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Lymphoma (Hodgkin's Disease and

Non-Hodgkin's Lymphoma)Medical Author:

Jerry R. Balentine, DO, FACEP

Jerry R. Balentine, DO, FACEP

Dr. Balentine received his undergraduate degree from McDaniel College in Westminster,Maryland. He attended medical school at the Philadelphia College of Osteopathic Medicine

graduating in1983. He completed his internship at St. Joseph's Hospital in Philadelphia and

his Emergency Medicine residency at Lincoln Medical and Mental Health Center in the Bronx,

where he served as chief resident.

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Medical Editor:

Melissa Conrad Stppler, MD, Chief Medical Editor

Melissa Conrad Stppler, MD, Chief Medical Editor

Melissa Conrad Stppler, MD, is a U.S. board-certified Anatomic Pathologist with

subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stppler's

educational background includes a BA with Highest Distinction from the University of Virginia

and an MD from the University of North Carolina. She completed residency training in

Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in

molecular diagnostics and experimental pathology.

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Lymphoma (Hodgkin's Disease and Non-Hodgkin's Lymphoma) Overview

Lymphoma CausesLymphoma Symptoms and SignsWhen to Seek Medical CareLymphoma DiagnosisLymphoma TreatmentMedical TreatmentLymphoma MedicationsOther TherapyFollow-up

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Authors and EditorsViewer Comments: Lymphoma - Effective TreatmentViewer Comments: Lymphoma - Symptoms

Lymphoma (Hodgkin's Disease and Non-Hodgkin's Lymphoma) Overview

Lymphoma is a type of cancer involving cells of the immune system, called lymphocytes. Just

as cancer represents many different diseases, lymphoma represents many different cancers

of lymphocytes -- about 35 different subtypes, in fact.

Lymphoma is a group of cancers that affect the cells that play a role in the immune system

and primarily represents cells involved in the lymphatic system of the body.

The lymphatic system is part of the immune system. It consists of a networkof vessels that carry a fluid called lymph, similar to the way that the networkof blood vessels carry blood throughout the body. Lymph contains whiteblood cells called lymphocytes. Lymphocytes attack a variety of infectiousagents as well as many cells in the precancerous stages of development.

Lymph nodes are small collections of lymph tissue that occur throughoutthe body. The lymphatic system involves lymphatic channels that connectthousands of lymph nodes scattered throughout the body. Lymph flows

through the lymph nodes, as well as through other lymphatic tissuesincluding the spleen, the tonsils, the bone marrow, and the thymus gland.

These lymph nodes filter the lymph, which may carry bacteria, viruses, orother microbes. At infection sites, large numbers of these microbialorganisms collect in the regional lymph nodes and produce the swellingand tenderness typical of a localized infection. These enlarged andoccasionally confluent collections of lymph nodes (so-calledlymphadenopathy) are often referred to as "swollen glands." In some areasof the body (such as the anterior part of the neck), they are often visible

when swollen.

Lymphocytes recognize infectious organisms and abnormal cells and destroy them. There are

two major subtypes of lymphocytes: B lymphocytes and T lymphocytes, also referred to as B

cells and T cells.

B lymphocytes produce antibodies (proteins that circulate through the bloodand lymph and attach to infectious organisms and abnormal cells).

Antibodies essentially alert other cells of the immune system to recognizeand destroy these intruders, also known as pathogens (the process is


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known as humoral immunity).

T cells, when activated, can kill pathogens directly. T cells also play a partin the mechanisms of immune system control, to prevent the system frominappropriate overactivity or underactivity (in the process of cell mediatedimmunity).

After fighting off an invader, some of the B and T lymphocytes "remember"the invader and are prepared to fight it off if it returns.

Cancer occurs when normal cells undergo a transformation whereby they grow and multiply

uncontrollably. Lymphoma is a malignant transformation of either B or T cells or their

subtypes.

As the abnormal cells multiply, they may collect in one or more lymphnodes or in other lymph tissues such as the spleen.

As the cells continue to multiply, they form a mass often referred to as atumor.

Tumors often overwhelm surrounding tissues by invading their space,thereby depriving them of the necessary oxygen and nutrients needed tosurvive and function normally.

In lymphoma, abnormal lymphocytes travel from one lymph node to thenext, and sometimes to remote organs, via the lymphatic system.

