This information has been prepared to help you understand more about non-Hodgkin’s lymphoma.
Many people feel understandably shocked and upset when they are told they have non-Hodgkin’s lymphoma cancer.This information is intended to help you understand the diagnosis and treatment of non-Hodgkin’s lymphoma cancer.
We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.
The lymphatic system
Non-Hodgkin’s lymphoma is a cancer of the white blood cells that starts in the lymphatic system. The lymphatic system is a key part of the immune system, which protects the body against disease and infection.
The lymphatic system includes:
- Lymph vessels – a network of thin tubes found all over the body.
- Lymph – a clear fluid carried by the lymph vessels. This fluid travels to and from the tissues before being emptied into the bloodstream
- Lymphocytes – white blood cells found in lymph, which help fight infection. Lymphocytes can be B-cells or T-cells
- Lymph nodes or glands – a network of small, bean-shaped structures found throughout the body, including the neck, under the arm, chest, abdomen and groin. Any bacteria the lymph picks up from the tissues become trapped in the lymph nodes causing them to swell. This is why the gland in your neck becomes enlarged when you have a sore throat.
Other parts of the lymphatic system include:
- Spleen – found on the left side of the abdomen, under the ribs. It produces lymphocytes, filters the blood of waste products, and destroys old and abnormal cells and bacteria.
- Thymus gland – found inside the rib cage, behind the breastbone.
- Tonsils – a collection of lymphoid tissue at the back of the throat
- Bone marrow – soft spongy material inside bones. Bone marrow makes three types of blood cells:
- Red cells: carry oxygen
- White cells: fight infection
- Platelets: help the blood to clot and stop bleeding.
The lymph glands, spleen, thymus and tonsils allow lymphocytes to mature and multiply.
What is non-Hodgkin’s lymphoma?
- Non-Hodgkin’s lymphoma (NHL) is a type of lymphoma, which is a cancer of the lymphatic system. Sometimes NHL is called B-cell lymphoma or T-cell lymphoma, depending on the type of cells affected.
- In lymphoma, lymphocytes become abnormal. They grow and multiply uncontrollably or don’t die as they become old. As abnormal lymphocytes replace normal lymphocytes, the immune system becomes less able to fight infection
- Lymph nodes also become enlarged, forming painless lumps (tumours)
- Non-Hodgkin’s lymphoma may occur in a single lymph node, a group of lymph nodes, or in another organ
- Sometimes, non-Hodgkin’s lymphoma can appear at the same time in several parts of the body
- This type of cancer can spread to almost any part of the body, including the liver, spleen and bone marrow.
Types of non-Hodgkin’s lymphom
There are many different types of non-Hodgkin’s lymphoma. Lymphomas are grouped according to their cell type – either B-cell or T-cell
- B-cells develop in the bone marrow and lymphatic organs.
- T-cells develop in the thymus (the gland behind the breastbone)
B-cell lymphoma is more common than T-cell lymphoma. Lymphomas are also divided into two main groups
- slow growing – also known as low-grade or indolent lymphoma
- fast growing – also called high-grade or aggressive.
How common is it?
The seventh most common cancers in NSW. About 1,300 people diagnosed each year. Most NHL occurs in adults. The chance of developing it increases as you get older. It can occur in children and is one of the most common cancers in adolescents and young adults.
The causes of non-Hodgkin’s lymphoma are unknown. For most people there is no identifiable reason they have the disease. However, there are some risk factors that may increase a person’s chance of developing it. These include:
- immune system deficiency caused by infections such as human immunodeficiency virus (HIV), human T lymphotrophic virus (HTLV-1), herpes virus 8 or Helicobacter pylor
- taking drugs that affect the immune system (immuno-suppressants) after an organ transplant, or for HIV or an autoimmune diseas
- having an autoimmune disease (e.g. rheumatoid arthritis)
- a diet high in animal fats, including red meat and dairy products.
- Often the first sign is a painless swelling of a lymph node, usually in the neck, underarm or groin.
- Other symptoms may include unexplained fever; sweating, particularly at night; weight loss; tiredness and intractable itch not responsive to antihistamines.
- Sometimes lymphoma starts in the lymph nodes in deeper parts of the body, such as the abdomen (causing bloating) or the chest (causing coughing, discomfort and difficulty breathing).
Tests for diagnosis
If non-Hodgkin’s lymphoma is suspected, your doctor will feel the lymph nodes in your neck, underarm or groin for signs of swelling. An initial blood test and chest x-ray may be taken to check how your kidney, liver and bone marrow are working.
A diagnosis is made by removing a small piece of tissue from an enlarged lymph node and examining it under a microscope. This is called a biopsy.
- Quick and simple procedure.
- Usually done with a local anaesthetic or general anaesthetic.
If the biopsy shows you have non-Hodgkin’s lymphoma, a number of other tests will be done. You may have one of these tests or a combination of several tests.
- Blood tests
- Bone marrow biopsy
- CT scan
- MRI scan
- PET scan
- Gated heart pool scan
- Gallium scan
- Lumbar puncture.
Stages of non-Hodgkin’s lymphoma
After the biopsy and the results of these tests, one of the following stages will be used to describe your lymphoma:
- Stage I – only one lymph node area or one area or organ outside the lymph nodes are affected.
- Stage II – two or more lymph node areas are affected on one side of the diaphragm only.
- Stage III – lymph nodes on both sides of the diaphragm are affected.
