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Non-Hodgkin's lymphoma

Highlights

Non-Hodgkins Lymphoma

The non-Hodgkins lymphomas (NHL) are a group of cancers that develop in the bodys lymphatic system. There are many different types of non-Hodgkins lymphoma. Most types of NHL involve B cells, while a small percentage involve T cells. Common types of B-cell non-Hodgkins lymphomas include diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma.

Prognosis

Non-Hodgkins lymphomas are classified as indolent (slow-growing) or aggressive (fast-growing). Aggressive lymphomas, such as DLBCL, are often curable. Indolent lymphomas, such as follicular lymphoma, are more difficult to treat and tend to recur after periods of remission. With the advancement of new treatments and drugs, survival rates for patients with NHL have significantly improved.

Risk Factors

The risk of NHL increases with age, and most patients are diagnosed when they are in their 60s and 70s. NHL can develop, however, in people of any age, including children. People who have had immune system impairment through infections, disease, or exposure to certain types of chemicals appear to have increased risk. Still, people without any known risk factors can develop NHL.

Symptoms

The most common first sign of lymphomas is painless enlargement of one or more lymph node, usually in the neck, armpits, or groin.

More generalized symptoms can include:

  • Drenching night sweats
  • Unexplained weight loss
  • Fever
  • Severe itching

Diagnosis

NHL is diagnosed based on the results of physical examination, blood tests, imaging tests, and biopsy. A lymph node biopsy is the definitive test for diagnosing NHL, determining the type of NHL, and distinguishing NHL from Hodgkins disease.

Treatment

Radiation and chemotherapy are the main treatments for NHL. Rituximab, a biologic drug, is increasingly being used and may be added to a chemotherapy regimen. For some patients, stem cell or bone marrow transplantation may be an option.

Introduction

Lymphomas are malignancies of the lymph system that are generally subdivided into two groups, Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Hodgkin's disease accounts for about 15% of all lymphomas. [For more information, see In-Depth Report #83: Hodgkin's disease.]

Non-Hodgkin's lymphomas is a term for malignancies that range from a very slow disease to an extremely aggressive but curable condition. They have certain features in common.

Lymphatic system
The lymphatic system filters fluid from around cells. It is an important part of the immune system. When people refer to swollen glands in the neck, they are usually referring to swollen lymph nodes. Common areas where lymph nodes can be easily felt, especially if they are enlarged include the groin, armpits (axilla), above the clavicle (supraclavicular), in the neck (cervical), and the back of the head just above hairline (occipital).

The Lymphatic System

Lymphomas, such as non-Hodgkin's lymphomas and Hodgkin's disease, represent tumors of the lymphatic system. This system is a network of organs, ducts, and nodes. The system interacts with the blood's circulatory system to transport a watery clear fluid called lymph throughout the body. The lymphatic system contains lymphocytes, important cells involved in defending the body against infectious organisms. This system also restores 60% of the fluid that leaks out from blood capillaries back into circulation, and its ducts provide transportation for fats, proteins, and other substances collected from the body's tissues.

Lymphocytes. The lymphatic system is involved in the production and transportation of lymphocytes, white blood cells that are a primary component of the immune system. Among other vital functions, certain lymphocytes are responsible for producing antibodies, factors that can target and attack specific foreign proteins (antigens).

  • Lymphocytes develop in the bone marrow or thymus gland and are therefore categorized as either B cells (bone marrow-derived cells) or T cells (thymus gland-derived cells).
  • Lymphatic vessels begin as tiny tubes and lead to larger lymphatic ducts and branches until they drain into two ducts in the neck, where the fluid re-enters the bloodstream.
  • Along the way, the fluid passes through lymph nodes, oval structures composed of lymph vessels, connective tissue, and white blood cells. Here, the lymphocytes are either filtered out or added to the contents of the node.
  • Both leukemia and lymphomas (Hodgkins disease and non-Hodgkins lymphomas) are cancers of lymphocytes. The difference is that leukemia starts in the bone marrow while lymphomas originate in lymph nodes and then spread to the bone marrow or other organs.

Lymph Nodes. In the lymph node, lymphocytes receive their initial exposure to foreign substances (antigens), such as bacteria or other microorganisms, activating the lymphocytes to perform their immune functions. The size of a lymph node varies generally from that of a pinhead to a bean. Most nodes are in clusters located throughout the system. Important node clusters are found in the neck, lower arm, armpit, and groin.

Other Structures in the Lymphatic System. The tonsils and adenoids are secondary organs composed of masses of lymph tissue that also play a role in the lymphatic system. The spleen is another important organ that processes lymphocytes from incoming blood.

Lymph nodes

Click the icon to see an animation about lymph nodes.

Click the icon to see an image of lymph nodes in the head and neck.

Click the icon to see an image of the immune system structures.

Locations of Non-Hodgkin's Lymphomas

Non-Hodgkin's lymphomas occur most often in lymph nodes in the chest, neck, abdomen, tonsils, and the skin. NHLs may also develop in sites other than lymph nodes such as the digestive tract, central nervous system, and around the tonsils.

Non-Hodgkin's Lymphomas Categories

There are more than 30 distinct types of non-Hodgkin's lymphomas. Lymphomas are categorized in a several ways:

  • As indolent (slow-growing) or aggressive (fast-growing). Indolent and aggressive lymphomas are equally common in adults. Aggressive lymphomas are more common in children. Aggressive lymphomas tend to be more curable than indolent lymphomas.
  • As arising from B cells or T cells. About 85 - 90% of Non-Hodgkins lymphomas are B cell subtypes and 10 - 15% are T cell subtypes. This report focuses on B cell lymphomas.

B-Cell Lymphomas

Common types of B-cell lymphoma include:

Diffuse Large B-Cell Lymphoma (DLBLC). DLBCL is the most common type of non-Hodgkins lymphoma, accounting for about 30% of all NHL cases. It is an aggressive, fast-growing lymphoma that usually affects adults but can also occur in children. DLBCL can occur in lymph nodes or in organs outside of the lymphatic system. DLBCL includes several subtypes such as mediastinal large B-cell lymphoma, intravascular large B-cell lymphoma, and primary effusion lymphoma.