While lymphomas are often confined to lymph nodes and otherlymphatictissue, they can spread to other types of tissue almost anywhere in thebody. Lymphoma development outside of lymphatic tissue is calledextranodal disease.

Lymphomas fall into one of two major categories: Hodgkin's lymphoma (HL, previously calledHodgkin's disease) and all other lymphomas (non-Hodgkin's lymphomas or NHLs).

These two types occur in the same places, may be associated with thesame symptoms, and often have similar appearance on physicalexamination. However, they are readily distinguishable via microscopicexamination.

Hodgkin's disease develops from a specific abnormal B lymphocyte lineage.NHL may derive from either abnormal B or T cells and are distinguished byunique genetic markers.


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There are five subtypes of Hodgkin's disease and about 30 subtypes ofnon-Hodgkin's lymphoma.

Because there are so many different subtypes of lymphoma, theclassification of lymphomas is complicated (it includes both the microscopicappearance as well as genetic and molecular markers).

Many of the NHL subtypes look similar, but they are functionally quitedifferent and respond to different therapies with different probabilities ofcure. HL subtypes are microscopically distinct, and typing is based uponthe microscopic differences as well as extent of disease.

Lymphoma is the most common type of blood cancer in the United States. It is the seventh

most common cancer in adults and the third most common in children. Non-Hodgkin's

lymphoma is far more common than Hodgkin's lymphoma.

In the United States, about 66,000 new cases of NHL and 8,500 new casesof HL were expected to be diagnosed in 2010, and the overall incidence isincreasing each year.

About 20,000 deaths due to NHL were expected in 2010 as well as 1,300deaths due to HL, with the survival rate of all but the most advanced casesof HL greater than that of other lymphomas.

Lymphoma can occur at any age, including childhood. Hodgkin's disease ismost common in two age groups: young adults 16-34 years of age and inolder people 55 years of age and older. Non-Hodgkin's lymphoma is morelikely to occur in older people.

Lymphoma Causes

The exact causes of lymphoma are not known. Several factors have been linked to an

increased risk of developing lymphoma, but it is unclear what role they play in the actual

development of lymphoma. These risk factors include the following:

Age: Generally, the risk of NHL increases with advancing age. HL in theelderly is associated with a poorer prognosis than that observed in youngerpatients. In the 20-24-year age group, the incidence of lymphoma is 2.4cases per 100,000 while it increases to 46 cases per 100,000 in the 60-64-year-old age group.

Infections


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Infection with HIV

Infection with Epstein-Barr virus (EBV), one of the etiologic factors inmononucleosis

Infection with Helicobacter pylori, a bacterium that lives in the digestivetract

Infection with hepatitis B orhepatitis C virus

Medical conditions that compromise the immune system

HIV

Autoimmune disease

Use of immune suppressive therapy (often used following organtransplant)

Inherited immunodeficiency diseases (severe combinedimmunodeficiency, ataxia telangiectasia, among a host of others)

Exposure to toxic chemicals

Farm work or an occupation with exposure to certain toxic chemicalssuch as pesticides, herbicides, orbenzene and/or other solvents

Hair dye use has been linked to higher rates of lymphoma especially inpatients who started to use the dyes before 1980.

Genetics: Family history of lymphoma

The presence of these risk factors does not mean a person will actually develop lymphoma. In

fact, most people with one or several of these risk factors do not develop lymphoma.


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Lymphoma Symptoms and Signs

Often, the first sign of lymphoma is a painless swelling in the neck, under an arm, or in the

groin.

Lymph nodes or tissues elsewhere in the body may also swell. The spleen,for example, often becomes enlarged in lymphoma.

The enlarged lymph node sometimes causes other symptoms by pressingagainst a vein or lymphatic vessel (swelling of an arm or leg), a nerve (pain,numbness, or tingling), or the stomach (early feeling of fullness).

Enlargement of the spleen may cause abdominal pain or discomfort.

Many people have no other symptoms.

Symptoms of lymphoma may include the following:

Fevers

Chills

Unexplained weight loss

Night sweats

Lack of energy

Itching (up to 25% of patients develop this itch, most commonly in the lowerextremity but it can occur anywhere, be local, or spreading over the wholebody)

These symptoms are nonspecific. This means that they could be caused by any number ofconditions unrelated to cancer. For instance, they could be signs of the flu or otherviral

infection, but in those cases, they would not last very long. In lymphoma, the symptoms

persist over time and cannot be explained by an infection or another disease.

