Adult Non-Hodgkin Lymphoma

Overview

What is adult non-Hodgkin lymphoma (NHL)?

Adult non-Hodgkin lymphoma (NHL) is a malignant cancer that begins in the lymph system. The lymph system is part of the body’s immune system. “Malignant” means a disease spreads from where it starts and invades other areas of the body. Adult non-Hodgkin lymphoma differs from lymphoma in children and has a different course of treatment. “Non-Hodgkin” means the absence of a certain type of cell, called Reed-Sternberg cells, in the cancerous tissue.

The lymph includes the following:

  • Bone marrow. The spongy interior of large bones where white blood cells, red blood cells (which carry oxygen), and platelets (which help blood clot) are made.
  • Lymph. Colorless, watery fluid that carries white blood cells (lymphocytes) through the vessels of the lymph system all through the body. Lymphocytes can be either B-cells or T-cells. Their job is to fight disease and the growth of tumors.
  • Lymph vessels. Tubes that collect lymph from different parts of the body and send it back to the bloodstream.
  • Lymph nodes. Small oval or round structures that filter lymph and store white blood cells. Lymph nodes are located throughout the body but are concentrated in the underarms, pelvis, neck, abdomen and groin.
  • Thymus. An organ behind the breastbone in which lymphocytes grow and reproduce.
  • Spleen. An organ on the left side of the body near the stomach. The spleen filters blood, stores blood cells, and removes old blood cells. It also makes lymphocytes.
  • Tonsils. Lymph tissue in the back of the throat that makes lymphocytes.

Because the lymph system is present throughout the body, lymphoma can begin in almost any area and spread to other tissues and organs such as the liver.

What are the types of non-Hodgkin lymphoma (NHL)?

NHL comes in many types, but is often divided into indolent (slow-moving, usually with few symptoms) or aggressive (growing quickly, often causing symptoms). These two forms of NHL behave quite differently and are treated differently. Some types of indolent NHL (i.e., follicular lymphoma, chronic lymphocytic leukemia/small lymphocytic leukemia, and marginal zone lymphomas) can occasionally change or “transform” into more aggressive lymphomas.

NHL is also grouped by types based on whether the cancer has started in the B cells (B lymphocytes) or the T cells (T lymphocytes). The majority of cases begin in the B cells, which are responsible for creating antibodies that are able to stop foreign substances from causing problems in the body. T cells, on the other hand, attack foreign substances directly.

What are types of aggressive B-cell non-Hodgkin lymphoma (NHL)?

Types include:

  • Diffuse large B-cell lymphoma (DLBCL).
  • Primary mediastinal B-cell lymphoma (PMBL).
  • Burkitt lymphoma.

What are types of indolent B-cell non-Hodgkin lymphoma (NHL)?

  • Follicular lymphoma.
  • Marginal zone lymphoma.
  • Chronic lymphocytic leukemia (CLL) and small lymphomcytic lymphoma (SLL) are interchangeable terms for an indolent B-cell cancer that is found mostly in the blood or tissues of the body, respectively.
  • Cutaneous B-cell lymphoma.

What are types of T-cell non-Hodgkin lymphoma (NHL)?

These types of T-cell NHL are relatively rare and include:

  • Cutaneous T-cell lymphoma.
  • Peripheral T-cell lymphoma.
  • Anaplastic large cell lymphoma. There is a version of this cancer that is associated with breast implants called breast-implant associated anaplastic large cell lymphoma.
  • Angioimmunoblastic T-cell lymphoma.
  • Adult T-cell leukemia/lymphoma.
  • Lymphoblastic lymphoma, which more often develops in T-cells but can develop in B-cells.

What is the difference between non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL)?

Both types of lymphomas are diseases that start in lymphocytes, a type of white blood cells. Hodgkin lymphoma, which is also known as Hodgkin disease, involves a certain type of mature and very large cells called Reed-Sternberg cells. HL is less common than NHL.

What is the difference between leukemia and lymphoma?

Both diseases involve the blood, but start in different places. Leukemia begins in the bone marrow and is found in the blood. Non-Hodgkin lymphoma develops in the tissue of the body such as lymph nodes or other organs

What are the risk factors for non-Hodgkin lymphoma (NHL)?