Follicular Lymphoma (FLs). Follicular lymphoma is the second most common type lymphoma, accounting for about 20% of all NHL cases. It is usually indolent (slow growing) but about half of follicular lymphomas transform over time into the aggressive diffuse large B-cell lymphoma.

Mantle Cell Lymphoma. Mantle cell lymphoma is an aggressive type of lymphoma that represent about 7% of NHL cases. It is a difficult type of lymphoma to treat and often does not respond to chemotherapy. It is found in lymph nodes, the spleen, bone marrow, and gastrointestinal system. Mantle cell lymphoma usually develops in men over age 60.

Small Lymphocytic Lymphoma (SLL). SLL is an indolent type of lymphoma that is closely related to B-cell chronic lymphocytic leukemia (CLL). It accounts for about 5% of NHL cases.

Marginal Zone Lymphomas (MZL). MZLs are categorized depending on where the lymphoma is located. Mucosa-associated lymphoid tissue lymphomas (MALT) usually involve the gastrointestinal tract, thyroid, lungs, saliva glands, or skin. MALT is often associated with a history of an autoimmune disorder (such as Sjogren syndrome in the salivary glands or Hashimoto's thyroiditis in the thyroid gland). MALT is also associated with bacterial infection in the stomach (H. pylori ) and can be potentially cured by antibiotics when treated in its early stages. Splenic marginal zone lymphoma affects the spleen, blood, and bone marrow. Nodal marginal zone B-cell lymphoma is a rare type of indolent lymphoma that involves the lymph nodes.

Lymphoplasmacytic Lymphoma. Lymphoplasmacytic lymphoma, also called Waldenstrom's macroglobulinemia or immunocytoma, is a rare type of lymphoma accounting for about 1% of NHL cases. It usually affects older adults and most often involves bone marrow, lymph nodes, and spleen.

Primary Central Nervous System Lymphoma. This lymphoma involves the brain and spinal cord. Although it is generally rare, it is common in people who have AIDS.

Burkitt's Lymphoma. This is one of the most common types of childhood NHL, accounting for about 40% of NHL pediatric cases in the United States. It usually starts in the abdomen and spreads to other organs, including the brain. In African children, it often involves facial bones and is associated with Epstein-Barr infection.

Lymphoblastic Lymphoma. This lymphoma is also common in children, accounting for about 25% of NHL pediatric cases, most often boys. It is associated with a large mediastinal mass (occurring in chest cavity between the lungs) and carries a high risk for spreading to bone marrow, the brain, and other lymph nodes.

Risk Factors

Non-Hodgkins lymphoma is the fifth most common cancer in the United States. Each year, about 66,000 Americans were diagnosed with non-Hodgkin's lymphomas in 2007, and about 19,000 people die of the disease. Since the 1970s, NHL incidence rates have doubled. Part of the reason for this dramatic rise may be due to AIDS, which increases the risk for high-grade lymphomas.

The cause of non-Hodgkins lymphoma is unknown, but certain factors may increase a persons risk of developing this cancer.

Age

Non-Hodgkins lymphoma can develop in people of all ages, including children, it is most common in adults. The most common types of NHL usually appear in people in their 60s and 70s.

Gender

In general, NHL is more common in men than in women.

Race

Overall, the risk for NHL is slightly higher in Caucasians than in African-Americans and Asian Americans.

Family History

People who have close family relatives who have developed NHL may be at increased risk for this cancer. However, no definitive hereditary or genetic link has been established.

Infections

Viral or bacterial infections may play a role in some lymphomas. These include:

  • Epstein-Barr virus (EBV), the cause of mononucleosis, is highly associated with Burkitt's disease and NHLs associated with immunodeficiency diseases. It is also a risk factor for Hodgkin's disease.
  • The human immodeficiency virus (HIV), which causes AIDS, increases the risk for Burkitt lymphoma and diffuse large B-cell lymphoma
  • The hepatitis C virus (HCV) may increase the risk for certain types of lymphomas.
  • The Helicobacter pylori bacterium, which causes stomach ulcers, is associated withincreased risk for mucosa-associated lymphoid tissue lymphomas (MALT). (The use of antibiotics to get rid of the bacteria may cause remission in some patients who have an early stage form of lymphoma in an early stage.)

Immune System Deficiency Disorders

Patients with diseases or conditions that affect the immune system may be at higher risk for lymphomas:

  • HIV-positive patients and those with full-blown AIDS are at higher risk for NHL, and the disease is more likely to be widespread in these patients than in those without the immune disease. Most AIDS-related NHLs are high-grade lymphomas.
  • People who have organ transplants are at higher risk for NHL, probably due to multiple factors, including the drugs used to suppress the immune system and the transplanted organ itself.
  • Patients who have had high-dose chemotherapy with stem-cell transplantation are at higher risk.
  • Other immunodeficiency syndromes that put people at risk for NHL include Chediak-Higashi syndrome, ataxia-telangiectasia, B-cell lymphoproliferative syndrome, Bruton agammaglobulinemia, common variable immunodeficiency, and Wiskott-Aldrich syndrome.

Autoimmune Disorders

Patients with a history of autoimmune diseases, including rheumatoid arthritis (RA), systemic lupus erythematosus, Hashimoto's thyroiditis, Crohn's disease, and Sjogren syndrome, are at an increased risk for certain NHLs, such as marginal zone lymphomas.

Chemical Exposure

Overexposure to a number of industrial and agricultural chemicals (such as pesticides, herbicides, and petrochemicals) has been frequently linked to an increased risk for lymphomas. The data, however, are not consistent.

Researchers are also investigating whether some chemotherapy drugs may increase the risk for later developing non-Hodgkins lymphoma. At this point, it is not clear whether these drugs or the other cancers themselves increase risk. Other types of drugs, such as tumor necrosis factor (TNF) inhibitors that are used to treat autoimmune disorders, are also being studied as possible risk factors for lymphomas.