When to Seek Medical Care

Swelling in the neck, armpit, or groin, or unexplained swelling in an arm or leg should prompt

one to seek medical attention. Such swellings may have many causes or have nothing to do

with lymphoma, but they should be checked.


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If any of the following symptoms persist for more than a few days, seek medical attention:

Fevers

Chills

Unexplained weight loss

Night sweats

Lack of energy

Itching

Lymphoma Diagnosis

If a person has swelling or symptoms described in the Symptoms section, his or her

health-care provider will ask many questions about the symptoms (when they began, recent

illnesses, past or current medical problems, any medications, workplace, health history, family

history, and habits and lifestyle). These questions are followed by a thorough examination.

If, after an initial interview and examination, the health-care provider suspects that a patient

may have lymphoma, the patient will undergo a series of tests designed to provide further

clarification. At some point in this workup, the patient will likely be referred to a specialist inblood diseases and cancer (hematologist/oncologist).

Blood tests

Blood is drawn for various tests.

Some of these tests evaluate the function and performance of blood cellsand important organs, such as the liver and kidneys.

Certain blood chemicals orenzymes (lactate dehydrogenase [LDH]) may bedetermined. High levels of LDH in cases in which NHL is suspected mayindicate a more aggressive form of the disorder.

Other tests may be done to learn more about lymphoma subtypes.

Biopsy

If there is a swelling (also called lump or mass), a sample of tissue from the swelling will be

removed for examination by a pathologist. This is called a biopsy. Any of several methods

can be used to obtain a biopsy of a mass.


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Masses that can be seen and felt under the skin are relatively easy tobiopsy. A hollow needle can be inserted into the mass and a small sampleremoved with the needle (called a core-needle biopsy). This is usually donein the health-care provider's office with a local anesthetic.

Core-needle biopsy does not always obtain a good-quality sample. For thatreason, many health-care providers prefer a surgical biopsy. This involvesremoval of the entire swollen lymph node through a small incision in theskin. This procedure often is done with a local anesthetic, but it sometimesrequires a general anesthetic.

If the mass is not immediately under the skin but is instead deep inside thebody, access is somewhat more complicated. The tissue sample is usuallyobtained via laparoscopy. This means making a tiny incision in the skin andinserting a thin tube with a light and a camera on the end (a laparoscope).The camera sends pictures of the inside of the body to a video monitor, andthe surgeon can see the mass. A small cutting tool on the end of thelaparoscope can remove all or part of the mass. This tissue is withdrawnfrom the body with the laparoscope.

A pathologist (a physician who specializes in diagnosing diseases bylooking at cells and tissues) examines the tissue sample with a microscope.The pathologist's report will specify whether the tissue is lymphoma and thetype and subset of lymphoma.

Imaging studies

If there is no palpable mass in the presence of persistent symptoms, imaging studies will likely

be carried out in order to determine whether a mass is present and, if so, how then to direct a

biopsy.

X-rays: In certain parts of the body, such as the chest, a simple X-ray cansometimes detect lymphoma.

CT scan: This test provides a three-dimensional view and much greaterdetail and may detect enlarged lymph nodes and other masses anywhere inthe body.

MRI scan: Similar to the CT scan, MRI gives three-dimensional images withexcellent detail. MRI provides better definition than CT scan in certain partsof the body, especially the brain and the spinal cord.

Lymphangiogram: This approach, which provides an image of the lymphaticsystem by tracing a dye that moves though the system, has essentially


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been replaced by either CT scan, MRI, or PET (see below).

Gallium scan: Lymphomas tend to collect a substance called gallium wheninjected into the body. For this test, a tiny amount of radioactive gallium isinjected into the body. A scan is then done to find areas where the galliumhas collected. Collections of gallium suggest a tumor.

Positron-emission tomographic (PET) scan: PET scan is a newer alternativeto lymphangiogram and gallium scan for detecting areas in the body thatare affected by lymphoma. A tiny amount of a radioactive substance isinjected into the body and then traced on the PET scan. Sites ofradioactivity on the scan indicate areas of increased metabolic activity, whichimplies the presence of a tumor.

Bone marrow examination

Most of the time, an examination of the bone marrow is necessary to see if the marrow isaffected by the lymphoma. This is done by collecting a biopsy of the bone marrow.

Samples are taken, usually from a hip bone.

A pathologist examines the bone marrow under a microscope.

Bone marrow containing certain types of abnormal B or T lymphocytesconfirms lymphoma.

