Non-Hodgkin's Lymphoma Diagnosis

  • Diagnosis

    Non-Hodgkin's lymphoma (NHL) is a type of cancer that affects the lymph system. A lymphoma is a cancer that originates in the lymphatic system, which is part of the body's immune system. The lymphatic system contains tiny vessels similar to blood vessels that transport lymph, a colorless fluid made of cells that fight infection, throughout the body. Lymphomas occur when cells in the lymph system are injured, become abnormal, and begin to multiply continuously. This proliferation makes it difficult for the body to produce healthy cells to protect against infection.

    Because lymphoid tissue is found in many parts of the body (e.g., groin, spleen, thymus, tonsils, bone marrow, chest, neck, and abdomen), non-Hodgkin's lymphoma (NHL) can start anywhere and spread to any other part of the body, including the liver, bone marrow, spleen, and nose.

    Non-Hodgkin's lymphoma can progress either slowly or aggressively. Lymphomas that grow slowly and produce fewer symptoms than more aggressive tumors are called indolent lymphomas. Aggressive lymphomas--also called intermediate- and high-grade lymphomas—grow and spread at an accelerated rate, and are associated with more severe symptoms. The prognosis for patients with Non-Hodgkin's lymphoma is based on whether the tumors are indolent or aggressive.

    Lymphomas account for approximately 5% of all cases of cancer in the U.S. About 50,000 new cases of NHL occur annually in the U.S. The disease is becoming more common, possibly because of its link to human immunodeficiency virus (HIV). People who have autoimmune diseases like HIV or immune deficiencies are at risk for developing NHL because their immune systems are compromised, making it hard for them to fight off cancer cells. In addition, 3 out of 10,000 people receiving an organ transplant or who have a suppressed immune system will develop lymphoma. NHL is more common in men, Caucasians, and people who are over 50 years of age.

    Treatment for patients with NHL depends on the number and location of tumors. Treatment usually involves radiation therapy, chemotherapy, or a combination of both. Treatment may also involve surgery, immunotherapy, and bone marrow transplantation.

    Treatment for NHL is determined by the stage of the condition. Patients with highly aggressive or non-responsive disease are treated with more intensive therapy. In a few cases of NHL, high-dose chemotherapy, bone marrow transplantation, biological therapies, or surgery may be needed.

    While there are some known risk factors for NHL, there are no known direct causes.

    A painless swelling of the lymph nodes is the most common sign of NHL. The lymph nodes in the groin, abdomen, neck, or armpit are most commonly affected. A lump can be felt on either side of the neck, in the groin, in the armpit, or above the collarbone. Because enlarged lymph nodes are also a sign of infection, a doctor may observe them for a period of weeks to see if they change in size.

    Abdominal swelling can occur in the abdomen because of fluid collection or swollen lymph nodes. This abdominal swelling may also cause constipation.

    Other symptoms of NHL include:

    • Enlarged lymph nodes
    • Fever
    • Excessive sweating or night sweats
    • Weight loss; loss of appetite
    • Fatigue
    • Weakness
    • Bone/flank pain
    • Severe itchiness
    • Coughing, shortness of breath, suffocation
    • Constant tiredness
    • Red patches on the skin
    • Enlarged spleen

    Patients experiencing general symptoms such as weight loss, night sweats, and fever (referred to as B symptoms ) may have an increased number of cancer cells. While these symptoms do not necessarily mean that a patient has NHL, patients who have been diagnosed with NHL and are experiencing B symptoms typically have more advanced disease and a poorer prognosis.

    A malfunction in the immune system may trigger an infection that predisposes people to NHL. As the body's defenses are altered, the risk of infection increases. People with particular infections such as HIV are at high risk for developing lymphoma.

    Infections that are associated with NHL are:

    • HIV
    • human T-cell leukemia or lymphoma virus
    • Epstein-Barr virus
    • H. pylori infection
    • Tuberculosis
    • Kaposi's sarcoma-associated herpesvirus (KSHV)

    Exposure to large amounts of chemicals or radiation may predispose people to NHL. Exposure to large quantities of chemicals (e.g., weed killers, pesticides, chemotherapy) or high levels of radiation (e.g., radiation therapy, nuclear reactor accidents) may increase your risk for NHL. Ironically, although chemotherapy and radiation therapy are used to treat cancer, they also predispose patients to NHL for 10 years after treatment.