Radiation Exposure

People who have had radiation treatment for cancer, such as Hodgkins disease, appear to have an increased risk for later developing non-Hodgkins disease. The risk may be higher for patients treated with both chemotherapy and radiation.

Survivors of nuclear reactor disasters have an increased risk of developing NHL, as well as other types of cancers.

Lifestyle Factors

Lifestyle does not seem to be a major risk factor for NHL. Some studies have suggested that obesity may increase risk, but this association is not definite. Other studies have investigated the role of diet. Although some research has indicated an increased risk for diets high in consumption of red meat and lower risk for diets high in vegetables, for the most part a strong association remains speculative. There is no evidence that smoking increases the risk for NHL itself, although it has been linked with high-grade and follicular NHLs in people with lymphoma.

Symptoms

The most common first sign of lymphomas is painless enlargement of one or more lymph node, usually in the neck, armpits, or groin. These enlarged lymph nodes may cause discomfort depending on where they are located. For example, abdominal tumors may cause stomach distention or pain, while lymph nodes in the chest may cause coughing or difficulty breathing. Patients should see their doctors if these symptoms do not go away within 2 - 3 weeks.

Sometimes patients with NHL do not experience any symptoms, or symptoms may not appear until the cancer is very advanced. Enlarged lymph nodes can also be caused by many noncancerous conditions, such as infections.

Neck lump
The most common lumps or swellings in the neck are enlarged lymph nodes. They can be caused by bacterial or viral infections, cancer, and other rare causes.

Systemic and B Symptoms

Lymphomas sometimes cause systemic symptoms -- symptoms that affect the whole body, rather than a specific location. Some systemic generalized symptoms are referred to as B symptoms. Patients who have B symptoms have a more severe condition than asymptomatic patients with the same cancer stage or tumor location or size.

B systemic symptoms include:

  • Drenching night sweats
  • Unexplained weight loss
  • Fever
  • Severe itching

Diagnosis

The doctor will first ask questions about the patient's medical history and perform a physical examination to detect any node enlargements. If these steps point to lymphoma, additional tests will be done to rule out other diseases or to confirm the diagnosis and extent of the lymphoma.

Physical Examination

The doctor will examine not only the affected lymph nodes but also the surrounding tissues and other lymph node areas for signs of infection, skin injuries, or tumors. The consistency of the node sometimes indicates certain conditions. For example, a stony, hard node is often a sign of cancer, usually one that has metastasized (spread to another part of the body). A firm, rubbery node may indicate lymphoma. Soft nodes suggest infection or inflammatory conditions.

Biopsy

A biopsy is the most important test for diagnosing non-Hodgkins lymphoma and determining the subtype. Tissue samples retrieved from biopsy are also examined under a microscope to find out if the cell type involved is indicative of Hodgkins disease or non-Hodgkins. (Hodgkins disease is marked by the presence of the Reed-Sternberg cell, which is not found in non-Hodgkins lymphomas.) Sometimes a doctor may choose to wait and observe the involved lymph nodes, which will usually go away on their own if a temporary infection is causing the swelling. (However, some lymphomas may go away and appear to be benign, only to reappear at a later time.)

The Procedure. The type of biopsy performed depends in part on the location and accessibility of the lymph node. The doctor may surgically remove the entire lymph node (excisional biopsy) or a small part of it (incisional biopsy). In some cases, the doctor may use fine needle aspiration to withdraw a small amount of tissue from the lymph node.

Results. Even if biopsies do not show any problems, disease may still be present in some cases. The doctor should continue to observe the patient until swelling or other signs of disease are gone. Biopsied tissue samples should be frozen in case special tests are later required. Such tests may include detection of particular antibodies, genetic and immune factors, and certain markers (substances that may indicate disease) located on the surface of the cells. If lymphoma has been diagnosed, the tissue will be examined for its histology, the cellular structures that will determine the lymphoma type.

Bone Marrow Aspirate and Biopsy

Bone marrow aspirate and biopsy are routinely performed to determine whether the disease has spread. With bone marrow aspirate, bone marrow cells are sucked out through a special needle. A biopsy may be performed before or after the aspiration. In this procedure, a special needle removes a core of the marrow that is structurally intact.


Click the icon to see an image of bone marrow aspiration.

Imaging Techniques

Chest X-Ray. A chest x-ray shows the lymph nodes in the chest and neck area. It is particularly useful in detecting Hodgkin's disease and enlarged lymph nodes.


Click the icon to see an image of an x-ray machine.

Computer Tomography. Computed tomography (CT) scans are more accurate than x-rays. They can detect abnormalities in the chest and neck area, as well as revealing the extent of the cancer and whether it has spread. CT scans are used to evaluate symptoms and help diagnose lymphomas, help with staging of the disease, monitor response to treatment, and evaluate when the symptoms occur. A CT scan is also often used in detecting lymphomas in the abdominal and pelvic areas, the brain, and chest area.


Click the icon to see an image of a CT machine.

Magnetic Resonance Imaging (MRI). MRIs may be used to detect the spread of the disease to the brain, spine, chest, pelvis, and abdomen.


Click the icon to see an image of a MRI machine.

Positron Emission Tomography (PET). PET scans can help predict whether an enlarged lymph node is benign or cancerous. PET scans are more accurate than CT scans or other imaging tests for staging lymphomas. PET scans may also help doctors determine how well a patient has responded to treatment, if any residual cancer exists, and if a patient has achieved remission.

Blood Tests

Blood tests help rule out infection and other diseases. Such tests include a complete blood count to measure the number of white blood cells. In a patient already diagnosed with lymphoma, blood tests that measure the enzyme lactate dehydrogenase are important in determining the prognosis of patients with fast-growing lymphomas. High levels indicate bulkier tumors.

Molecular Diagnostic Tests

Tests of lymphoma's DNA are in use or are being developed to detect particular gene defects that help determine prognosis and response to treatment. Examples of such abnormal genetic arrangements are those that affect normal cell death, resist chemotherapy, or trigger aggressive cancer growth.