Bone marrow biopsy can be an uncomfortable procedure, but it can usuallybe performed in a medical office. Most people receive pain medication priorto the procedure to make them more comfortable.

Other tests

Lumbar puncture: This test, sometimes called a spinal tap, is a method forcollecting a sample of the fluid surrounding the brain and spinal cord. Thisfluid is called cerebrospinal fluid. If the lymphoma has affected the centralnervous system, the cerebrospinal fluid will likely contain lymphoma cells.

Organ function tests: These tests are usually done before starting treatmentto make sure that one's organs are healthy enough to withstand the sideeffects of therapy. Examples include an echocardiogram or MUGA scan (atest that provides a movie-like image of the working heart) for the heart andpulmonary function tests for the lungs.

Staging


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Staging is the classification of a cancer type by its size and whether and how much it has

spread around the body. Determining a cancer's stage is very important because it tells the

oncologist which treatment is most likely to work and what are the chances ofremission or a

cure (prognosis).

Staging of lymphomas is based on the results of imaging studies and related tests that reveal

the extent of the cancer involvement.

HL is often described as being "bulky" or "nonbulky." Nonbulky means the tumor is small; bulkymeans the tumor is large. Nonbulky disease has a better prognosis than bulky disease.

NHL is a complicated set of diseases with a complex classification system. In fact, the

classification system is continuously evolving as we learn more about these cancers. The

newest classification system takes into account not only the microscopic appearance of the

lymphoma but also its location in the body and genetic and molecular features.

Grade is also an important component of the NHL classification.

Low grade: These are often called "indolent" lymphomas because they growslowly. Low-grade lymphomas are often widespread when discovered, but

because they grow slowly, they usually do not require immediate treatmentunless organ function is compromised. They are rarely cured and cantransform over time to a combination of indolent and aggressive types.

Intermediate grade: These are rapidly growing (aggressive) lymphomas thatusually require immediate treatment, but they are often curable.

High grade: These are very rapidly growing and aggressive lymphomas thatrequire immediate, intensive treatment and are much less often curable.

The "staging," or evaluation of extent of disease, for both HL and NHL, are similar.

Stage I (early disease): Lymphoma is located in a single lymph node regionor in one area or organ outside the lymph node.

Stage II (locally advanced disease): Lymphoma is located in two or morelymph node regions all located on the same side of the diaphragm or in onelymph node region and a nearby tissue or organ. (The diaphragm is a flatmuscle that separates the chest from the abdomen.)

Stage III (advanced disease): Lymphoma affects two or more lymph noderegions, or one lymph node region and one organ, on opposite sides of thediaphragm.

Stage IV (widespread or disseminated disease): Lymphoma is outside thelymph nodes and spleen and has spread to another area or organ such asthe bone marrow, bone, or central nervous system.


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Both HL and NHL are further classified with letters.

An "A" or "B" designation indicates whether the person with lymphoma hadsymptoms such as fevers and/or weight loss at the time of diagnosis. "A"indicates no such symptoms, and "B" indicates symptoms.

An "E" designation indicates that the tumor spread directly from a lymphnode into an organ or that a single organ outside the lymphatic system isaffected with no apparent lymphatic involvement. If the spleen is involved an"S" designation is added.

Prognostic factors

Several risk factors have been extensively evaluated and shown to play a role in treatment

outcome. For HL, the International Prognostic Index includes the following seven risk factors:

Male sex1.

Age 45 years or older2.

Stage IV disease3.

Albumin (blood test) less then 4.0 g/dL4.

Hemoglobin (red blood cell level) less than 10.5 g/dL5.

Elevated white blood cell (WBC) count of 15,000/mL6.

Low lymphocyte count less than 600/mL or less than 8% of total WBC7.

The absence of any of the above risk factors is associated with an 84% rate of control of

Hodgkin's disease, whereas the presence of a risk factoris associated with a 77% rate of

disease control. The presence of five or more risk factors was associated with a disease

control rate of only 42%.

The outcomes for these patients were also determined by the treatment they received, which

occurred primarily in the 1980s. Newer treatments for Hodgkin's lymphoma may improve

these predicted outcomes. Furthermore, new treatments are being developed for patients

with greater risk factors.

The International Prognostic Index for NHL includes five risk factors:

Age older than 60 years1.


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Stage III or IV disease2.

High LDH3.

More than one extranodal site4.