You're more at risk for non-Hodgkin lymphoma if you:

  • Are older, assigned male at birth or white.
  • Have an inherited immune system disorder.
  • Have an autoimmune disease, such as rheumatoid arthritis or psoriasis.
  • Have HIV/AIDS.
  • Have Human T-lymphotrophic virus Type I or Epstein-Barr virus.
  • Have repeated bouts of Helicobacter pylori infection, which causes stomach ulcers.
  • Take immunosuppressant drugs following an organ transplant.
  • Work around pesticides. High levels of exposure to certain pesticides have been found in some observational studies to slightly increase the risk of NHL in in agricultural workers. The risk from low level and/or periodic exposure to these substances is not certain.
  • Have been exposed to radiation.
  • Consume a diet containing high amounts of meat and fat.
  • Had previous treatment for Hodgkin lymphoma.

How common is adult non-Hodgkin lymphoma (NHL)?

An estimated 74,200 new cases of NHL are expected to be diagnosed in 2019. About 1,000 people will die from the disease in 2019. NHL is the seventh most common cancer in U.S. adults.

Symptoms and Causes

What are the symptoms of adult non-Hodgkin lymphoma (NHL)?

  • Painless swelling in the lymph nodes of the neck, underarm, groin or stomach.
  • Unexplained fever.
  • Heavy night sweats.
  • Feeling much more tired than usual for at least several weeks for no apparent reason.
  • Unexplained weight loss.
  • Skin rash or itchy skin.
  • Unexplained pain in the chest, abdomen or bones.
  • A feeling of fullness even though you did not eat a lot.

These symptoms and signs are common to many conditions. You shouldn’t assume that you have NHL. However, you should contact your healthcare provider when you have symptoms that worry you.

Diagnosis and Tests

How is adult non-Hodgkin lymphoma (NHL) diagnosed and assessed?

  • Physical examination and medical history, focusing especially on lumps or anything that seems unusual.
  • Blood tests to measure levels of red blood cells, white blood cells and platelets.
  • Blood and sometimes urine tests that measure the amounts of certain immunoglobulins (proteins produced by the immune system to help fight infections).
  • Blood levels of lactate dehydrogenase (LDH) can be helpful to obtain a rough estimate of the amount or activity of lymphoma in the body.
  • Tissue biopsy and sometimes bone marrow biopsy. The sample from a biopsy is then viewed under a microscope for signs of cancer.

If cancer is detected, more laboratory tests will be needed to pinpoint what specific form of the disease is present.

Management and Treatment

Can adult non-Hodgkin lymphoma (NHL) be treated?

Yes, NHL is a very treatable disease and curable in many cases, particularly with aggressive NHL. Before treatment begins, it is necessary to know how far the cancer has advanced. This is called the stage of the disease. The stages begin with I (least severe) and go through IV (most severe). Stages of adult non-Hodgkin lymphoma may include “E” (meaning extranodal, or that cancer has spread beyond the lymph nodes) and “S” (meaning that cancer has been found in the spleen).

Because NHL is a blood and lymph system disease, most patients are at an advanced stage at diagnosis.

How is adult non-Hodgkin lymphoma (NHL) treated?

There are several types of treatments used to kill cancer cells or keep them from dividing:

  • Traditional systemic chemotherapy: This includes drugs taken either by mouth or injected into a vein, or less commonly into the cerebrospinal fluid.
  • Targeted systemic anti-cancer medications: These include treatments such as monoclonal antibodies that bind to targets on the surface of lymphocytes or small molecules designed to block pathways that make lymphoma cells grow but are not critical to normal cells.
  • Biologic therapy (also called biotherapy or immunotherapy): This involves using substances or cells made by the patient’s own immune system or in a laboratory to help boost the body’s natural defenses. The best example of this is chimeric antigen receptor (CAR) T-cells.
  • Radiation therapy: This type of treatment includes X-rays or other types of radiation.
  • Clinical trials of new treatments: Sometimes, this allows access to therapies that are not yet approved for more widespread use.

Some patients with indolent lymphoma that is not causing problems do not need treatment. This is called watchful waiting or active monitoring. This is the close monitoring of the patient without giving any treatment until symptoms appear or change.