Prognosis

Survival rates for NHL vary widely, depending on the lymphoma type, stage, age of the patient, and other variables. According to the American Cancer Society, the overall 5-year relative survival rate for patients with non-Hodgkins lymphoma is 63% and the 10-year relative survival rate is 51%. (The relative survival rate estimates the likelihood that a patient will survive a certain number years after diagnosis. It is calculated to exclude the likelihood of death from diseases other than the cancer.)

Because the outlook varies so widely, making a definite prognosis is very difficult. For example, patients with very slow growing (indolent) lymphomas can live many years. However, they are usually diagnosed at a late stage, after the cancer has spread, thus reducing the survival rate. Aggressive lymphomas are more likely to cause rapid death, but they are also often curable.

Survival rates for patients with NHL have greatly improved since the early 1990s, especially for patients under age 45. Advances in treatment have contributed to this improvement.

Outlook for Indolent Lymphomas

Follicular lymphomas, the most common indolent (slow-growing) NHLs, are potentially curable in early stages I and II. Unfortunately, however, these slow-growing malignancies produce no symptoms until they are in advanced stages. In most cases, these lymphomas are not diagnosed until they have spread to other sites, including the spleen and bone marrow. In such cases, they are difficult to cure. Predicting outcome for indolent follicular lymphomas is more difficult than for aggressive lymphomas. Even if treatment achieves a response, these tumors almost always recur. Even after relapse, however, the tumors can be treated again if they are still very slow-growing.

In general, the average survival rate for follicular lymphoma is 7 - 10 years, depending on other risk factors. New drug treatments, particularly monoclonal antibodies, have significantly improved survival rates. According to a recent study, 91% of patients with follicular lymphoma now survive the first 4 years after diagnosis, compared with 69% of patients treated in the past with older types of drugs.

Outlook for Aggressive Lymphomas

High-grade aggressive lymphomas are often symptomatic early on and are potentially curable with aggressive treatments. Diffuse large B-cell lymphoma (DLBLC), the most common aggressive non-Hodgkin's lymphomas, while fatal if not treated, is often curable with intensive chemotherapy combinations. If relapse occurs after chemotherapy, it usually does so within 2 years.

Most other aggressive lymphomas respond to aggressive chemotherapy. Some aggressive lymphomas, such as mantle cell lymphoma, are less responsive to standard chemotherapy.

International Prognostic Index

A scoring system called the International Prognostic Index has proved to be fairly accurate for predicting outcome in patients with most aggressive B-cell lymphomas such as DLBCL. It uses five risk factors to help predict survival odds:

  • Being older than 60 -- this age group tends to have other medical conditions, which contribute to the poorer prognosis
  • Having a disseminated tumor (stage III or IV)
  • Disease that has spread to more than one site beyond the lymph nodes
  • The patient's functional ability
  • Having elevated levels of the lactate dehydrogenase (LDH) protein

Having one or none of these risk factors indicates the best outlook. Two factors indicate a low-to-intermediate likelihood of a poor outlook. Three factors predict an intermediate-to-high likelihood of poor outlooks. Finally, four or five factors pose the highest likelihood of poor survival. However, the International Prognostic Index was developed before the introduction of newer drug therapies like rituximab, which has dramatically helped improve the outcome of patients with DLBCL.

A similar prognostic index has been developed for follicular lymphoma.

Long-Term Complications of Treatments

Medical Problems. The radiation and chemotherapies used in treating NHL can have long-term effects on many organs in the body and can increase the risk for serious illnesses, including heart disease and certain cancers.

Emotional Problems. Depression and anxiety are common in survivors, particularly those who suffer additional medical conditions. Many patients also suffer from fatigue and aches and pains, called somatic symptoms, which have no apparent physical basis.

Treatment

Treatment for non-Hodgkin's lymphoma is highly specific for each patient and is determined by the tumor classification. It includes the following factors:

  • Stage (the extent of the tumor)
  • Grade (the growth pattern of the tumor)
  • Histologic type (cellular structure)
  • Location of tumor
  • Other factors, such as blood levels of lactate dehydrogenase or patient's age and overall health status

Staging and Grading

Grading refers to how fast the tumor grows and spreads. In NHL, indolent lymphomas are slow growing and aggressive lymphomas are fast growing. Aggressive lymphomas are usually more curable than indolent lymphomas. Indolent lymphomas may respond to treatment but tend to recur. (Recurrence is also called relapse.)

Staging refers to where the tumor is contained and where it has spread. The stages of non-Hodgkins lymphoma are:

Stage I. In Stage I (early disease), lymphoma is found in only one lymph node area or in only one area or organ outside the lymph nodes.

Stage II. In Stage II (locally advanced disease), lymphoma is found in two or more lymph nodes on the same side of the diaphragm or the lymphoma extends from a single lymph node or single group of lymph nodes into a nearby organ.

Stage III. In Stage III (advanced disease), lymphoma is found in lymph node areas on above and below the diaphragm. Lymphoma may have also spread into areas or organs adjacent to lymph nodes, such as the spleen.

Stage IV. In Stage IV (widespread disease), the lymphoma has spread (metastasized) via the bloodstream to organs outside the lymph system, such as the bone marrow, brain, skin, or liver.

Treatment Options

The main treatments for non-Hodgkins lymphoma are:

  • Radiation therapy
  • Chemotherapy
  • Biologic therapy (immunotherapy)
  • Stem cell or bone marrow transplantation

In early stages of lymphoma, doctors may recommend watchful waiting where treatment is delayed until symptoms appear or worsen. Treatment for lymphomas generally uses chemotherapy (particularly intensive regimens using several drugs) or a combination of chemotherapy and radiation. Monoclonal antibody biologic drugs, (a treatment approach also called immunotherapy), are now being used more frequently in combination with chemotherapy drugs. Transplantation is mainly used to treat patients who relapse or who are in remission. Surgery is not commonly used as a treatment option.

Patients may also wish to consider enrolling in a clinical trial that tests new and experimental drugs or treatments.