Poor performance status (as a measure of general health): From thesefactors, the following risk groups were identified:

5.

Low risk: one risk factor, five-year lymphoma-free survival (LFS) of 70%

Intermediate risk: two to three risk factors, five-year LFS of 49%-50%

Poor risk: four to five risk factors, five-year LFS of 26%

The prognostic models were developed to evaluate groups of patients and are useful in

developing therapeutic strategies. It is important to remember that any individual patient might

have significantly different results than the above data, which represent statistical results for

a patient group.

Lymphoma Treatment

General health-care providers rarely undertake the sole care of a cancer patient. The vast

majority of cancer patients receive ongoing care from oncologists but may in fact be referredto more than one oncologist should there be any question about the disease. Patients are

always encouraged to gain second opinions if the situation so warrants this approach.

Although medical treatments are fairly standardized, not all physiciansbehave similarly.

One may choose to speak with more than one oncologist to find the onewith whom he or she feels most comfortable.

In addition to one's primary-care physician, family members or friends mayoffer information. Also, many communities, medical societies, and cancercenters offer telephone or Internet referral services.

Once one settles in with an oncologist, there is ample time to ask questions and discuss

treatment regimens.

The doctor will present each type of treatment, discuss the pros and cons,and make recommendations based on published treatment guidelines andhis or her own experience.


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Treatment for lymphoma depends on the type and stage. Factors such asage, overall health, and whether one has already been treated forlymphoma before are included in the treatment decision-making process.

The decision of which treatment to pursue is made with the doctor (withinput from other members of the care team) and family members, but thedecision is ultimately the patient's.

Be certain to understand exactly what will be done and why and what canbe expected from these choices.

As in many cancers, lymphoma is most likely to be cured if it is diagnosed early and treated

promptly.

The most widely used therapies are combinations ofchemotherapy andradiation therapy.

Biological therapy, which takes advantage of the body's innate cancer-fighting ability, is used in some cases.

The goal of medical therapy in lymphoma is complete remission. This means that all signs of

the disease have disappeared after treatment. Remission is not the same as cure. In

remission, one may still have lymphoma cells in the body, but they are undetectable and

cause no symptoms.

When in remission, the lymphoma may come back. This is calledrecurrence.

The duration of remission depends on the type, stage, and grade of thelymphoma. A remission may last a few months, a few years, or maycontinue throughout one's life.

Remission that lasts a long time is called durable remission, and this is thegoal of therapy.

The duration of remission is a good indicator of the aggressiveness of thelymphoma and of the prognosis. A longer remission generally indicates abetter prognosis.

Remission can also be partial. This means that the tumor shrinks after treatment to less than

half its size before treatment.

The following terms are used to describe the lymphoma's response to treatment:


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Improvement: The lymphoma shrinks but is still greater than half its originalsize.

Stable disease: The lymphoma stays the same.

Progression: The lymphoma worsens during treatment.

Refractory disease: The lymphoma is resistant to treatment.

The following terms to refer to therapy:

Induction therapy is designed to induce a remission.

If this treatment does not induce a complete remission, new or different

therapy will be initiated. This is usually referred to as salvage therapy.

Once in remission, one may be given yet another treatment to preventrecurrence. This is called maintenance therapy.

Medical Treatment

Standard first-line therapy (primary therapy) for lymphoma includes radiation therapy for most

early-stage lymphomas, or a combination of chemotherapy and radiation. For later-stage

lymphomas, chemotherapy is primarily used, with radiation therapy added for control of bulky

disease. Biological therapy, orimmunotherapy, is increasingly being used in addition to or asan alternative to these standard therapies.

Radiation therapy

Radiation therapy uses high-energy rays to kill cancer cells. It is considered a local therapy,

meaning that it should be used to target areas of the body involved by tumor masses. A

radiation oncologist will plan and supervise therapy.

The radiation is targeted at the affected lymph node region or organ.Occasionally, nearby areas are also irradiated to kill any cells that mighthave spread there undetected.

Depending on how and where the radiation is administered, it may causecertain side effects such as fatigue, loss of appetite, nausea, diarrhea, andskin problems. Radiation of lymph node areas may result in suppression ofthe immune system to varying degrees. Irradiation of the underlying boneand the marrow within the bone may result in suppression of the bloodcounts.


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The radiation is usually administered in short bursts on five days a weekover the course of several weeks. This keeps the dose of each treatment lowand helps prevent or lessen side effects.

