Non-Hodgkin Lymphoma (NHL)

What is non-Hodgkin lymphoma?

Non-Hodgkin Lymphoma (NHL) is a cancer that starts in the lymphatic tissue found in the lymph nodes and related organs (spleen, bone marrow, tonsils and thymus) that make up the body’s immune and blood-forming systems. Lymphomas are divided into two general types: Hodgkin’s Disease (Hodgkin lymphoma) and non-Hodgkin lymphoma. Non-Hodgkin lymphoma is the sixth most common cancer in the United States. It is far more common than Hodgkin lymphoma. About 54,400 cases of non-Hodgkin lymphoma will be diagnosed in the United States this year. Non-Hodgkin lymphoma is found in both children and adults.

There are many different kinds of non-Hodgkin lymphoma (dozens), and it is very important when researching information to know the specific type of lymphoma in question. The physicians at the Rocky Mountain Blood and Marrow Transplant Program are specialists in this area. They treat only patients with blood cancers like non-Hodgkin lymphoma and are active in clinical research in lymphoma.

What causes non-Hodgkin lymphoma?

All lymphomas, including non-Hodgkin lymphoma, result from an acquired injury to the DNA of a lymphocyte sometime after birth, resulting in uncontrolled and excessive growth of the lymphocyte. Being older, male or white can increase the risk of developing non-Hodgkin lymphoma. Having an inherited immune disorder, an autoimmune disease, HIV/AIDS, human T-lymphotrophic virus type I or Epstein-Barr virus, or a history of Helicobacter pylori infection can also increase risk. Taking immunosuppressant drugs following an organ transplant, being exposed to certain pesticides, eating a diet high in meats and fat, and past treatment for Hodgkin lymphoma can all increase the risk as well.

How is non-Hodgkin lymphoma diagnosed?

The most common early sign of non-Hodgkin lymphoma is a painless swelling in the lymph nodes of the neck, armpits, groin or stomach. Other symptoms include unexplained fever, sweating (especially at night), constant tiredness, weight loss, itching, and unexplained pain. Some patients may experience loss of appetite, nausea, vomiting, indigestion and abdominal pain or bloating. Pressure or pain in the lower back—often extending down one or both legs—is a common symptom. Other symptoms include bone pain, headaches, constant coughing and abnormal pressure and congestion in the face, neck and upper chest

Doctors may use the following tests to diagnose and stage non-Hodgkin lymphoma:

• Physical examination and history


• Complete blood count


• Blood chemistry studies especially the LDH


• Lymph node biopsy


• Bone marrow biopsy


• Immunophenotyping


• Cytogenetic analysis


• CAT scan, PET scan, MRI

There are more than thirty sub-types of non-Hodgkin lymphoma. In some, the cancer grows very slowly, and in others it progresses very rapidly. Once non-Hodgkin lymphoma has been diagnosed, tests may be conducted to see if the cancer has spread. The spread of most cancers is usually described as stages. There are four stages of non-Hodgkin lymphoma:

• Stage I – cancer is found in a single lymph node region or a single organ.


• Stage II – the involvement of two or more lymph node regions that are close to each other.


• Stage III – the involvement of several lymph node regions in the neck, chest and abdomen.


• Stage IV – widespread involvement of lymph nodes and other organs such as the lungs, liver, intestines and bone.

Stages of non-Hodgkin lymphoma may be described as E and S. E stands for extranodal and means the cancer is found in an area other than the lymph nodes or has spread to other tissues beyond, but near, the major lymphatic areas. S means the cancer is found in the spleen. If patients have fever, sweats, or unintentional weight loss, the letter B follows their stage (e.g., IVB); otherwise, the letter A follows the stage number.

Other factors than stage are also very important for determining the prognosis or outlook of non-Hodgkin lymphoma. Examples are the LDH blood level (high is worse), how sick or impaired the disease makes one feel at diagnosis and age above 60 years.

Non-Hodgkin lymphoma is also described according to how fast the cancer grows and the location of the affected lymph nodes. Indolent lymphomas tend to grow and spread slowly and have few symptoms. Aggressive lymphomas grow and spread quickly and have several symptoms. Recurrent non-Hodgkin lymphoma is a cancer that has come back after it has been treated. It may recur in the lymph system or in other parts of the body.

What are the treatment options?

The prognosis (chance of recovery) and treatment options depend on the stage of the cancer, the type of non-Hodgkin lymphoma, the patient’s age and general health, and whether the lymphoma has just been diagnosed or has recurred (come back). These vary widely and should be reviewed on an individual basis with your doctor. A second opinion is often a good idea as there may be many treatment options.

Radiation therapy, chemotherapy, biologic threrapies (such as monoclonal anitbodies) and watchful waiting are standard treatments for non-Hodgkin lymphoma. High-dose chemotherapy with stem cell transplantation is frequently a standard treatment for non-Hodgkin lymphoma.

Indolent non-Hodgkin lymphoma:

• Radiation therapy in the area where the cancer is located


• Watchful waiting


• Radiation therapy in the area where the cancer is located and nearby lymph nodes


• Chemotherapy with radiation therapy


• Chemotherapy


• Monoclonal antibodies


• Clinical trials

Aggressive, Stage I and Contiguous Stage II Treatments:

• Combination chemotherapy with or without radiation therapy

Aggressive, Noncontiguous Stage II, III, IV Treatments:

• Combination chemotherapy alone


• Combination chemotherapy with radiation therapy or monoclonal antibody therapy


• Combination chemotherapy with CNS prophylaxis


• Clinical trial or autologous or allogenic stem cell transplantation for patients who are likely to relapse

Indolent, Recurrent Treatments:

• Chemotherapy with one or more drugs


• Radiation therapy


• Radiation therapy and/or chemotherapy as palliative therapy to relive symptoms and improve quality of life


• Monoclonal antibody therapy


• Clinical trials of radiolabeled monoclonal antibody therapy


• Clinical trials of monoclonal antibody therapy as palliative therapy to relieve symptoms and improve quality of life


• Clinical trials of autologous or allogeneic stem cell transplantation


• Vaccine studies

Aggressive, Recurrent Treatments:

• Stem cell transplantation


• Monoclonal antibody therapy


• Clinical trials of autologous or allogeneic stem cell transplantation


• Clinical trials of combined chemotherapy followed by radiation therapy or stem cell transplantation and radiation therapy


• Clinical trial of radiolabeled monoclonal antibody therapy