Bone marrow - series

Click the icon to see an illustrated series detailing bone marrow transplant surgery.

Assessing Treatment Success

In assessing the success of a clinical trial, doctors often refer to the tumor response. A complete response, for example, means that there is no longer any evidence at all of the disease by examination, blood tests, or x-ray studies. It does not necessarily mean, however, that the disease is cured. It may still recur later on.

In judging the success of a treatment for NHL, the most important criteria are overall survival and the duration of time until the disease progresses or the patient dies.

Chemotherapy

Chemotherapy plays a role in the treatment of nearly all lymphoma patients and has achieved remarkable results, even in late stages. It uses drugs to kill cancer cells. Such drugs are called cytotoxic drugs. Chemotherapy is referred to as systemic therapy because the drugs travel throughout the bloodstream to the entire body.

Chemotherapy may also be used along with radiation.

Chemotherapy Administration

A chemotherapy cycle is usually 21 - 28 days. Patients take the drugs for a few days, then have a period of rest. The drugs may be taken by mouth or given by injection. Chemotherapy is injected into the spinal fluid if the cancer has spread to the brain. This is called intrathecal chemotherapy. Intrathecal chemotherapy is also used as a preventive measure in patients at high risk for central nervous system involvement. Chemotherapy may be administered at a medical center or in a doctor's office. Some patients receiving chemotherapy need to remain in the hospital for several days so the effects of the drug can be monitored.

Effective Regimens and Drugs

CHOP. The current standard chemotherapy regimen for NHL is CHOP. CHOP is a combination of cyclophosphamide, doxorubicin hydrochloride (Adriamycin), vincristine (Oncovin), and prednisone. It is proving to be particularly effective for many stages of lymphoma when used in combination with rituximab (Rituxan), a monoclonal antibody. (See Biologic Therapy section of this report.) Some studies of this combination in low-grade lymphomas have reported response rates of 70 - 100%.

CVP. This stands for cyclophosphamide, vincristine, and prednisone. It is another common chemotherapy regimen for non-Hodgkins lymphoma. It is also used in combination with rituximab.

Fludarabine. Fludarabine (Fludara) is a type of drug called a nucleoside analogue. It is one of the most active drugs for treating low-grade lymphomas. Fludarabine is often used in a chemotherapy regimen called FND (fludarabine, mitoxantrone, and dexamethasone). Other fludarabine regimens for follicular and low-grade lymphomas are FAD (fludarabine, doxorubicin, and dexamethasone) and FMD (fludarabine, mitoxantrone, and dexamethasone). Fludarabine is also being studied in combination with rituximab.

Etoposide. Etoposide is another cancer drug that is sometimes used in a regimen called EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin.) EPOCH may be used in combination with rituximab.

Side Effects and Complications

Side effects and complications of any chemotherapeutic regimen are common. They are more severe with higher doses. Side effects may increase over the course of treatment. Radiation treatment may worsen chemotherapy side effects.

Common Side Effects. Common side effects include:

  • Nausea and vomiting -- Drugs known as serotonin antagonists, such as ondansetron (Zofran) or granisteron (Kyril), can relieve these side effects.
  • Diarrhea
  • Hair loss
  • Weight loss
  • Depression

These side effects are nearly always temporary. Most patients are able to continue with normal activities for all but perhaps a few days a month.

Serious Side Effects. Serious chemotherapy side effects can also occur and may vary depending on the specific drugs used. They include:

  • Neutropenia is a severe drop in white blood cells. Neutropenia increases the chance for infection from suppression of the immune system and is a potentially life-threatening condition. Drugs known as granulocyte colony stimulating factor (G-CSF) are used to help boost white blood cell count. These drugs, which include filgrastim (Neupogen) and pegfilgrastim (Neulasta), can help lessen the risk for neutropenia occurrence and, if neutropenia does occur, to reduce its length and severity. Patients should also use lifestyle precautions to prevent infection. (See Transplantation section of this report.)
  • Anemia is a lack of red blood cells. Erythropoietin stimulates red blood cell (hemoglobin) production and can help reduce or prevent this side effect. It is available as epoetin alfa (Epogen, Procrit) and darbepoetin alfa (Aranesp). In patients with cancer, these drugs should be used to treat only anemia associated with chemotherapy and to increase hemoglobin levels to no more than 12 g/dL. Treatment should stop as soon as chemotherapy is complete. These drugs may not be safe or appropriate for all patients.
  • Liver and kidney damage
  • Abnormal blood clotting (thrombocytopenia)
  • Allergic reaction

Long-Term Complications.

  • Fatigue and Somatic Symptoms. Chemotherapy has been associated with long-term somatic symptoms, which are general conditions, such as fatigue and aches and pains that have no apparent physical basis. Fatigue is especially common after chemotherapy and can even last for years.
  • The most serious long-term complications from chemotherapy are secondary cancers, particularly in people over age 40.
  • Infertility is a risk, particularly with the use of cyclophosphamide.
  • Some patients get osteoporosis (bone thinning) and damage in bone cells.
  • Regimens containing certain drugs, particularly doxorubicin or mitoxantrone, increase the risk for future heart failure.

In general, these serious late side effects are dependent on the cumulative drug dose and rate of administration.

Biologic Therapy (Immunotherapy)

Biological response modifier therapy, also called immunotherapy, uses the body's own immune system to fight cancer using natural or laboratory-developed factors. These drugs are often combined with other treatments.

Monoclonal antibodies (MAbs) are the main drugs used in biologic therapy. MAbs are designed in the laboratory to produce the same effects as natural antibodies. They bind to specific proteins called antigens and make them vulnerable to attack by other factors in the immune system. Lymphomas carry antigens that provoke strong immune responses and so are particularly good candidates for MAb therapy.

Rituximab

Rituximab (Rituxan) was the first monoclonal antibody approved for cancer. This drug targets the CD-20 antigen, which is found on most B-cell lymphomas. It is the most commonly used biologic drug, particularly in combination with standard chemotherapy regimens.