    Advancing age and gender may predispose people to NHL. The chances of developing NHL increase as one ages. NHL is more common in men than in women.

    Non-Hodgkin's lymphoma is diagnosed based on the cell types present as well as the extent to which the disease has spread throughout the body. A tissue sample (biopsy) from a lymph node is the most useful method for diagnosis, as it can be examined under a microscope to look for cancer cells. Table 01 Based on how the tumor cells appear under a microscope, the pathologist estimates the potential of the cells to grow and spread. Doctors use information from the biopsy to “stage” cancer calls, or determine the extent of the disease by what parts of the body are affected. In order to stage a tumor, doctors consider:

    • The number and location of the lymph nodes that have cancer cells
    • The location of the affected lymph nodes: above, below, or on both sides of the diaphragm
    • The presence of cancer cells in the bone marrow, spleen, or organs outside the lymphatic system

    Your physician will ask about B symptoms, such as fever, night sweats, and weight loss. He or she will also carefully examine enlarged lymph nodes in your neck, armpits, or groin. Your physician will ask you about your medical history and conduct a physical examination to detect lymph node enlargement. As swelling of lymph nodes may indicate infection and not necessarily NHL, the physician may watch the swelling for a period of weeks before sending you for more testing.

    Your physician may order scans, such as x-rays, computed tomography (CT scan), and MRI (which is the most sensitive imaging test) to detect the size and location of lymphomas throughout the body.

    Table 1.  Stages and Grades of Tumors and Treatment Options for Patients with NHL

    Stage Grade Location NHL Treatment Comment
    I Low Only one lymph node or one area/organ outside the lymph nodes Radiation and/or chemotherapy depending on location Stage I often put into remission or alleviated
    I Intermediate Only one lymph node or one area/organ outside the lymph nodes Radiation and/or chemotherapy ?
    I High Only one lymph node or one area/organ outside the lymph nodes Aggressive chemotherapy; some radiation Treatment depends on cell type
    II Low Two or more lymph nodes in similar areas of the body, or one lymph node and area outside the lymph nodes Radiation and/or chemotherapy Treatment and remission or alleviation rates for stage II are 30% to 75%
    II Intermediate Two or more lymph nodes in similar areas of the body, or one affected lymph node and area outside the lymph nodes Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies ?
    II High Two or more lymph nodes in similar areas of the body, or one lymph node and area outside the lymph nodes Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies Treatment depends on cell type
    III Low Multiple areas of the body adjacent to lymph tissue, particularly to an area or organ near the lymph nodes or spleen Radiation and/or chemotherapy Standard therapies are not very effective
    III Intermediate Multiple areas of the body adjacent to lymph tissue, particularly to an area or organ near the lymph nodes or spleen Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies ?
    III High Multiple areas of the body adjacent to lymph tissue, particularly to an area or organ near the lymph nodes or spleen Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies ?
    IV Low Many areas of the body near and far from the lymph system Chemotherapy with or without radiation; bone marrow transplantation Patients without symptoms may not be treated, only monitored
    IV Intermediate Many areas of the body near and far from the lymph system Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies ?
    IV High Many areas of the body near and far from the lymph system Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies Treatment depends on cell type

    PBSC; peripheral blood stem cell

    Though it is difficult to prevent non-Hodgkins lymphoma, it is possible to lower the risk of certain infections, such as tuberculosis and HIV, that increase the likelihood of developing lymphoma. HIV patients should talk to their providers about their risk for developing NHL and any steps that can be taken to help lower that risk.

  • Prevention and Screening

    Though it is difficult to prevent non-Hodgkins lymphoma, it is possible to lower the risk of certain infections, such as tuberculosis and HIV, that increase the likelihood of developing lymphoma. HIV patients should talk to their providers about their risk for developing NHL and any steps that can be taken to help lower that risk.

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