolent or low-grade lymphomas.
  • Fast-growing lymphomas, which spread quickly and cause severe symptoms. These may also be called aggressive lymphomas and may be classified as intermediate-grade or high-grade.

Over time, lymphoma cells may replace the normal cells in the bone marrow. Bone marrow failure results in the inability to produce red blood cells that carry oxygen, white blood cells that fight infection, and platelets that stop bleeding.

Long-term survival depends on the type of non-Hodgkin's lymphoma and the stage of the disease when it is diagnosed. About 80 out of 100 people diagnosed with non-Hodgkin's lymphoma are alive 1 year after the disease is diagnosed. That number drops to about 67 out of 100 at 5 years, and 57 out of 100 at 10 years.1

What Increases Your Risk

Some things can increase your chances of getting non-Hodgkin's lymphoma (NHL). These things are called risk factors. But many people who get non-Hodgkin's lymphoma don't have any of these risk factors. And some people who have risk factors don't get the disease.

Risk factors include:2

  • Being male. NHL is more common in men than in women.
  • Age. The likelihood of getting NHL increases as you get older.
  • Impaired immune system. NHL is most common among those who have an impaired immune system, an autoimmune disease, or HIV or AIDS. It also occurs among those who take immunosuppressant medicines, such as medicines following an organ transplant.
  • Viral infection. A viral infection, such as Epstein-Barr virus, increases the risk of developing NHL.
  • Bacterial infection. Infection with Helicobacter pylori increases the risk of lymphoma involving the stomach.
  • Environmental exposure. Exposure to agricultural pesticides or fertilizers, solvents, and other chemicals may increase the risk of developing NHL.

When To Call a Doctor

Call your doctor to schedule an appointment if you have had any symptoms for longer than 2 weeks, such as:

  • Painless swelling in the lymph nodes in the neck, underarm, or groin.
  • Unexplained fever.
  • Drenching night sweats.
  • Extreme fatigue.
  • Unexplained weight loss in the past 6 months.
  • Itchy skin.
  • Cough or shortness of breath.
  • Pain in the belly or back.

Who to see

Health professionals who can evaluate your symptoms of non-Hodgkin's lymphoma (NHL) include:

When NHL is suspected, a tissue sample (biopsy) is needed to make a diagnosis. A biopsy for non-Hodgkin's lymphoma is usually taken from a lymph node. But other tissues may be sampled as well. A surgeon will remove a sample of tissue so that a pathologist can examine it under a microscope to check for cancer cells.

Non-Hodgkin's lymphoma is usually treated by a medical oncologist or a hematologist. If you need radiation therapy, you will also see a radiation oncologist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

If non-Hodgkin's lymphoma (NHL) is suspected, your doctor will ask about your medical history and perform a physical exam. This exam includes checking for enlarged lymph nodes in your neck, underarm, and groin.

Diagnostic tests

A tissue sample (biopsy) is needed to make a diagnosis. A biopsy for non-Hodgkin's lymphoma is usually taken from a lymph node, but other tissues may be sampled as well.

A bone marrow aspiration and biopsy is usually done to find out if lymphoma cells are present in the bone marrow.

Other tests

Your doctor may also order other tests, including:

  • Blood tests, such as a chemistry screen to measure the levels of several substances in the blood and a CBC (complete blood count) to provide information about the kinds and numbers of cells in the blood.
  • A chest X-ray, to provide a picture of the inside of the chest.
  • A CT scan or MRI, to provide detailed pictures of the inside of the chest, abdomen, and pelvis.
  • A PET scan, to show areas of increased metabolic activity. Metabolic activity is often high in cancer cells.
  • Lab tests, such as flow cytometry, that check the types of cells in a biopsy sample. These tests help your doctor find out the type of lymphoma.
  • Lumbar puncture (also called a spinal tap), to find out whether lymphoma cells are in the fluid (cerebrospinal fluid, or CSF) surrounding your brain and spinal cord.

Treatment Overview

Treatment for non-Hodgkin's lymphoma (NHL) depends on:

  • The stage of the disease.
  • The type of lymphoma. The kind of treatment you have will depend on whether you have B-cell or T-cell lymphoma and whether it is fast-growing or slow-growing.
  • The size of the tumor, where the lymphoma is located, and what organs are involved.
  • Your general health.

