Lymphoma

Types of Lymphoma

Hodgkin Lymphoma (HL)

Hodgkin lymphoma accounts for about 10% of all lymphomas. It is characterized by the presence of Reed-Sternberg cells (large, abnormal lymphocytes) seen under a microscope.

• Classical Hodgkin lymphoma (95%)
  • Nodular sclerosis (most common, 60-70%)
  • Mixed cellularity (20-25%)
  • Lymphocyte-rich (5%)
  • Lymphocyte-depleted (rare, <1%)
• Nodular lymphocyte-predominant HL (5%)

Non-Hodgkin Lymphoma (NHL)

Non-Hodgkin lymphoma is much more common, accounting for about 90% of lymphomas. There are more than 70 different subtypes, classified by how fast they grow:

Indolent (slow-growing) NHL:

• Follicular lymphoma (20% of all NHL) - slow-growing, usually responds well to treatment
• Marginal zone lymphoma - includes MALT lymphoma, often associated with H. pylori infection
• Small lymphocytic lymphoma (SLL) - similar to chronic lymphocytic leukemia

Aggressive (fast-growing) NHL:

• Diffuse large B-cell lymphoma (DLBCL) (30-40% of all NHL) - most common type, usually curable with treatment
• Mantle cell lymphoma - moderately aggressive, newer treatments improving outcomes
• Burkitt lymphoma - very aggressive but highly curable with intensive chemotherapy
• Peripheral T-cell lymphomas - group of aggressive T-cell cancers

Signs and Symptoms

Common symptoms of lymphoma include:

• Swollen lymph nodes - painless lumps in the neck, armpit, or groin that don't go away
• B symptoms (present in 30-40% of cases):
  • Night sweats (drenching, requiring change of clothes)
  • Unexplained fever (>38°C / 100.4°F)
  • Unintentional weight loss (>10% of body weight in 6 months)
• Persistent fatigue
• Itching all over the body (pruritus)
• Shortness of breath or cough (if lymphoma affects chest)
• Abdominal pain or swelling (if lymphoma affects abdomen)

Diagnosis

Diagnosing lymphoma involves several tests:

Biopsy

• Lymph node biopsy - removing part or all of a lymph node for examination (gold standard)
• Excisional biopsy - entire lymph node removed (preferred)
• Core needle biopsy - sample taken with a needle (if excisional not possible)
• Pathologist examines tissue under a microscope and performs special tests

Additional Tests

• Immunohistochemistry - identifies specific proteins on cancer cells
• Flow cytometry - analyzes cell surface markers
• Cytogenetic tests - looks for chromosome changes (e.g., t(14;18) in follicular lymphoma)
• Blood tests - CBC, LDH, beta-2 microglobulin, liver and kidney function
• Imaging:
  • PET/CT scan - standard for staging and treatment response
  • CT scan of chest, abdomen, and pelvis
• Bone marrow biopsy - checks if lymphoma has spread to bone marrow

Staging

Lymphoma is staged using the Ann Arbor staging system (modified Lugano classification):

Additional modifiers:

• A - no B symptoms present
• B - B symptoms present (fever, night sweats, weight loss)
• E - extranodal (involves organ adjacent to involved lymph nodes)
• S - spleen involvement

For example: "Stage IIIB" means lymph nodes on both sides of diaphragm with B symptoms present.

Treatment Options

Hodgkin Lymphoma Treatment

Early-stage (I-II):

• ABVD chemotherapy (Adriamycin, Bleomycin, Vinblastine, Dacarbazine)
  • 2-4 cycles depending on risk factors
  • Most common regimen, cure rate 85-90%
• Involved-site radiation therapy (ISRT) may be added (20-30 Gy)

Advanced-stage (III-IV):

• ABVD for 6 cycles (standard)
  • Cure rate 70-80%
  • PET scan after 2 cycles guides treatment decisions
• Escalated BEACOPP (for high-risk disease)
  • More intensive but higher cure rates
  • More side effects, used selectively
• Brentuximab vedotin (Adcetris) - antibody-drug conjugate targeting CD30
  • Can replace bleomycin in A+AVD regimen
  • Reduces lung toxicity risk

Relapsed/Refractory:

