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Non-Hodgkin lymphoma

Non-Hodgkin lymphoma, also known as NHL, is a type of cancer in your lymphatic system (your lymphatic system helps to fight infections). Like all cancers, it’s caused by an abnormal and uncontrolled growth of cells. Around 13,000 people are diagnosed with non-Hodgkin lymphoma in the UK every year. Most people who are affected are over 50 years old, although NHL can develop in children too. The main treatments include chemotherapy, radiotherapy and monoclonal antibody therapy.

How cancer develops
Cells begin to grow in an uncontrolled way

Details

  • The lymphatic system The lymphatic system

    Your lymphatic system is part of your immune system. It 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 image below 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. You may be able to feel some of them under your skin. There are deeper lymph glands in other areas of your body, such as in your abdomen (tummy), pelvis and chest, though you can’t feel these.

    An image showing the lymphatic system 

  • What is non-Hodgkin lymphoma? What is non-Hodgkin lymphoma?

    There are many different types of cancer (malignant tumour) that can form in the lymphatic system. These are called lymphomas, and the main ones are Hodgkin lymphoma and non-Hodgkin lymphoma. Lymphomas happen when the white blood cells (lymphocytes) that help fight infection become abnormal and turn into cancerous cells.

    A lymphoma can start in a group of lymph glands almost anywhere in your body. It can also start in one of your lymph organs; for example, in your spleen or thymus. Sometimes, but not often, the cancer can start outside your lymphatic system such as in your liver.

    See our FAQ: Hodgkin and non-Hodgkin lymphoma for more information about the difference between the two.

  • Types Types of non-Hodgkin lymphoma

    There are many different types of non-Hodgkin lymphoma, which look different under the microscope. They are separated into two categories called low grade and high grade.

    Low grade non-Hodgkin lymphomas

    Low grade non-Hodgkin lymphomas include:

    • follicular lymphoma
    • marginal zone lymphoma
    • small lymphocytic lymphoma

    High grade non-Hodgkin lymphomas

    High grade non-Hodgkin lymphomas include:

    • diffuse large B-cell lymphoma
    • Burkitt's lymphoma
    • mantle cell lymphoma
    • primary mediastinal large B-cell lymphoma.

    For more information about the difference between low and high grade lymphomas, see our FAQ: Low and high grade.

    Non-Hodgkin lymphomas may also be defined by the type of cell (lymphocyte) they start in. The three main cell types are:

    • B cells (which produce antibodies to fight infection)
    • T cells (which may fight infected cells directly)
    • natural killer cells (which may fight infected cells directly).

    Non-Hodgkin lymphomas that affect B cells are most common.

    Your doctor will explain which type of non-Hodgkin lymphoma you have and which course of treatment is right for you. Treatments vary depending on which type of lymphoma you have.

  • Symptoms Symptoms of non-Hodgkin lymphoma

    The symptoms of non-Hodgkin lymphoma vary depending on the type of lymphoma you have. Not everyone has symptoms. The main symptom is a swollen lymph gland (in the neck, armpit or groin).

    You might have some other general symptoms including:

    • feeling out of breath
    • sweating at night
    • a high temperature
    • unexplained weight loss
    • itchy skin

    Where you may have or feel symptoms depends on where in your lymphatic system the cancer has developed. You might have an enlarged spleen or liver, or tonsils. You may feel out of breath if the lymph glands in your chest are affected. You might have a lump in your tummy if the glands there are enlarged.

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

  • Diagnosis Diagnosis of non-Hodgkin lymphoma

    To diagnose non-Hodgkin lymphoma (NHL), your GP will ask about your symptoms and examine you. They’ll also ask you questions about your medical history. Some of the symptoms of NHL are non-specific, which means they could be caused by something else. Depending on your symptoms, your GP may organise some initial tests such as blood tests and a chest X-ray to check for other possible causes. If your GP then suspects you could have non-Hodgkin lymphoma, he or she will refer you to a hospital specialist for further tests.