Chemotherapy

Chemotherapy is the use of powerful drugs to kill cancer cells. Chemotherapy is a systemic

therapy, meaning that it circulates through the bloodstream and affects all parts of the body.

Unfortunately, chemotherapy also affects healthy cells; this accounts for its well-known side

effects.

The side effects of chemotherapy depend partly on the drugs used and thedoses.

Some people, because of variability in metabolism of chemotherapy drugs,tolerate chemotherapy better than other people.

The most common side effects of chemotherapy include suppression ofblood counts, which could result in increased susceptibility to infection (lowwhite blood cell count), anemia (low red blood cell count), or blood-clottingproblems (low platelet count). Other side effects may include nausea andvomiting, loss of appetite, hair loss, sores in the mouth and digestive tract,fatigue, muscle aches, and changes in fingernails and toenails.

Medications and other treatments are available to help people tolerate theseside effects, which can be severe.

It is very important to discuss and review the potential side effects of eachchemotherapy drug in the treatment with the oncologist, pharmacist, oroncology nurse. Medications to lessen the side effects should also bereviewed.

Chemotherapy may be given in pill form, but it is typically a liquid infused directly into the

bloodstream through a vein (intravenous).

Most people who receive intravenous chemotherapy will have asemi-permanent device placed in a large vein, usually in the chest or arm.

This device allows the medical team quick and easy access to the bloodvessels, both for administering medications and for collecting bloodsamples.

These devices come in several types, usually referred to as a "catheter,""port," or "central line."


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Experience has shown that combinations of drugs are more efficient than monotherapy (use

of a single medication).

Combinations of different drugs both increase the chance that the drugs willwork and lower the dose of each individual drug, reducing the chance ofintolerable side effects.

Several different standard combinations are used in lymphoma. Whichcombination one receives depends on the type of lymphoma and theexperiences of the oncologist and the medical center where a person isreceiving treatment.

The combinations of drugs are usually given according to a set schedulethat must be followed very strictly.

In some situations, chemotherapy can be given in the oncologist's office. Inother situations, one must stay in the hospital.

Chemotherapy is given in cycles.

One cycle includes the period of actual treatment, usually several days,followed by a period of rest for several weeks to allow recovery from sideeffects caused by the chemotherapy, particularly anemia and low whiteblood cells.

Standard treatment typically includes a set number of cycles, such as fouror six.

Spreading the chemotherapy out this way allows a higher cumulative doseto be given, while improving the person's ability to tolerate the side effects.

Biological therapy

Biological therapies are sometimes referred to as immunotherapy because they take

advantage of the body's natural immunity against pathogens. These therapies are attractive

because they offer anticancer effects without many of the undesirable side effects of

standard therapies. There are many different types of biological therapies. The following aresome of the most promising for treating lymphoma:

Monoclonal antibodies: Antibodies are substances produced by our body tofight pathogens. Every cell, organism, or pathogen within our body carriesmarkers on its surface that antibodies may recognize. These surfacemarkers are called antigens. A monoclonal antibody is an antibody that ismade in a laboratory to find and attach itself to a specific antigen.Monoclonal antibodies can be used to help one's own immune systems killtumor cells and other pathogens directly, or they can deliver cancer-killing


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therapies (such as radiation or chemotherapy) directly to a specific antigenfound on cancer cells.

Cytokines: These naturally occurring chemicals are produced by the body tostimulate the cells in the immune system and other organs. They can alsobe produced artificially and administered in large doses to patients withgreater effect. Examples include interferons and interleukins, whichstimulate the immune system, and colony-stimulating factors, whichstimulate the growth of blood cells.

Vaccines: Unlike the more familiar vaccines for infectious diseases such aspolio and flu, cancer vaccines do not prevent the disease. Rather, they aredesigned to stimulate the immune system to mount a specific responseagainst the cancer. They also create a "memory" of the cancer so that theimmune system activates very early in cases of recurrence, thus preventingthe development of a new tumor.

Other therapies under continuing development include drugs that target cancer cells on a

molecular level, various new monoclonal antibodies, and other biologic therapies.

Lymphoma Medications

Numerous chemotherapy and biological drug combinations may be prescribed by an

oncologist. Which type and combination of therapy depends on many factors, including the

type and stage of lymphoma, the age of the patient, the ability to tolerate chemotherapy side

effects, and if any previous treatment for the lymphoma has occurred. Oncologists often work

together regionally to decide which combination of chemotherapy and biological drugs are

currently working best for their patients. Because of this regional collaboration, the drugcombinations often vary and are able to change rapidly when improved results occur.