Your doctor will work with you and your medical team (which may include an oncologist, a hematologist, and an oncology nurse) to come up with your treatment plan.

Treatment options

  • Watchful waiting (surveillance) is a period of time after the diagnosis of some types of NHL when you are not receiving treatment but are still being watched closely by your doctor.
  • Radiation therapy is often the treatment of choice for localized slow-growing (indolent or low-grade) NHL. For more information, see Other Treatment.
  • Chemotherapy kills cancer cells or stops them from dividing. The way chemotherapy is taken depends on the type and stage of cancer.
  • Targeted therapy with monoclonal antibodies destroys cancer cells without harming normal cells.
  • A stem cell transplant may be used to treat NHL that has come back. Or it may be used right after having very high-dose chemotherapy.

Side effects

A common concern of cancer patients are the side effects of treatments like chemotherapy and radiation. Your medical team will let you know ahead of time what side effects you can expect and help you manage them. And there are things you can do at home. To learn more, see Home Treatment.

Recurrent NHL

Sometimes NHL comes back after treatment. This is called recurrence or relapse. Treatments for recurrent NHL include chemotherapy, radiation, or a combination of the two. This treatment may be followed by a stem cell transplant.

Follow-up care

You will need regular exams after you have been treated for NHL.

Let your doctor know if you have any problems as soon as they appear.

Support

Finding out that you have cancer can change your life. You may feel like your world has turned upside down and you have lost all control. Talking with family, friends, or a counselor can really help. Ask your doctor about support groups. Or call the American Cancer Society (1-800-227-2345) or visit its website at www.cancer.org.

What to think about

Your doctor may use the term "remission" instead of "cure" when talking about the effectiveness of your treatment. Although many people with non-Hodgkin's lymphoma are successfully treated, the term remission is used because cancer can return. It is important to discuss with your doctor the possibility of recurrence.

Even after effective treatment for NHL, you may be at slightly higher risk for other types of cancer, especially melanoma, lung, brain, kidney, and bladder cancers. Be watchful for any symptoms of cancer.

For more information about specific treatments, see the following topics:

Supportive care

Cancer treatment has two main goals: curing cancer and making your quality of life as good as possible. Palliative care can improve your quality of life by helping you manage your symptoms. It can also help you with other concerns that you may have when you are living with a serious illness.

For some people who have advanced cancer, a time comes when treatment to cure cancer no longer seems like a good choice. This can be because the side effects, time, and costs of treatment are greater than the promise of cure or relief. But this isn't the end of treatment. You and your doctor can decide when you may be ready for hospice care.

It can be hard to decide when to stop treatment aimed at prolonging your life and shift the focus to end-of-life care.

To learn about the different types of supportive care, see the topics:

Prevention

There is no known way to prevent non-Hodgkin's lymphoma (NHL).

Home Treatment

You can do things at home to help manage your side effects. If your doctor has given you instructions or medicines to treat these symptoms, be sure to follow them. In general, healthy habits such as eating a balanced diet and getting enough sleep and exercise may help control your symptoms.

  • Home treatment for nausea or vomiting includes watching for and treating early signs of dehydration, such as a dry mouth or feeling lightheaded when you stand up. Eating smaller meals may help. A little bit of ginger candy or ginger tea can help too.
  • Home treatment for diarrhea includes resting your stomach and being alert for signs of dehydration. Check with your doctor before you use any nonprescription medicines for your diarrhea.
  • Home treatment for constipation includes gentle exercise along with adequate intake of fluids and a diet that is high in fruits, vegetables, and fiber. Check with your doctor before you use a laxative for your constipation.

Other problems that can be treated at home include:

  • Sleep problems. If you have trouble sleeping, tips such as going to bed at a regular time and getting exercise daily can help.
  • Feeling very tired. If you lack energy or become weak easily, try to manage your energy and get extra rest.
  • Sore mouth. Home treatment measures can ease mouth pain and speed healing.
  • Hair loss. Tips include using a mild shampoo and a soft hairbrush.
  • Pain. Home treatment can help you manage pain.

Handling the stress of having cancer

Having cancer can be very stressful, and it may feel overwhelming to face the challenges in front of you. Finding new ways of coping with the symptoms of stress may improve your overall quality of life.

These ideas may help:

  • Get the support you need. Spend time with people who care about you, and let them help you.
  • Take good care of yourself. Get plenty of rest, and eat nourishing foods.
  • Talk about your feelings. Find a support group where you can share your experience.
  • Try new ways to relax. And do things each day that help you stay calm and relaxed. Stress reduction techniques may help.