    If you have swollen glands and your GP suspects it could be NHL, it’s likely that he or she will refer you to a specialist at hospital for further tests straightaway. You’ll usually get an appointment within two weeks (or two days for children).

    Further tests may include having scans (such as a CT or positron emission tomography (PET) scan, or ultrasound). These are all to look at the inside of your body. You may have a biopsy, where a sample of skin tissue, lymph gland or bone marrow is taken to look at under a microscope. If you have a biopsy taken, this may be done under local or general anaesthesia.

    If you’re diagnosed with non-Hodgkin lymphoma, tests will look at whether or not the cancer has spread and how big it is. This is described by the ‘stage’ of the disease; from stage 1 (the cancer has stayed within the organ it started in) to stage 4 (the cancer has spread from where it started to another part of the body). See Related information for explanations of the terminology used in cancer.

  • Treatment Treatment of non-Hodgkin lymphoma

    Your treatment will depend on the type of non-Hodgkin lymphoma you have and whether or not it has spread. The main types of treatment are chemotherapy, radiotherapy and monoclonal antibody therapy. You may receive more than one type of treatment.

    Your healthcare team

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

    • a specialist nurse
    • 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 imaging to diagnose conditions)
    • a radiation oncologist (or clinical oncologist) who uses radiation to treat conditions
    • a counsellor

    They’ll explain your treatment options and help you make treatment choices that are right for you.

    After treatment, your team will assess whether or not there are any remaining signs of your cancer. If there are, you’ll need to have more treatment. You’ll 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 lymphoma you had.

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

    Watch and wait

    Not all non-Hodgkin lymphomas need treatment immediately – your doctor may suggest a watch-and-wait approach. This means that you will be monitored but won’t receive any treatment. People who wait until they need treatment live just as long as those who start treatment straightaway. And there are other benefits such as not having the side-effects from chemotherapy. Your doctor will explain more about watchful waiting and if it’s appropriate for you.

    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’ll have breaks to allow your body to recover from the side-effects of the medicines. See our information on chemotherapy to learn about the side-effects of the treatment.

    Sometimes you may take steroid medicines (e.g. prednisolone) alongside your chemotherapy. These medicines help the chemotherapy to work and you usually take them as tablets. You may also have a monoclonal antibody therapy called rituximab with your chemotherapy (see Monoclonal antibodies).

    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 non-Hodgkin 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. Your doctor will let you know how long they expect you’ll need treatment for.

    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 lymphoma. It’s given through a drip into a vein or as an injection. Rituximab is often given with chemotherapy.

    Stem cell transplant

    If your first chemotherapy for non-Hodgkin lymphoma hasn’t worked well or if you have relapsed following your initial treatment, you may need a higher dose of chemotherapy. This kills off any remaining NHL cells. It also kills your stem cells which your body needs 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. Your body will use the stem cells to make new blood cells to replace the ones the high-dose chemotherapy destroys.

    Your stem cells will be collected before you have the high-dose chemotherapy. High-dose chemotherapy and stem cell transplants aren’t used for all types of non-Hodgkin lymphoma. For more information about stem cell transplants, see our FAQ: Stem cell transplant.

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  • Causes Causes of non-Hodgkin lymphoma

    Doctor’s don’t know exactly why people develop non-Hodgkin lymphoma. But 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
    • coeliac disease
    • certain viruses, including Epstein–Barr virus (which causes glandular fever), human T cell lymphoma virus 1 or hepatitis C
    • infection with Helicobacter pylori bacteria
    • a close relative having had non-Hodgkin lymphoma
    • previously having had Hodgkin lymphoma
    • age – it’s more common in people aged 50 and over (though it can affect all age groups)
    • gender – it is slightly more common in men than women
  • FAQ: Hodgkin and non-Hodgkin lymphoma What’s the difference between these two conditions?