First approved in 1997 for treatment of relapsed or refractory NHL, rituximab has received several expanded indications since that time. Rituximab is approved for:

  • Relapsed or refractory, low-grade or follicular, CD20-positive, B-cell, NHL as a single drug
  • First-line treatment of follicular, CD20-positive, B-cell NHL in combination with CVP (cyclophosphamide, vincristine and prednisolone) chemotherapy
  • As a single drug for low-grade, CD20-positive, B-cell NHL in patients with stable disease or patients who have been partially or completely helped by first-line treatment with CVP chemotherapy
  • First-line treatment of diffuse large B-cell (DLBC), CD20-positive, NHL in combination with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) or other anthracycline-based chemotherapy regimens

Rituximab in combination with CHOP (a regimen called R-CHOP, or CHOP-R) is used for first-line treatment for aggressive lymphomas, with studies reporting 3-year event-free survival of 53% compared to 35% with CHOP alone. Rituximab is given by infusion. The treatment has mild-to-moderate short-term side effects, including nausea, fever, chills, hives, dizziness, and headache. Uncommon and more serious side effects are severe allergic reactions, very low blood pressure, blood abnormalities, wheezing, infections, and sudden heart events.

Rituximab has also been associated with cases of progressive multifocal leukoencephalopathy (PML), a rare and potentially deadly brain infection. Patients who experience any of the following symptoms should immediately contact their doctors:

  • Vision problems or unusual eye movements
  • Confusion
  • Dizziness or loss of balance
  • Difficulty talking or walking

Patients who have previously had hepatitis B, or who are at high-risk for this viral infection, should be tested before taking rituximab because the drug has been linked to reactivation of the hepatitis B virus. Patients who are HIV-positive may experience more adverse effects from rituximab than with CHOP.

Radioimmunotherapies

Some newer MAbs are used to treat NHL by attaching radioactive molecules to them. When the drug is injected, the monoclonal antibody targets an antigen (protein) on the surface of the tumor. The radioisotope is then delivered directly into the tumor where it kills the cancer. Ibritumomab and tositumomab both target the CD-20 antigen. Treatment with these drugs takes about 7 - 9 days to complete, compared to several months for traditional chemotherapy treatments.

  • Ibritumomab (Zevalin) is approved for patients with relapsed or refractory low-grade, follicular or transformed B-cell NHL. It is also approved for patients with follicular NHL who have not responded to rituximab (Rituxan). Research indicates it may also be safe for patients with advanced NHL who have had stem cell transplantation. Zevalin uses an yttrium-90 (90-Y) radioactive isotope.
  • Tositumomab (Bexxar) combines the monoclonal antibody tositumomab with the radioisotope I-131. Tositumomab is approved for treatment of relapsed or refractory low-grade, follicular, or transformed B-cell NHL. Overall response rates of 56% have been reported with Bexxar, with up to 30% having no evidence of cancer. Well-designed studies suggest that when Bexxar is used as a first treatment, it may produce long-term complete remission in patients with advanced stage follicular lymphoma.

In general, these drugs cause fewer side effects than traditional chemotherapy. However, serious complications may include skin infections, severe allergic reactions, and temporary lowering of blood counts. Due to the radioisotope component, these drugs are also more difficult to administer than rituximab. They tend to be used if patients do not respond to rituximab.

Interferon Alpha

Interferon alpha (Intron A) is used as an antiviral drug that also has properties that are effective against some common forms of NHL, particularly low-grade, follicular NHL in advanced stages. It is sometimes combined with chemotherapy regimens such as CHOP that contain an anthracycline drug (usually doxorubicin). The combination is toxic, however, and outcomes vary. For this reason, interferon is not used that often for NHL treatment.

Side Effects. Side effects of interferon include flu-like symptoms, severe depression, irritability, weight loss, vomiting, general weakness and loss of strength, and fever. About a third of patients have a severe drop in white blood cells. About 10% of patients cannot tolerate the drug's side effects.

Other Biologic Drugs

Proteasome Inhibitors. Bortezomib (Velcade) is approved for treatment of mantle cell lymphoma in patients who have received at least one prior therapy.

Investigational Biologic Therapies

Vaccines. Although still experimental, lymphoma vaccines are used to treat -- not prevent -- cancer. They are part of an immunotherapy approach called personalized medicine; each vaccine is individually tailored to the genetic composition of the patients tumor. The vaccine is usually given a few months after a patient receives chemotherapy. Several different vaccines, including BiovaxID and MYVax, are in late-stage clinical trials.

Radiation

Radiation uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation is commonly used to treat indolent lymphomas and may also be used palliatively to relieve symptoms. It is very often the sole therapy for early stage (stage I or II) lymphomas. The dose administered ranges from 35 - 50 Gy and depends on a number of factors: The type of lymphoma, the age of the patient, whether the intent is to cure or relieve symptoms, how close sensitive organs are to the diseased area, and whether radiation is being combined with chemotherapy.

Radiation is tailored to the individual and usually limited to the diseased areas and possibly nearby regions:

  • If the lymphoma is confined to tissues above the diaphragm, radiation is delivered to the neck, chest, and under arms (called the mantle-field) and sometimes to lymph nodes in the upper abdomen or spleen or both.
  • If the lymphoma is below the diaphragm, subtotal nodal radiation may be used, which is directed to other regions, including lymph nodes in the upper abdomen, spleen, and pelvis, in addition to the mantle-field.
  • Radiation to the brain is called cranial radiation.
  • Total body irradiation is sometimes performed, although it is not clear whether its high toxicity outweighs any advantages.