Other Therapy

Watchful waiting means choosing to observe and monitor the cancer rather than treat it right

away. This is strategy is sometimes used for indolent recurrent tumors. Treatment is given

only if the cancer starts to grow more rapidly or to cause symptoms or other problems.

Stem cell transplantation is usually not used as a primary therapy in lymphoma.

Stem cell transplantation is usually reserved for lymphoma that has been

previously treated into remission but has recurred.

Stem cell therapy as primary therapy has been used for aggressive T-cellNHL in first remission, usually as part of a clinical trial. Stem cell therapy isalso considered when standard primary treatment is unable to control thelymphoma and achieve remission.


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This procedure, which requires a lengthy hospital stay, involves very highdoses of chemotherapy to kill the aggressive cancer cells.

The chemotherapy doses are so high that the chemotherapy also stops thepatient's bone marrow from producing healthy new blood cells.

The patient then receives a transfusion of healthy bone marrow or bloodstem cells, either from previously collected stem cells from the patienthimself or herself (called autologous transplantation) or from a donor(calledallogeneic transplantation), to "kick start" the bone marrow into producinghealthy blood cells.

This is a very intensive therapy with a lengthy recovery period.

Clinical trials

An oncologist may belong to a network of investigators who offer novel treatments for various

types of cancers. These novel therapies are newer agents that have been recently

developed, and extensive data on treatment results are not yet known. Such new agents can

be offered in the context of a clinical trial. Usually, a consent form that explains the drug, its

known side effects, its potential side effects, and alternatives to the drug treatment arepresented to the patient. If the treatment seems promising for the particular subtype of

lymphoma, and the patient is fully educated about the potential benefits and risks associated

with such treatment and is interested in receiving such treatment, then the consent form is

signed by the patient and the managing physician, and possibly other involved parties. The

patient is then enrolled in a treatment protocol that specifies exactly how a patient is to be

treated with the new therapy.

Alternatively, an oncologist may refer a patient to another institution to receive investigational

treatment or intensive treatment, such as a stem cell transplant.

Complementary/alternative therapies

Several alternative therapies have undergone preliminary testing in lymphoma. None has

been found to work better than or as well as standard medical therapies. A few therapies, still

felt to be experimental, have been found to be potentially helpful as complements to medical

therapy, however.

Acupuncture has been helpful in relieving musculoskeletal symptoms, aswell as in controlling nausea and vomiting associated with chemotherapy.

The supplements coenzyme Q10 and polysaccharide K (PSK) areundergoing further evaluation to determine their effects on treatmentoutcome. Both drugs have immune enhancing properties. PSK has beenused more extensively in Japan as part of an anticancer therapy.

Neither of these therapies has undergone extensive blinded studies and


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cannot be considered a part of any planned therapeutic endeavor.

Follow-up

After completion of primary therapy for lymphoma, all appropriate tests will be repeated to see

how well the therapy worked.

The results of these tests will tell the oncologist whether the patient is inremission.

If the patient is in remission, the oncologist will recommend a schedule ofregular testing and follow-up visits to monitor the remission and to catch anyrecurrence early.

Keeping up with these visits and tests is very important in order to avoidadvanced or widespread disease.

If lymphoma recurs after treatment, the oncologist will likely recommend further treatment.

Lymphoma Prevention

There is no known way to prevent lymphoma. A standard recommendation is to avoid the

known risk factors for the disease. However, some risk factors for lymphoma are unknown,

and therefore impossible to avoid. Infection with viruses such as HIV, EBV, and hepatitis are

risk factors that can be avoided with frequent hand washing, practicing safe sex, and by not

sharing needles, razors, toothbrushes, and similar personal items that might be contaminated

with infected blood or secretions.

Lymphoma Prognosis

The outlook for HL is very good. It is one of the most curable cancers. The five-year survival

rate after treatment is greater than 80% for adults and greater than 90% for children.

As a result of refinements in and more aggressive approaches to therapy, the outlook for NHL

has improved significantly in the last few decades. The five-year survival rate after treatment

is 63% for adults and up to 90% for children. The addition of immunotherapy to standard

treatment for NHLs may further improve survival rates.

Many people live with lymphoma in remission for many years after treatment.