    Hodgkin lymphoma isn’t the same as non-Hodgkin lymphoma. It’s a different type of lymphoma. They are both cancers of your lymphatic system but these two types of lymphoma develop and spread differently, and they are treated in different ways. There are six types of Hodgkin lymphoma and 61 types of non-Hodgkin lymphoma. Hodgkin lymphomas involve a particular cell type called Reed–Sternberg cells. The two types of lymphoma can be told apart by looking at the cells under a microscope.

    Hodgkin lymphomas aren’t as common as non-Hodgkin lymphomas. It’s estimated 2,000 people are diagnosed with Hodgkin lymphoma in the UK every year, compared with almost 13,000 people diagnosed with non-Hodgkin lymphoma. Anyone can get either type of cancer but Hodgkin lymphoma is more common if you are around 25, or 50 to 60. Non-Hodgkin lymphoma is more common in older people, aged 50 and over.

    See our Hodgkin lymphoma topic for more detail about this type of cancer.

  • FAQ: Low and high grade What do low grade and high grade non-Hodgkin lymphoma mean?

    Non-Hodgkin lymphoma can be categorised as low grade or high grade.

    Low grade

    Low grade means that the cancer cells are dividing slowly. The treatment you have for low grade non-Hodgkin lymphoma will depend on what stage it is and how much of your body is affected by the cancer. Early stage asymptomatic (you don’t have any symptoms) low grade non-Hodgkin lymphoma is usually monitored (commonly known as watch and wait). If the cancer is in its advanced stages you’ll have chemotherapy, which can’t cure the cancer but can control it for several years (this is usually measured in decades).

    High grade

    High grade non-Hodgkin lymphoma means the cancer cells are dividing quickly and need treating straightaway. High grade lymphomas are sometimes called ‘aggressive’ but this doesn’t necessarily mean they can’t be treated. In fact, with intensive treatment high grade non-Hodgkin lymphomas often respond very well to treatment. A lot of people with high grade non-Hodgkin lymphoma go into remission (no traces of cancer).

    There are lots of factors involved when it comes to deciding on your treatment and what will be best for you. You cancer team will explain more about the type of cancer you have and help you make choices about your treatment.

  • FAQ: Stem cell transplant Where do the cells come from?

    Your doctor will usually take the stem cells from your own blood before you begin high-dose chemotherapy or, much less frequently, from your bone marrow. If for some reason this isn’t possible, the stem cells will need to come from another person, usually a close relative such as your brother or sister. This is because their cells are most likely to match your own. If you don’t have any siblings or they aren’t a match, you may be able to have stem cells from a donor who isn’t related to you. For more detailed information about what happens, see Bone marrow (stem cell) transplant.

  • FAQ: Stem cell transplant and side-effects How will a stem cell transplant affect me?

    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.

    Your immune system won't be very strong after high-dose chemotherapy and you’ll be more susceptible to infections. You’ll feel very tired. You may also lose your appetite, get a sore mouth, develop fevers, and have sickness and diarrhoea.

    Although your stem cell transplant will help your body get stronger, this will take several weeks. Your doctor might give you antibiotics and mouthwashes to help prevent you getting an infection and you’ll probably need to have blood transfusions. In general, you will be in hospital for two to three weeks.

    You will need to have new vaccinations against diseases, because you will have lost any immunity you previously had. You will also be offered the annual flu vaccine.

    It can take about three to six months to recover fully and go back to work.

    See our information on chemotherapy and bone marrow (stem cell) transplant to learn more about the side-effects of both.

  • FAQ: Having children Will I be able to have children after treatment?

    Chemotherapy and radiotherapy can reduce your chances of having children or cause infertility.

    Some chemotherapy medicines can cause infertility, particularly if you have very high doses. Radiotherapy may also affect your fertility if you have it in your pelvic or abdominal (tummy) area.

    It's sometimes possible for a clinic to freeze your eggs or sperm before you start treatment. But remember it’s not always possible to freeze and store sperm or eggs before starting treatment and infertility treatments don’t always work.

    You can ask your doctor about your options.

