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Non-Hodgkin's lymphoma

Non-Hodgkin's lymphoma, also known as NHL, is a type of cancer in your lymphatic system. Like all cancers, it’s caused by an abnormal and uncontrolled growth of cells.

The lymphatic system

Your lymphatic system includes your bone marrow, spleen, thymus and lymph glands (nodes). Your lymph glands make and store cells ready to fight any infections you might get. These cells are white blood cells called lymphocytes. Your lymphatic system also includes lymph vessels, which carry and recycle fluid (known as lymph fluid) in your body.

The diagram shows where the main glands, organs and vessels of your lymphatic system are. There are groups of lymph glands in your neck, armpit and groin. They appear in other areas too. You may be able to feel these as soft, round lumps (like a bean) under your skin.

What is non-Hodgkin's lymphoma?

There are many different types of cancer (malignant tumour) that can occur in the lymphatic system. These are called lymphomas, and non-Hodgkin’s lymphoma is the most common type of these cancers. It can start in a group of lymph glands in one area of your body or in your blood. Sometimes, the cancer cells can spread to other parts of your body such as your liver or spleen.

Around 12,800 people are diagnosed with non-Hodgkin’s lymphoma in the UK every year. It accounts for about four in every 100 cancers diagnosed.

Types of non-Hodgkin's lymphoma

There are many different types of non-Hodgkin’s lymphoma, which look different under the microscope. The two main types are described below.

  • Low grade non-Hodgkin’s lymphomas grow slowly and may need little or no treatment for months or years. These include follicular lymphoma, chronic lymphocytic leukaemia (also known as small lymphocytic lymphoma), cutaneous T-cell lymphoma and more.
  • High grade non-Hodgkin’s lymphomas grow faster and may need immediate treatment because of this. These include diffuse large B-cell lymphoma, Burkitt's lymphoma, mantle cell lymphoma, primary mediastinal large B-cell lymphoma and more.

Non-Hodgkin’s lymphomas are also defined by the type of cells (lymphocytes) they begin in. The three main types are B cells (which produce antibodies to fight infection) and T cells and natural killer cells (which can both sometimes fight infected cells directly). Non-Hodgkin’s lymphomas that affect B cells are most common.

Your doctor will explain which type of non-Hodgkin’s lymphoma you have and how it will be treated. Treatments vary depending on which type of the disease you have.

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How cancer develops
Cells begin to grow in an uncontrolled way
An image showing the lymphatic system

Details

  • Symptoms Symptoms of non-Hodgkin's lymphoma

    The symptoms of non-Hodgkin lymphoma vary depending on the type of lymphoma you have. Some of the common ones include:

    • a swollen lymph gland (in the neck, armpit or groin)
    • feeling out of breath or coughing
    • swelling of the face and arms
    • chest pain
    • swollen abdomen (tummy)

    You might also get what’s known as B symptoms and these include:

    • sweating at night
    • a high temperature
    • weight loss

    These symptoms aren't always caused non-Hodgkin’s lymphoma but if you have them, see your GP.

  • Diagnosis Diagnosis of non-Hodgkin's lymphoma

    To diagnose non-Hodgkin’s lymphoma, first your GP will ask about your symptoms and examine you. They will review your medical history and may take a blood test.

    Then if your GP suspects you may have non-Hodgkin’s lymphoma, he or she will refer you to a hospital specialist for further tests. These may include the following.

    • You may have blood tests to check your general health.
    • You may have a chest X-ray to look for evidence of swollen lymph glands inside your chest.
    • Your doctor may take a biopsy of your lymph gland. He or she may remove a whole gland or part of it to check in a laboratory. This may be done under local or general anaesthetic, depending on how deep underneath your skin the affected lymph gland is.
    • You may have a CT scan and/or PET (positron emission tomography) scan to look for signs of the disease in other parts of your body.
    • Your doctor may take a biopsy of your bone marrow. He or she may remove a sample of your bone marrow to check in a laboratory. This is usually done under a local anaesthetic and uses a needle to take a sample from your bone.

    If you’re diagnosed with non-Hodgkin’s Lymphoma, these tests will also look at whether the cancer has spread and how big it is. This is described by the ‘stage’ of the disease; from stage 1 (no spread) to stage 4 (extensive spread).

  • Treatment Treatment of non-Hodgkin's lymphoma

    Your treatment will depend on the type of non-Hodgkin’s lymphoma you have and whether it has spread. Not all non-Hodgkin’s lymphomas require treatment immediately – low grade ones may need little or no treatment for months or years. The main types of treatment are chemotherapyradiotherapy and monoclonal antibody therapy. You may receive more than one type of treatment.