Support Groups and Counseling for Lymphoma

Living with lymphoma presents many new challenges for an individual and his or her family

and friends.

There may be many worries about how the lymphoma will affect one's abilityto "live a normal life," that is, to care for family and home, to hold a job, andto continue the friendships and activities one enjoys.


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Many people feel anxious and depressed. Some people feel angry andresentful; others feel helpless and defeated.

For most people with lymphoma, talking about their feelings and concerns can be helpful.

Friends and family members can be very supportive. They may be hesitant

to offer support until they see how the affected person is coping. If theaffected person wishes to talk about his or her concerns, it is important tolet them know to do so.

Some people don't want to "burden" their loved ones, or they prefer talkingabout their concerns with a more neutral professional. A social worker,counselor, or member of the clergy can be helpful if one wishes to discusstheir feelings and concerns about having lymphoma. The treatinghematologist or oncologist should be able to recommend someone.

Many people with lymphoma are helped profoundly by talking to otherpeople who have lymphoma. Sharing such concerns with others who havebeen through the same thing can be remarkably reassuring. Supportgroups of people with lymphoma may be available through the medicalcenter where one is receiving treatment. TheAmerican Cancer Society alsohas information about support groups all over the United States.

For More Information on Lymphoma

For more information about support groups, contact these agencies:

American Cancer Society: 1-800-ACS-2345

National Cancer Institute, Cancer Information Service: 1-800-4-CANCER[1-800-422-6237]; TTY (for deaf and hard-of-hearing callers) 1-800-332-8615

Leukemia & Lymphoma Society: 1-800-955-4572

Lymphoma Research Foundation: 1-800-500-9976

Web Links

American Cancer Society

Leukemia and Lymphoma Society

Lymphoma Research Foundation


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2012 WebMD, LLC.All rights reserved.eMedicineHealth does not provide medical advice, diagnosis ortreatment. See Additional Information.

National Institutes of Health, National Cancer Institute

Synonyms and Keywords

cancer, cancer of the lymphatic system, lymphatic system, Hodgkins disease, Hodgkin's

disease, Hodgkin lymphoma, Hodgkin's lymphoma, immune system, lymph glands, lymph

nodes, swollen lymph glands, lymphocytes, B lymphocytes, T lymphocytes, B cells, T cells,

lymphadenopathy, lymphatic system, non-Hodgkin's lymphoma, non-Hodgkin's lymphoma,NHL, NHLs, chemotherapy, radiation therapy, radiation, biological therapy, watchful waiting,

stem cell transplantation, enlarged spleen, lymph, tumor, blood cancer, lymphoma

Authors and Editors

Author: Jerry Balentine, DO, FACEP

Editor: Melissa Conrad Stppler, MD, Chief Medical Editor, eMedicineHealth.com

Previous contributing authors and editors:

Author: Wendy Hu, MD, Consulting Staff, Department of Hematology/Oncologyand Bone Marrow Transplantation, Huntington Memorial Medical Center.

Coauthor(s): Kathryn L Hale, MS, PA-C, Medical Writer, eMedicine.com, Inc.

Editors: Clarence Sarkodee-Adoo, MD, Consulting Staff, Department of BoneMarrow Transplantation, City of Hope Samaritan BMT Program; Mary L Windle,Pharm D, Adjunct Assistant Professor, University of Nebraska Medical CenterCollege of Pharmacy; Pharmacy Editor, eMedicine.com, Inc; Samuel Gross, MD,Professor Emeritus, Department of Pediatrics, University of Florida; ClinicalProfessor, Department of Pediatrics, University of North Carolina; Adjunct

Professor, Department of Pediatrics, Duke University.

REFERENCES:

Johnston, J. Martin. "Non-Hodgkin Lymphoma." eMedicine.com. Dec. 5, 2008..

United States. National Cancer Institute. U.S. National Institutes of Health."Non-Hodgkin Lymphoma." Feb. 12, 2008. .

Last Editorial Review: 5/17/2011

http://emedicine.medscape.com/article/987540-overview%3Ehttp://www.cancer.gov/cancertopicshttp://www.emedicinehealth.com/script/main/art.asp?articlekey=58http://www.emedicinehealth.com/script/main/art.asp?articlekey=58http://www.cancer.gov/cancertopicshttp://emedicine.medscape.com/article/987540-overview%3E

lymphoma (hodgkin's disease and non-hodgkin's lymphoma) types, symptoms, prognosis, treatment,...

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