Medications

Your doctor may prescribe medicines that will affect the growth of non-Hodgkin's lymphoma and relieve your symptoms.

Chemotherapy

Chemotherapy may be used alone or with radiation therapy. Sometimes a combination of chemotherapy medicines is more effective than a single drug.

The most commonly used combination is called CHOP. It combines four medicines: cyclophosphamide, doxorubicin, vincristine, and prednisone.

Your doctor will work with you to find the best medicine for the type of lymphoma you have.

Chemotherapy causes many side effects. For help with how to deal with these, see Home Treatment. Your doctor may prescribe medicines to control nausea and vomiting from chemotherapy.

Monoclonal antibodies

Targeted therapy uses monoclonal antibodies in medicine that is injected into the body so these antibodies can attach to cancer cells and destroy them. The monoclonal antibodies used to treat NHL include:

  • Rituximab (Rituxan).
  • Alemtuzumab (Campath).
  • Ibritumomab (Zevalin).
  • Tositumomab (Bexxar).

Other medicines

Some treatments use interferon or antibiotic medicines. Your doctor will suggest the treatment that works best for your kind of lymphoma.

What to think about

You may not be able to become pregnant or father a child after chemotherapy treatment. Discuss fertility issues with your doctor before starting treatment. Chemotherapy medicines can also cause birth defects. If you are pregnant or wish to father a child, discuss the risk of birth defects with your doctor before using any chemotherapy medicine.

Surgery

Surgery is often used to obtain a biopsy sample when non-Hodgkin's lymphoma is being diagnosed or classified. But surgery is rarely used for treatment.

Other Treatment

Radiation therapy

Radiation therapy for non-Hodgkin's lymphoma (NHL) may be given in different ways.

  • With external radiation, X-rays from a machine are aimed at the part of the body with the lymphoma.
  • With targeted radiation, monoclonal antibodies are injected into the blood and deliver radiation directly to the cancer cells. This is done by making a medicine in which a radioactive form of an element (such as iodine) is attached to a monoclonal antibody.
  • With whole-body radiation, the entire body gets radiation. This may be done if you are getting a stem cell transplant.

Stem cell transplants

A stem cell transplant may be used to treat NHL that is in remission or that has come back. Stem cells may be obtained from blood, through a peripheral blood stem cell transplant (PBSCT). Or stem cells can be obtained from bone, in a bone marrow transplant (BMT). PBSCT is the most common method for treating NHL.

A stem cell transplant may be done right after you have very high-dose chemotherapy. (You may also have radiation to your entire body.) The stem cell transplant is done to replace your damaged bone marrow cells with healthy stem cells. A stem cell transplant may be offered as part of standard treatment or in a clinical trial.

Clinical trials

Clinical trials are research studies that try to find better NHL treatments. Your doctor may suggest that you join a clinical trial. Some treatments being used in clinical trials include lymphoma vaccines and stem cell transplants with high-dose chemotherapy. If you are interested in taking part in a clinical trial, check with your doctor to see if any are available in your area.

Complementary therapy

People sometimes use complementary therapies along with medical treatment to help relieve symptoms and side effects of cancer treatments. Some of the complementary therapies that may be helpful include:

These mind-body treatments may help you feel better. They can make it easier to cope with treatment. They also may reduce chronic low back pain, joint pain, headaches, and pain from treatments.

Before you try a complementary therapy, talk to your doctor about the possible value and potential side effects. Let your doctor know if you are already using any such therapies. They are not meant to take the place of standard medical treatment.

Other Places To Get Help

Organizations

Leukemia and Lymphoma Society
1311 Mamaroneck Avenue
White Plains, NY  10605
Phone: 1-800-955-4572
(914) 949-5213
Fax: (914) 949-6691
Web Address: http://www.leukemia.org
 

The Leukemia and Lymphoma Society is the world's largest voluntary health organization dedicated to funding blood cancer research, education, and patient services. The Society's mission is to cure leukemia, lymphoma, Hodgkin's lymphoma, and myeloma and to improve the quality of life for patients and their families.