Side Effects and Complications

Side effects and complications of radiation generally depend on the target site in the body. They include:

  • Dental problems
  • Lung damage and difficulty breathing may occur with chest radiation
  • Hypothyroidism
  • Infections
  • Long-term risk for heart disease
  • Long-term risk for certain cancers -- of particular concern is a possible increased risk for breast cancer among females treated with chest radiation. Studies indicate that young women and adolescent girls are at highest risk, with the incidence increasing significantly 15 years after treatment. The risk is greater in those who had higher radiation doses. Radiation may also increase the risk over time for other cancers, including lymphoma and thyroid, lung, and colon cancers, although the risk is still low.
  • Impaired bone growth -- children and adolescents are at special risk for bone problems caused by radiation. Some doctors believe that radiation should play no role in the treatment of young people, except in special cases, such as lymphomas that require radiation to the brain.
  • Infertility -- the negative effects on fertility may be worse in women than in men; sperm usually recover within 5 years. To protect the ovaries, a technique called ovarian transposition is sometimes used. Transposition may sometimes be performed through a laparoscope, a thin tube containing tiny instruments and cameras, which is introduced through a small incision. The doctor uses the laparoscope to move the ovaries out of the range of areas being treated with radiation.

Click the icon to see an image of the lungs.

Click the icon to see an image of hypothyroidism.

Click the icon to see an image of the uterus and ovaries.

Transplantation

Stem cell procedures have proven to produce long-term survival and even cures in some patients with intermediate- and high-grade non-Hodgkin's lymphomas.

Stem cell transplantation involves removing and replacing stem cells, which are produced in the bone marrow. Stem cells are the early forms for all blood cells in the body (including red, white, and immune cells). Cancer treatments harm growing cells as well as cancer cells, and so the healthy stem cells must be replaced by transplanting them from the donor into the patient.

Collecting the Stem Cells

Sources of Cells. Stem cells must first be collected in one of the following ways:

  • Directly from blood, called peripheral blood stem cell transplantation
  • From bone marrow, called bone marrow transplantation
  • From umbilical cords or placentas -- this procedure uses donor cells, but has a lower risk for immune system rejection of the cells than with a standard donor transplant. It takes longer to restore blood cells with this process, so it is generally used for children and sometimes adults with low weight.

Some evidence suggests that both stem cell and bone marrow procedures produce similar benefits in terms of response rates and duration of remission. However, peripheral blood stem cell transplantation is easier to perform and is done more often than bone marrow transplantation. It also seems to be superior in terms of cost, quality of life, and the need for less supportive care.

Donor or Patient Cells. The marrow or blood stem cells can be taken from the patient (autologous) or from a matched donor (allogeneic):

  • In an autologous transplant, the marrow or blood cells used for replacement are taken from the patient. There is some danger, however, that these cells may contain tumor cells, and that the cancer can regrow. It is unclear if this approach improves survival compared to standard chemotherapy for newly diagnosed disease. However, it clearly has benefits in the treatment of some forms of relapsed non-Hodgkin's lymphomas. There is also a higher risk for leukemia. (This risk is lower in peripheral stem cells transplants than in bone marrow transplants.)
  • In an allogeneic transplant, bone marrow or stem cells are taken from a donor. Siblings are the best donors. Relapse rates can be very low with this approach, and cure may be possible in some cases. However, it is highly toxic and donor and recipient must be matched as closely as possible to avoid rejection by the immune system, a serious complication called graft-versus-host disease. Advances in techniques are reducing the toxicities associated with this approach. Older patients who cannot tolerate the preparatory treatment required for a standard allogeneic transplant may be able to receive a non-myeloblative transplant (mini-transplant), which uses lower doses of chemotherapy and radiation.

The Blood Stem Cell Collection Procedure. With peripheral blood stem cell transplantation:

  • The donor is usually given a drug called granulocyte colony-stimulating factor, or G-CSF (filgrastim, lenograstim, pegfilgrastim) to stimulate stem cell growth.
  • The patient (or donor in an allogeneic procedure) then undergoes apheresis. With this process the blood is withdrawn from one of the patient's veins, then passes through a machine that filters out the white cells and platelets, which contain the stem cells. The blood is returned through another vein. The entire procedure takes 3 - 4 hours but needs to be repeated several times.
  • The stem cells are treated to remove contaminants and then are frozen to keep them alive until the patient is ready to receive them back.
Formed elements of blood
Blood is the only fluid tissue in the body. Blood transports oxygen and nutrients to body tissues, and returns waste and carbon dioxide. Blood distributes nearly everything that is carried from one area in the body to another place within the body. For instance, blood helps transport hormones from the endocrine organs to their target organs. Blood also helps maintain body temperature. The protective functions of blood include clot formation and the prevention of infection.

The Transplantation Procedure

  • Allogeneic transplants are preceded by chemotherapy treatment known as conditioning. The point of this treatment is to inactivate the immune system and to kill any residual malignant cells. It is extremely toxic since it also destroys non-malignant marrow cells. Drugs used are typically cyclophosphamide, carmustine, and etoposide. Alternative conditioning to reduce toxicity includes total-body radiation plus drugs. Monoclonal antibodies, such as rituximab, are promising drugs, since they have low toxicity and may add benefits for all stages of transplantation.
  • A few days after treatment, the patient given the stored stem cells, which are administered through a vein. This may take several hours. Patients may have a fever, chills, hives, shortness of breath, or a fall in blood pressure during the procedure.
  • The patient may be treated with granulocyte colony-stimulating factor after chemotherapy. The goal is to stimulate the growth of infection-fighting white blood cells. Adding thrombopoietin may help enhance stem cell production.
  • The patient is kept in a protected environment to minimize infection. Patients who have received an allogeneic transplant may need blood cell replacement, nutritional support, and drugs to treat graft-versus host disease. They usually can leave the hospital within 3 - 5 weeks.

Candidates

These procedures are typically used for patients with relapsed aggressive lymphoma who are still sensitive to the effects of chemotherapy. The procedures do not work for patients whose tumors are not responsive to drugs. Some evidence suggests that certain primary (non-relapsed) lymphomas initially unresponsive to a first round of chemotherapy but who respond to a second round may benefit from combination of high-dose chemotherapy and radiation followed by transplantation. Transplantation is also being investigated as first-line therapy for patients with aggressive lymphomas, although at this time evidence does not support its use.

Transplantation Side Effects and Complications

Common side effects include nausea, vomiting, fatigue, mouth sores, and loss of appetite.