    A team of professionals, called a multidisciplinary team (MDT), will guide you through your treatment. This team may include:

    • a nurse specialist
    • a haematologist (a doctor who specialises in treating conditions affecting the blood)
    • an oncologist (a doctor who specialises in cancer care)
    • a radiologist (a doctor who specialises in using X-rays to diagnose conditions)
    • a radiation oncologist (or clinical oncologist) who uses X-rays to treat conditions
    • a counsellor

    They can explain your treatment options and help you make choices.

    After treatment, you’ll have an assessment to check whether there are any remaining signs of your cancer. If there are, you’ll need more treatment. Then, you will have regular check-ups with your doctor to check for any signs of the cancer returning. Your follow-up plan will depend on the type of non-Hodgkin’s lymphoma you had.

    Over five out of every 10 people diagnosed with non-Hodgkin’s lymphoma survive at least 10 years after their diagnosis. The chances of your treatment being successful will depend on the type of non-Hodgkin’s lymphoma you have.

    Chemotherapy

    Chemotherapy uses medicines to destroy cancer cells. These medicines are usually given by a drip into a vein in your arm. You may be given a few different medicines over a few months. You won’t receive the medicines everyday – you will have breaks to allow your body to recover from the side-effects of the medicines.

    Side-effects are the unwanted effects of chemotherapy. They can include losing your hair, feeling sick, tired and having diarrhoea.

    Sometimes you may be given steroid medicines (e.g. prednisolone) alongside your chemotherapy. These are to help the chemotherapy to work and are taken as tablets. You may also have a monoclonal antibody therapy called rituximab with your chemotherapy (see below).

    Radiotherapy

    Radiotherapy uses X-rays to destroy cancer cells. A radiotherapy treatment only takes a few minutes. A beam of radiation is targeted to the cancer to shrink it. Depending on the type of Hodgkin’s lymphoma you have and its stage, you might have radiotherapy after your chemotherapy. You’ll need to go to the hospital for radiotherapy treatment, usually from Monday to Friday, and then have a rest over the weekend.

    Monoclonal antibodies

    Monoclonal antibodies are medicines that can recognise and target cancer cells. Rituximab is a monoclonal antibody that is used to treat many types of non-Hodgkin’s lymphoma. It’s given through a drip into a vein or as an injection. Rituximab is often given with chemotherapy.

    Stem cell transplant

    Sometimes, people need to have very high doses of chemotherapy, especially if their cancer comes back. This could kill off special cells in your body, known as stem cells. Your body needs stem cells to make blood cells. To stop you becoming unwell, you will have a stem cell transplant. This is an injection of stem cells into your body to replace the ones you lost. High-dose chemotherapy and stem cell transplants aren’t used for all types on non-Hodgkin’s lymphoma.

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  • Causes Causes of non-Hodgkin's lymphoma

    The exact reasons why you may develop non-Hodgkin’s lymphoma aren't fully understood. However, there are certain things that can increase your chance of getting it, including:

    • a weakened immune system for example if you have HIV/AIDS, or are taking medicines that suppress your immune system
    • an autoimmune disease such as rheumatoid arthritis or coeliac disease
    • certain viruses, including Epstein-Barr virus (which causes glandular fever), human T cell lymphoma virus 1 or hepatitis B or hepatitis C
    • infection with Helicobacter pylori bacteria
    • previous treatment for cancer with some types of chemotherapy and radiotherapy
    • a close relative having had non-Hodgkin’s lymphoma
    • a certain type of skin cancer, called melanoma
    • previously having had leukaemia or Hodgkin’s lymphoma
    • age - it’s more common in people aged 65 and over
    • gender - it is slightly more common in men than women
  • FAQs FAQs

    In treatment for non-Hodgkin’s lymphoma, where do the cells for a stem cell transplant come from?

    Answer

    The cells are usually taken from you before you have high-dose chemotherapy, but sometimes they come from another person (usually a close relative).

    Explanation

    If your first chemotherapy for classical non-Hodgkin’s Lymphoma hasn’t worked well, you may need a higher dose of chemotherapy and a stem cell transplant. Your body can use the stem cells to make new blood cells to replace the ones the high-dose chemotherapy destroys.

    The stem cells are usually taken from your own blood or bone marrow before you begin high-dose chemotherapy. If the stem cells are collected from your blood, you’ll be given injections of a substance called ‘growth factor’ first. This will increase the number of stem cells in your blood. The stem cells are collected through a needle and drip (usually in your arm).