• Salvage chemotherapy (ICE, DHAP, GDP regimens)
• Autologous stem cell transplant (for eligible patients)
• Brentuximab vedotin
• Checkpoint inhibitors (pembrolizumab, nivolumab)

Non-Hodgkin Lymphoma Treatment

DLBCL (Diffuse Large B-Cell Lymphoma):

• R-CHOP (standard first-line treatment)
  • Rituximab (monoclonal antibody)
  • Cyclophosphamide
  • Doxorubicin (Hydroxydaunorubicin)
  • Vincristine (Oncovin)
  • Prednisone
  • Given every 21 days for 6 cycles
  • Cure rate 60-70%
• Radiation therapy may be added for localized disease
• CNS prophylaxis - for high-risk patients (intrathecal chemotherapy)

Follicular Lymphoma (indolent):

• Watch and wait (active surveillance) for asymptomatic, low-burden disease
  • No survival benefit to early treatment
  • Quality of life consideration
• When treatment needed:
  • R-CHOP or R-bendamustine (rituximab + bendamustine)
  • Rituximab maintenance for 2 years after initial treatment
  • Radiation for localized disease
• Generally not curable but very treatable with long survival (median >10 years)

Mantle Cell Lymphoma:

• Intensive induction: R-hyperCVAD or R-CHOP
• Autologous stem cell transplant for eligible patients (in first remission)
• Rituximab maintenance
• BTK inhibitors (ibrutinib, acalabrutinib) for relapsed disease

Stem Cell Transplant

• Autologous transplant - uses your own stem cells
  • Standard for relapsed Hodgkin lymphoma
  • Option for relapsed aggressive NHL
  • Cure rates 40-60% for relapsed disease
• Allogeneic transplant - uses donor stem cells
  • Reserved for specific situations (multiple relapses, high-risk disease)
  • Higher risk but potentially curative for resistant disease

Novel Therapies

• CAR-T cell therapy (axicabtagene ciloleucel, tisagenlecleucel)
  • For relapsed/refractory DLBCL after 2+ prior therapies
  • Response rates 50-80%
  • One-time treatment, potential for long-term remission
• BTK inhibitors (ibrutinib, acalabrutinib) - for mantle cell and marginal zone lymphomas
• Checkpoint inhibitors (pembrolizumab, nivolumab) - especially for Hodgkin lymphoma
• Bispecific antibodies - newer targeted therapies in development

Prognosis

Hodgkin Lymphoma

• Overall 5-year survival: 85-90%
• One of the most curable cancers
• Early-stage: 90-95% cure rate
• Advanced-stage: 70-80% cure rate
• Even relapsed disease is often curable with transplant

Non-Hodgkin Lymphoma

Prognosis varies widely by subtype:

Prognostic Tools

International Prognostic Index (IPI) for aggressive NHL:

One point for each factor:

• Age >60 years
• Stage III or IV disease
• Elevated LDH (>normal)
• ECOG performance status ≥2
• More than 1 extranodal site

Risk groups:

• Low risk (0-1 points): 5-year survival ~90%
• Low-intermediate (2 points): ~75%
• High-intermediate (3 points): ~60%
• High risk (4-5 points): ~50%

Treatment Side Effects

Common Chemotherapy Side Effects

• Nausea and vomiting (well-controlled with modern anti-nausea medications)
• Hair loss (temporary, regrows after treatment)
• Fatigue
• Low blood counts
  • Increased infection risk (may need G-CSF support)
  • Anemia (may need transfusions)
  • Bleeding risk (low platelets)
• Neuropathy (numbness/tingling from vincristine)
• Heart problems (doxorubicin - heart function monitored)

ABVD-Specific Concerns

• Bleomycin lung toxicity - monitor with pulmonary function tests, chest X-rays
• Risk factors: age >40, smoking, high cumulative dose
• May switch to AVD (without bleomycin) if lung problems develop

Rituximab Side Effects

• Infusion reactions (fever, chills, rash) - usually first dose only
• Increased infection risk (B-cell depletion)
• Hepatitis B reactivation (screening required before treatment)

Long-term Effects

• Second cancers (small risk, 10-20 years after treatment)
• Heart disease (from chest radiation or doxorubicin)
• Infertility (discuss fertility preservation before treatment)
• Thyroid problems (from neck/chest radiation)