  • Other helpful websites Other helpful websites

    Further information

    Sources

    • Non-Hodgkin lymphoma. The MSD Manuals. www.msdmanuals.com, last full review/revision October 2012
    • Haematological cancers – recognition and referral. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised November 2015
    • Non-Hodgkin lymphoma. BMJ Best Practice. bestpractice.bmj.com, last updated 21 July 2016
    • Non-Hodgkin lymphoma. Lymphoma Association. www.lymphomas.org.uk, last reviewed April 2016
    • Non-Hodgkin lymphoma: diagnosis and management. National Institute for Health and Clinical Excellence (NICE). www.nice.org.uk, published 20 July 2016
    • Overview of the lymphatic system. The MSD Manuals. www.msdmanuals.com, last full review/revision October 2015
    • What is the lymphatic system? Macmillan Cancer Support. www.macmillan.org.uk, last reviewed 12 Jul 2016
    • The lymphatic system and cancer. Cancer Research UK. www.cancerresearchuk.org, last reviewed 29 October 2014
    • Lymphoma. National Cancer Institute. www.cancer.gov, accessed 18 January 2017
    • What is lymphoma? Lymphoma Association. www.lymphomas.org.uk, last reviewed June 2016
    • Map of Medicine. Lymphoma. International View. London: Map of Medicine; 2016 (Issue 4)
    • Low grade NHL. Cancer Research UK. www.cancerresearchuk.org, last reviewed 1 September 2014
    • Symptoms. Cancer Research UK. www.cancerresearchuk.org, last reviewed September 2014
    • Non-Hodgkin lymphoma. BMJ Best Practice. bestpractice.bmj.com, last updated 21 July 2016
    • Stages of cancer. Cancer Research UK. www.cancerresearchuk.org, last reviewed 29 October 2014
    • Watch and wait. Macmillan Cancer Support. www.macmillan.org.uk, last reviewed 1 April 2012
    • How treatment is planned. Macmillan Cancer Support. www.macmillan.org.uk, last reviewed 31 Aug 2014
    • Non-Hodgkin lymphoma survival statistics. Cancer Research UK. www.cancerresearchuk.org, last reviewed 8 December 2014
    • Chemotherapy treatment. Cancer Research UK. www.cancerresearchuk.org, last reviewed 15 September 2014
    • Radiotherapy treatment. Cancer Research UK. www.cancerresearchuk.org, last reviewed 15 September 2014
    • Biological therapy treatment. Cancer Research UK. www.cancerresearchuk.org, last reviewed 26 September 2014
    • Stem cell transplant. Cancer Research UK. www.cancerresearchuk.org, last reviewed 15 September 2014
    • Risks and causes. Cancer Research UK. www.cancerresearchuk.org, last reviewed 7 November 2014
    • Non-Hodgkin lymphoma. Lymphoma Research Foundation. www.lymphoma.org, accessed 24 February 2017
    • About lymphoma. Lymphoma Research Foundation. www.lymphoma.org, accessed 24 February 2017
    • Non-Hodgkin lymphoma. Patient Plus. patient.info/patientplus, last checked 1 December 2015
    • Side effects of bone marrow or stem cell transplants for non Hodgkin lymphoma. Cancer Research UK. www.cancerresearchuk.org, last reviewed 26 September 2014
    • Having a transplant. Cancer Research UK. www.cancerresearchuk.org, last reviewed 17 March 2015
    • Autologous stem cell transplant. Lymphoma Association. www.lymphomas.org.uk, published July 2016
    • Immunisation of individuals with underlying medical conditions. The Green Book. Gov UK. www.gov.uk, last updated 29 September 2016
    • Influenza. The Green Book. Gov UK. www.gov.uk, last updated 28 August 2015
    • Sex and fertility and non Hodgkin lymphoma. Cancer Research UK. www.cancerresearchuk.org, last reviewed 26 September 2014
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    Reviewed by Natalie Heaton, Specialist Health Editor, Bupa Health Content Team, May 2017
    Expert reviewer, Dr Prem Mahendra, Consultant Haematologist
    Next review due May 2020

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