The procedures themselves are fairly dangerous and carry a small risk for death. When it was first used, transplantation procedures had 10 - 25% morality rates. Now mortality rates are below 5%.

Infection resulting from a weakened immune system is the most common side effect. Because the stem cell procedure is done more swiftly, the risk period is shorter than with bone marrow transplantation. The risk for infection is most critical during the first 6 weeks following the transplant, but it takes 6 - 12 months post-transplant for a patients immune system to fully recover. Immune systems of patients with graft-versus-host disease can take even longer to function normally.

Many patients develop severe herpes zoster virus infections (shingles) or have a recurrence of herpes simplex virus infections (cold sores and genital herpes). Pneumonia, cytomegalovirus, aspergillus (a type of fungus), and Pneumocystis jirovecii (a fungus) are among the most important life-threatening infections.

It is very important that patients take precautions to avoid infections. Guidelines for post-transplant infection prevention include:

  • Discuss with your doctor what vaccinations you need and when you should get them.
  • Avoid crowds, especially during cold and flu season.
  • Be diligent about handwashing and make sure that visitors wash their hands. Alcohol-based handrubs are best.
  • Avoid eating raw fruits and vegetables -- food should be well cooked. Do not eat foods purchased at salad bars or buffets. In the first few months after the transplant, be sure to eat protein-rich foods to help restore muscle mass and repair cell damage caused by chemotherapy and radiation.
  • Boil tap water before drinking it.
  • Dental hygiene is very important, including daily brushing and flossing. Schedule regular visits with your dentist.
  • Do not sleep with pets. Avoid contact with pets excrement.
  • Avoid fresh flowers and plants as they may carry mold. Do not garden.
  • Swimming may increase exposure to infection. If you swim, do not submerge your face in water. Do not use hot tubs.
  • Report to your doctor any symptoms of fever, chills, cough, difficulty breathing, rash or changes in skin, and severe diarrhea or vomiting. Fever is one of the first signs of infection. Some of these symptoms can also indicate graft-versus-host disease.
  • Report to your ophthalmologist any signs of eye discharge or changes in vision. Patients who undergo radiation or who are on long-term steroid therapy have an increased risk for cataracts.

Graft-versus-host disease (GVHD) is a serious attack by the patient's immune system triggered by the donated new marrow in allogeneic transplants. Mild cases of GVHD can actually be helpful as they can cause graft-versus-lymphoma where the immune system kills remaining lymphoma cells. Still, severe GVHD can pose serious complications.

To reduce the risk for GVHD, doctors remove some immune T-cells from the donors stem cells before the transplant. Researchers are investigating new techniques to refine this process of T-cell depletion.

Acute GVHD occurs in 30 - 50% of allogeneic transplants, usually within 25 days. Its severity ranges from very mild symptoms to a life-threatening condition (more often in older patients). The first sign of acute GVHD is a rash, which typically develops on the palms of hands and soles of feet and can then spread to the rest of the body. Other symptoms may include nausea, vomiting, stomach cramps, diarrhea, loss of appetite and jaundice (yellowing of skin and eyes). To prevent acute GVHD, doctors give patients immune-suppressing drugs such as steroids, methotrexate, cyclosporine, tacrolimus, and monoclonal antibodies.

Chronic GVHD can develop 70 - 400 days after the allogeneic transplant. Initial symptoms include those of acute GVHD. Skin, eyes, and mouth can become dry and irritated, and mouth sores may develop. Chronic GVHD can also sometimes affect the esophagus, gastrointestinal tract and liver. Bacterial infections and chronic low-grade fever are common. Chronic GVHD is treated with similar medicines as acute GVHD.

Too much sun exposure can trigger GVHD. Be sure to always wear sunscreen (SPF 15 or higher) on areas of the skin that are exposed to the sun. Stay in the shade when you go outside.

Secondary cancers. There is a small long-term risk for leukemia after transplantation in young people. Use of newer chemotherapeutic drugs, however, may not pose as high a danger as older treatments.

Other potentially serious complications include:

  • Bleeding because of reduced platelets (highest risk within the first 4 weeks); blood transfusions may be required
  • Infertility
  • Organ complications to the liver, heart, kidney, or lungs
  • Failure of the transplant
  • Muscle problems including stiffness, cramps, and joint pain
  • Frequent urination and bladder control problems
  • Older patients should be screened for osteoporosis (bone thinning) and hypothyroidism (underactive thyroid)

Resources

References

Armitage JO, Wyndham HW. Non-Hodgkins lymphoma. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKena WG, eds. Clinical Oncology. 4th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2008:chap 112.

Boffetta P, de Vocht F. Occupation and the risk of non-Hodgkin lymphoma. Cancer Epidemiol Biomarkers Prev. 2007: 16(3):369-72.

Cheson BD, Leonard JP. Monoclonal antibody therapy for B-cell non-Hodgkin's lymphoma. N Engl J Med. 2008 Aug 7;359(6):613-26.

Ferrara JL. Novel strategies for the treatment and diagnosis of graft-versus-host-disease. Best Pract Res Clin Haematol. 2007. 20(1):91-7.

Juweid ME, Stroobants S, Hoekstra OS, et al. Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma. J Clin Oncol. 2007 Feb 10;25(5):571-8. Epub 2007 Jan 22.

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Non-Hodgkins Lymphoma. V.1.2009.

Oeffinger KC, Ford JS, Moskowitz CS, Diller LR, Hudson MM, Chou JF, et al. Breast cancer surveillance practices among women previously treated with chest radiation for a childhood cancer. JAMA. 2009 Jan 28;301(4):404-14.

Pulte D, Gondos A, Brenner H. Ongoing improvement in outcomes for patients diagnosed as having Non-Hodgkin lymphoma from the 1990s to the early 21st century. Arch Intern Med. 2008 Mar 10;168(5):469-76.

Seam P, Juweid ME, Cheson BD. The role of FDG-PET scans in patients with lymphoma. Blood. 2007 Nov 15;110(10):3507-16. Epub 2007 Aug 20.


Review Date: 3/5/2009
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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