Living with Lymphoma

During Treatment

• Infection prevention - wash hands frequently, avoid crowds during low counts
• Nutrition - eat well-balanced meals, stay hydrated
• Exercise - gentle activity as tolerated (reduces fatigue)
• Support - lean on family, friends, support groups

Follow-up After Treatment

• First 2 years: visits every 3 months with physical exam, blood tests
• Years 3-5: visits every 6 months
• After 5 years: annual visits
• PET/CT scans at end of treatment, then as clinically indicated
• Monitor for late effects of treatment

Signs of Recurrence

Contact your doctor if you notice:

• New or growing lumps
• Return of B symptoms (fever, night sweats, weight loss)
• Persistent fatigue
• New pain or swelling

Current Research

• CAR-T cell therapy - expanding to earlier lines of treatment
• Bispecific antibodies - engaging immune system to fight lymphoma
• Checkpoint inhibitors - combination strategies
• Reduced-intensity regimens - maintaining cure rates with less toxicity
• Genomic profiling - personalized treatment based on tumor genetics
• Minimal residual disease (MRD) testing - detecting tiny amounts of disease to guide treatment

Frequently Asked Questions

Is lymphoma hereditary?

Most cases of lymphoma are not hereditary. While having a first-degree relative with lymphoma slightly increases your risk, the vast majority of lymphoma patients have no family history. There are no specific genes that cause lymphoma to run in families like BRCA genes do for breast cancer.

Can lymphoma be cured?

Yes, many types of lymphoma are curable. Hodgkin lymphoma has cure rates of 85-90%, and aggressive NHLs like DLBCL can be cured in 60-70% of patients. Even when indolent lymphomas like follicular lymphoma cannot be cured, patients can live for many years (often decades) with excellent quality of life.

What's the difference between Hodgkin and non-Hodgkin lymphoma?

The main difference is the presence of Reed-Sternberg cells, which are found in Hodgkin lymphoma but not in non-Hodgkin lymphoma. Hodgkin lymphoma tends to spread in a more predictable pattern and is generally more curable. Non-Hodgkin lymphoma includes many different subtypes with varying behaviors and treatments.

How long does lymphoma treatment take?

Treatment duration varies by type. ABVD for Hodgkin lymphoma is typically 2-6 months (4-12 cycles). R-CHOP for DLBCL is usually 4-6 months (6-8 cycles given every 3 weeks). Indolent lymphomas may require longer treatment, and some patients receive maintenance therapy for 2 years.

Will I lose my hair?

Most lymphoma chemotherapy regimens cause complete hair loss, including ABVD and R-CHOP. Hair typically begins falling out 2-3 weeks after starting chemotherapy. The good news is that hair almost always grows back after treatment ends, sometimes with a different texture or color initially.

Can I work during treatment?

Many patients are able to work during treatment, though you may need to reduce hours or take time off, especially during the first few days after each chemotherapy cycle when side effects are worst. It depends on your job's physical demands, your treatment regimen, and how you feel. Discuss with your employer about flexible arrangements.

Should I change my diet?

No special diet is required, but eating well-balanced, nutritious meals helps your body handle treatment. During chemotherapy, you may need to avoid raw or undercooked foods when your white blood cell counts are low. Focus on getting enough protein and calories. A dietitian can provide personalized advice.

What is the role of PET scans?

PET/CT scans are the gold standard for staging lymphoma and assessing treatment response. For Hodgkin lymphoma, an interim PET scan after 2 cycles of chemotherapy helps determine if treatment is working and whether changes are needed. End-of-treatment PET scans help confirm remission. Not all lymphoma types are PET-avid (visible on PET scan).

What happens if my lymphoma comes back?

Relapsed lymphoma is still often treatable and potentially curable. Options include different chemotherapy regimens, stem cell transplant (especially for Hodgkin lymphoma and aggressive NHL), CAR-T cell therapy, targeted therapies, or clinical trials. Many patients achieve long-term remission even after relapse.

How often will I need blood tests?

During active chemotherapy, you'll typically have blood tests before each treatment cycle (every 2-3 weeks) to check your blood counts and make sure it's safe to proceed. Between treatments, you may need additional blood tests if you develop fever or other symptoms. After completing treatment, blood tests are done at each follow-up visit (every 3-6 months initially).