- Stage IV – lymphoma has spread outside the lymph nodes, for example, to the liver, lungs or bone.
Each stage is also assigned a letter indicating if you have symptoms.
A – means you have no symptoms.
B – means symptoms are present. These include fever, night sweats and unexplained weight loss.
Prognosis means the expected outcome of a disease.
You need to discuss the prognosis of your lymphoma with your doctor. Only someone who knows your medical history can tell you what to expect and the management options best for you.
While some people may be cured of non-Hodgkin’s lymphoma after treatment, other people experience multiple episodes of the disease, going in and out of remission (absence of disease symptoms) over several years.
Which health professionals will I see?
As well as your family doctor, health professionals who may care for you while you are being treated for non-Hodgkin’s lymphoma include:
- Haematologist – specialises in diseases of the blood, lymphatics and bone marrow, and is responsible for diagnosing and treating the lymphoma and supporting you throughout the illness.
- Medical oncologists – are responsible for chemotherapy. Some oncologists also treat patients with lymphoma.
- Radiation oncologists – prescribe and co-ordinate the course of radiotherapy.
- Nurses – give the course of treatment and support you through all stages of your illness.
- Dieticians – recommends the best eating plan to follow while you are in treatment and recovering.
- Social workers, physiotherapists and occupational therapists – advise you on support services and help you to resume normal activities.
Not everyone will have the same treatment. When the doctors plan your treatment, they will look at different factors:
- general health
- the type of lymphoma you have
- the parts of your body affected.
Some lymphoma, called low-grade or indolent lymphoma, grows very slowly and cause few problems.
Your doctor may decide that you don’t need treatment initially, but will keep an eye on you with regular checkups and blood tests. This is called watchful waiting.
Doctors do this because clinical studies have shown that therapy given at an early stage does not affect the outcome of indolent lymphoma.
Some people find this approach hard to accept, and would prefer to have treatment straight away, but doctors don’t want to order any treatment that might cause side effects, unless there is proof that it can help you.
Doctors can spot the warning signs or any change or growth in the lymphoma and can start treatment immediately – if and when you need it.
Many people with low-grade lymphomas continue their usual activities without disruption for many years.
This type of lymphoma grows faster and needs treatment as soon as possible. Chemotherapy is the main initial treatment.
There are other options to control the lymphoma, such as radiotherapy, peripheral blood stem cell transplantation and biological therapy. You may have one of these treatments or a combination.
Chemotherapy mainly kills fast-growing cells like cancer cells. Other fast-growing cells can also be affected, such as the cells involved in hair growth and cells in the mouth.
Some of the drugs are taken as tablets, others are given intravenously (using a drip into a vein) at a clinic.
After each course of treatment, your doctor will monitor your progress and do tests to see what effect the drugs have had on the lymphoma. The treatment may be repeated several times until the lymphoma goes into remission.
Radiotherapy uses x-rays to kill cancer cells or injure them so they cannot multiply.
Treatment is usually given over several weeks.
The length of treatment will depend on the size and type of cancer and on your general health.
Biological therapies (also called biotherapies) a range of treatments developed from natural substances in the body, usually proteins. They are concentrated and purified for use as drugs. The therapies work in different ways to help the body fight cancer.
- Monoclonal antibodies – work by targeting diseased cells, attaching to them and then destroying them. Medication is given intravenously and is used alone or with other treatments for certain types of lymphoma. The monoclonal antibodies available in Australia include rituximab and alemtuzumab.
- Immunotherapy – increases the strength of the immune system so that it is able to attack cancer cells more effectively. One treatment is interferon, which is a hormone-like protein made by white blood cells. Vaccines to help the main treatment (adjuvant therapy) for lymphoma is under investigation.
- Granulocyte-colony stimulating factor (G-CSF) – helps white blood cells recover faster following chemotherapy. G-CSF is also sometimes used in stem cell transplants to help blood stem cells multiply quickly.
Radioimmunotherapy is only available in a limited number of treatment centres.
It uses monoclonal antibodies to deliver radiation to the cancer cells.
It may be used if the lymphoma came back after initial treatment.
It can cause side effects such as fever, nausea or rashes.
Your doctor will tell you what to expect if you have this treatment.
Steroids are made naturally in the body but can be produced artificially and used as drugs.
Steroid therapy is often given with chemotherapy to help destroy lymphoma.
Steroid therapy is usually given for a few weeks only.
Peripheral blood stem cell transplantation
A transplant may be used when lymphoma comes back or doesn’t respond to treatment.
This process makes it possible to use higher doses of chemotherapy to destroy the lymphoma. High doses of chemotherapy will destroy your bone marrow but transplanted stem cells can restore blood cell numbers to normal.
Stem cells are early-stage cells from which blood cells develop. They are found in the bone marrow but can be made to move to the peripheral blood (the blood circulating throughout the body).
Palliative treatment helps to improve people’s quality of life by alleviating symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer. However, it is not just for people who are about to die and it can be used at different stages of cancer.
Often treatment is concerned with pain relief and stopping the spread of cancer, but it can also involve the management of other physical and emotional symptoms. Treatment may include radiotherapy, chemotherapy, blood transfusions and medication.
After treatment: follow-up
After your treatment, you will need regular checkups with your doctor to monitor the size of your lymph nodes and confirm the cancer hasn’t come back.
Blood tests, x-rays or other scans may be done.
Checkups will become less frequent if you have no further problems.
Between follow-up appointments, let your doctor know immediately of any health problems.