There are also a number of new treatments being developed in clinical trials. A clinical trial might be preferred if standard treatments do not work or are too toxic. Ask the doctor about clinical trials.

Can non-Hodgkin lymphoma (NHL) spread to other organs?

Yes, NHL can spread (metastasize) can spread outside of the lymph nodes. Local disease stays in one lymph node. If the disease goes outside of that one lymph node, it is called extranodal. It can go almost anywhere in the body, including:

  • Other nodes.
  • Bone marrow.
  • Liver.
  • Spleen.
  • Stomach and intestines.
  • Skin.
  • Lungs.
  • Testicles.
  • The central nervous system, like the brain.
  • Eyes.
  • Sinuses.

Prevention

How can adult non-Hodgkin’s lymphoma (NHL) be prevented?

Many of the risk factors for NHL are outside a person’s direct control. The following factors, however, can be controlled:

  • Avoiding behaviors that increase the chance of getting AIDS and hepatitis C infections, both of which weaken the immune system.
  • Avoiding unnecessary exposure to radiation.
  • Maintaining a normal weight and eating a healthy diet.
  • Rarely, some women develop lymphoma in the scar tissue around breast implants. The decision to get breast implants should be well thought-out.

Outlook / Prognosis

What is the outlook for people with adult non-Hodgkin lymphoma (NHL)?

The outlook for people with this disease depends upon the stage of the cancer. Another factor is the type of lymphoma present. The age and general health of the patient also are taken into account. In general, the survival rate of patients with NHL at the five-year mark is generally favorable

Other facts:

  • Indolent NHLs have a median survival rate of as long as 20 years, and Stage I and Stage II varieties can often be treated with radiation alone.
  • When treated early, over half of people with aggressive NHL can be cured with combination chemotherapies.

Can non-Hodgkins lymphoma (NHL) come back?

Yes. Most relapses of aggressive NHL occur within two years of treatment. Relapses of indolent lymphoma can occur later.

NHL might recur in two types of situations. In one, the NHL was never completely cured during treatment and so requires additional kinds of treatment. In the second, the disease was put into remission and then returns. This is called relapsed disease. It might happen because the slow-growing cells of low-grade lymphoma might not be affected by the treatment (which tends to kill faster-growing cells).

Living With

What can be expected after treatment for adult non-Hodgkin lymphoma (NHL)?

Regular appointments with the patient’s doctor are necessary following any treatment for cancer. It is important to monitor how the patient feels and to do physical exams. Also, providers need to perform laboratory tests or imaging tests to look for signs of cancer or side effects from treatment.

For many people with NHL, treatment successfully removes the cancer. For others, the lymphoma may never completely disappear. Ongoing treatments will be needed as long as possible to keep the disease under control.

Last reviewed by a Cleveland Clinic medical professional on 09/15/2019.

References

  • National Cancer Institute. Adult non-Hodgkin lymphoma treatment (PDQ®). (https://www.cancer.gov/types/lymphoma/patient/adult-nhl-treatment-pdq#section/all) Accessed 9/16/2019.
  • American Cancer Society. What is non-Hodgkin lymphoma? (https://www.cancer.org/cancer/non-hodgkin-lymphoma/about/what-is-non-hodgkin-lymphoma.html) Accessed 9/16/2019.
  • Leukemia and Lymphoma Society. Facts and statistics. (https://www.lls.org/facts-and-statistics/facts-and-statistics-overview/facts-and-statistics) Accessed 9/16/2019.
  • Leukemia and Lymphoma Society. Non-Hodgkin lymphoma. (https://www.lls.org/lymphoma/non-hodgkin-lymphoma) Accessed 9/16/2019.
  • American Cancer Society. Living as a Non-Hodgkin lymphoma survivor. (https://www.cancer.org/cancer/non-hodgkin-lymphoma/after-treatment/follow-up.html) Accessed 9/16/2019.
  • Chase ML, Armand P. Minimal residual disease in non-Hodgkin lymphoma - current applications and future directions. Br J Haematol. 2018;180(2):177-188.
  • Lymphoma Action. What happens if lymphoma relapses? (https://lymphoma-action.org.uk/about-lymphoma-living-lymphoma/what-happens-if-lymphoma-relapses) Accessed 9/16/2019.

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