    If the stem cells are collected from your bone marrow, a doctor will use a needle to take bone marrow from your pelvic bone. You will have a general anaesthetic, which means you will be asleep during the procedure. Your stem cells will be put back in your body through a drip after you have finished your high-dose chemotherapy. This is known as an autologous stem cell transplant or autologous bone marrow transplant.

    Sometimes, you may need a stem cell or bone marrow transplant from another person. This is called an allogeneic transplant. It will usually be from a close family member because their cells are most likely to match your own. A common reason for needing an allogeneic transplant is if your cancer has returned after a previous stem cell transplant of your own cells.

    How will a stem cell transplant for non-Hodgkin’s lymphoma affect me?

    Answer

    The side-effects usually come from the high-dose chemotherapy you have before the transplant, not the transplant itself. This treatment affects everyone differently and the length of time it takes to recover varies.

    Explanation

    Your immune system won't be very strong after high-dose chemotherapy and you’ll be more susceptible to infections. Although your stem cell transplant will help your body get stronger, this will take several weeks. You’ll need to stay in hospital for this time and will probably be nursed in a private room to stop you getting infections.

    Most side effects come from the high-dose chemotherapy rather than the transplant. You’ll feel very tired. You may also lose your appetite, get a sore mouth and have sickness and diarrhoea.

    Your doctor might give you antibiotics and mouthwashes to help prevent you getting an infection and you’ll probably need to have blood transfusions. Once recovered, you will need to have new immunisations against diseases, as you will have lost any immunity you previously had.

    Some people need to have a stem cell or bone marrow transplant from another person. This is called an allogeneic transplant. If you have this type of transplant, there’s a chance you could develop a condition called ‘graft versus host disease’. This happens when white blood cells donated from the other person attack tissues in your body because they don’t recognise them. This causes symptoms such as diarrhoea, weight loss and rashes, but you will be given medicines to prevent this.

    Will I be able to have children after treatment for non-Hodgkin's lymphoma?

    Answer

    Chemotherapy and radiotherapy can reduce your chances of having children or cause infertility. Sometimes this is only temporary. You may have your sperm or eggs frozen before starting treatment, so you might be able to use them to have children in the future.

    Explanation

    Hodgkin's lymphoma is commonly treated with chemotherapy. Some chemotherapy medicines can cause infertility, particularly if you have very high doses. Radiotherapy may also affect your fertility if used in your pelvic or abdominal (tummy) area. Ask your doctor about your treatment and whether it can affect your chances of having children.

    It's sometimes possible for a clinic to freeze your eggs (if you’re a woman) or sperm (if you’re a man) before you start treatment. This is so you can use them with infertility treatment to have children in the future.

    Sometimes, it’s not possible to freeze and store sperm or eggs before starting chemotherapy. Be aware that, unfortunately, infertility treatments don’t always work.

    Your doctor will be able to give you more information about your options and let you know about sources of further information and support.

  • Resources Resources

    Further information

    Sources

    • Fisher SG, Fisher RI. The epidemiology of non-Hodgkin's lymphoma. Oncogene 2004;  23:6524–34. doi:10.1038/sj.onc.1207843
    • Campbell NA. Biology. 4th ed. Menlo Park, California: The Benjamin/Cummings Publishing Company, Inc.; 1996
    • Map of Medicine. Lymphoma. International View. London: Map of Medicine; 2013 (Issue 4). www.mapofmedicine.com
    • Non-Hodgkin lymphoma. Cancer Research UK. www.cancerresearchuk.org, reviewed 7 November 2012
    • Jaffe ES. The 2008 WHO classification of lymphomas: implications for clinical practice and translational research. Hematology Am Soc Hematol Educ Program 2009; 523–31. doi:10.1182/asheducation-2009.1.523
    • Non-Hodgkin’s lymphoma. The Merck Manuals. www.merckmanuals.com, updated November 2013
    • Mabthera ® (rituximab). European Medicines Agency. www.ema.europa.eu, published 9 July 2014
    • Stem cell transplants. Cancer Research UK. www.cancerresearchuk.org, reviewed 15 July 2013
    • Bone marrow transplants. Cancer Research UK. www.cancerresearchuk.org, reviewed 12 July 2013
    • Side effects of bone marrow and stem cell transplants. Cancer Research UK. www.cancerresearchuk.org, reviewed 12 July 2013
    • Royal College of Physicians. The effects of cancer treatment on reproductive functions: Guidance on management. www.rcr.ac.uk, published 2007
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