American Cancer Society (ACS)
Phone: 1-800-ACS-2345 (1-800-227-2345)
TDD: 1-866-228-4327 toll-free
Web Address: www.cancer.org
 

The American Cancer Society (ACS) conducts educational programs and offers many services to people with cancer and to their families. Staff at the toll-free numbers have information about services and activities in local areas and can provide referrals to local ACS divisions.

Cancer.Net
Phone: 1-888-651-3038
(571) 483-1300
Fax: (571) 366-9537
Email: contactus@cancer.net
Web Address: www.cancer.net
 

Cancer.Net is the information website of the American Society of Clinical Oncology (ASCO) for people living with cancer and for those who care for them. ASCO is the world's leading professional organization representing physicians of all oncology subspecialties. Cancer.Net provides current oncologist-approved information on living with cancer.

Lymphoma Research Foundation
115 Broadway, 13th Floor
New York, NY 10006
Phone: 1-800-500-9976
(310) 204-7040
Fax: (310) 204-7043
Email: Helpline@lymphoma.org
Web Address: www.lymphoma.org
 

The Lymphoma Research Foundation (LRF) is devoted to funding lymphoma research and providing patients and health professionals with information about lymphoma. Some states have local chapters of the Lymphoma Research Foundation. Services for patients and their loved ones include in-person programs, a patient aid grant program, and publications and newsletters. There are also teleconferences, webcasts, and podcasts.

National Cancer Institute (NCI)
6116 Executive Boulevard
Suite 300
Bethesda, MD  20892-8322
Phone: 1-800-4-CANCER (1-800-422-6237)
Web Address: www.cancer.gov (or https://cissecure.nci.nih.gov/livehelp/welcome.asp# for live help online)
 

The National Cancer Institute (NCI) is a U.S. government agency that provides up-to-date information about the prevention, detection, and treatment of cancer. NCI also offers supportive care to people who have cancer and to their families. NCI information is also available to doctors, nurses, and other health professionals. NCI provides the latest information about clinical trials. The Cancer Information Service, a service of NCI, has trained staff members available to answer questions and send free publications. Spanish-speaking staff members are also available.

References

Citations

  1. American Cancer Society (2011). Cancer Facts and Figures 2011. Atlanta: American Cancer Society. Available online: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-029771.pdf.
  2. Friedberg JW, et al. (2011). Non-Hodgkin lymphoma. In VT DeVita Jr et al., eds., DeVita, Hellman and Rosenberg’s Cancer: Principles and Practice of Oncology, 9th ed., pp. 1855–1893. Philadelphia: Lippincott Williams and Wilkins.

Other Works Consulted

  • National Cancer Institute (2011). Childhood Non-Hodgkin Lymphoma Treatment (PDQ): Patient Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/child-non-hodgkins/Patient.
  • American Joint Committee on Cancer (2010). Hodgkin and non-Hodgkin lymphomas section in Lymphoid neoplasms. AJCC Cancer Staging Manual, 7th ed., pp. 607–611. New York: Springer.
  • Bierman PJ, Armitage JO (2012). Non-Hodgkin’s lymphomas. In L Goldman, A Shafer, eds. Goldman’s Cecil Medicine, 24th ed., pp. 1218–1228. Philadelphia: Saunders.
  • Hillman R, et al. (2011). Non-Hodgkin lymphomas. In Hematology in Clinical Practice, 5th ed., pp. 279–300. New York: McGraw-Hill.
  • Kyle F, Hill M (2010). NHL (diffuse large B-cell lymphoma), search date January 2010. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
  • National Cancer Institute (2011). Adult Non-Hodgkin Lymphoma Treatment (PDQ): Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/adult-non-hodgkins/HealthProfessional.
  • National Cancer Institute (2011). Adult Non-Hodgkin Lymphoma Treatment (PDQ): Patient Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/adult-non-hodgkins/Patient.
  • National Cancer Institute (2011). Childhood Non-Hodgkin Lymphoma Treatment (PDQ): Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/child-non-hodgkins/HealthProfessional.
  • National Comprehensive Cancer Network (2011). Non-Hodgkin's lymphomas. Clinical Practice Guidelines in Oncology, Version 4. Available online: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.

Credits

By Healthwise Staff
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer Douglas A. Stewart, MD - Medical Oncology
Last Revised March 29, 2012

Last Revised: March 29, 2012

Author: Healthwise Staff

Medical Review: Anne C. Poinier, MD - Internal Medicine & Douglas A. Stewart, MD - Medical Oncology

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