An expert guide to non-Hodgkin's lymphoma

It's an understatement to say it's a shock to learn you have a lymphoma. However, when it comes to life after this news, you may want to discover more about the specific type of tumour you have as they come in two main forms; Hodgkin's and non-Hodgkin's lymphoma.

Here to differentiate the two is leading consultant haematologist Dr David Wrench. In this informative article, he provides those with lymphoma a detailed insight to both types alongside further information about Hodgkin's lymphoma. Read on to find out more.

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

The difference between Hodgkin's and non-Hodgkin's lymphoma is firstly, the similarity is that they're both types of cancer and lymphoma but the difference is that then when we take specimens from them, they have different appearances under the microscope and different features and molecular changes. Also, at a clinical level, as in how the patient is affected, they can be slightly different, too.

Non-Hodgkin's lymphoma is a very diverse group of disorders, from very indolent or low-grade diseases that, if you like, bumble along and may not adversely impact the patient physically, and to far more aggressive, rapid presentations that may make a patient unwell if they aren't treated promptly. There are very diverse populations of disorders in non-Hodgkin's lymphomas, whereas the Hodgkin's are a smaller cohort and less common set of disorders. They can present in similar ways but the non-Hodgkin lymphomas are very diverse.    

What symptoms can non-Hodgkin's lymphoma have?

Most commonly they do present with lumps and that are lumps in the body, typically in the neck, the armpits or the groins because that's where we have our lymph nodes that we can feel. We've lymph nodes normally throughout our bodies, but these are the areas we might notice first and if the non-Hodgkin lymphoma, that is a type of cancer, involves these, then that process of unregulated growth of the cells can lead to increasing size of the nodes and the presentation as the lump.

They can cause sweats, fevers and weight loss that unexplained; patients may be losing weight or having sweats at night. They may also affect any area of the body, so they may affect the skin, they may affect inside the body and patients may present with symptoms in the chest, sometimes a cough or breathing issues, or in their abdomen or tummy; they may have symptoms there because of the site of that lymphoma affecting different bits of the body. 

How is non-Hodgkin's lymphoma diagnosed?

Non-Hodgkin's lymphoma is diagnosed typically with what we call a biopsy. That's when we take a solid specimen from what we call a representative site of what we think might be lymphoma or another cause of a lump, of course, because not all lumps are lymphoma.

It's critical to have what we call a biopsy specimen and to emphasise that, the earlier that patients present with lumps and the earlier we get the chance to take a biopsy for diagnosis. We firmly believe that overall, for our patients, the earlier that we can give treatment, the better outcomes we will have.

So, while a lump or mass biopsy is typically the upfront diagnostic aspect, the way we do that can vary. Ideally, we'll ask for surgical excision biopsy which is a mini operation, but realistically, and certainly in my practice and most of my colleagues, we tend to use core needle biopsies. If you can feel a see a lump that is safe to do, we'll have a radiology colleague, with an ultrasound probe with numbing agents and local anaesthetic, take some tissue with a special needle. The patient can then go home on the same day and then within a week or so, we get results and that can give us diagnosis.

That's a far more tolerable process for the patient, of course, for the laboratory colleagues of mine, it's less specimen so while better for the patient, it's sometimes harder to diagnose so sometimes we ask for a second biopsy in these situations to make sure. This is a challenge.

We also may do a bone marrow test. That's less common nowadays because we generally get the diagnosis from a mass and sometimes interrogate the blood, so blood tests can actually, occasionally, not often, reveal certain lymphomas and relatives of lymphomas. We may need to take some other specimens from different bits of the body less commonly.

Can it be treated? How?

Non-Hodgkin's lymphoma certainly can be treated. How it's treated, there's a myriad of ways. The number one thing to consider is we are very pro-clinical trials. They're the way medicine advances and that's the way we have treatments now from over the years, and it's the way that we can improve and develop treatments and management for patients. So, we will always, if possible, consider and offer a clinical trial. Patients are not obligated to go on a trial but we strongly encourage them to at least consider that.

Many cases of non-Hodgkin's lymphoma may not need treatment, so if that cancer is called an indolent, or low-grade, Hodgkin's lymphoma, as opposed to one of the more aggressive ones, there's a reasonable chance upfront where we can pursue 'active monitoring' which is a surveillance program that used to be called 'watch and wait' and now we call that process 'active monitoring', and it doesn't involve treatment. At some point in the future, that patient may need treatment, but initially, often it's safe and appropriate, and doesn't impact anything like survival, for example, if we adopt that approach.

To be fair, most non-Hodgkin’s lymphomas either need treatment immediately or after some time, and that treatment can be diverse. There are various different types; antibiotics can actually cure certain types of lymphoma, particularly in the stomach. Well-tolerated, effective chemotherapy is used across many different lymphomas. Immunotherapy which is typically monoclonal antibodies, which are, if you like, factory-made antibodies similar to what we produce ourselves to fight infection. These are produced to fight the cancer that can be given to patients. Radiotherapy has a role to play in many types of non-Hodgkin's lymphoma, and these different combinations of these treatments can be utilised across different subtypes of non-Hodgkin’s lymphoma.

Novel, or new, therapies coming through include targeted molecular therapies, and there's using cellular therapies. So, sometimes patients need something called a transplant. That can be from themselves to support chemotherapy to eradicate a lymphoma or from a donor to try and get rid of a resistant lymphoma. There are novel therapies such as CAR T-cell therapy (chimeric antigen receptor), which is becoming increasingly used and have become a standard of care in certain, relatively uncommon scenarios, but are proving very effective. There are many different treatments that do have side effects but which we can manage very well so the treatments we can apply are effective overall and can be managed so they are generally tolerable to patients.

How effective is treatment for non-Hodgkin's lymphoma?

Non-Hodgkin's lymphoma is a very diverse group of disorders. There are over sixty different types of non-Hodgkin's lymphoma but treatment is increasingly effective. There are very different treatments for different types of lymphoma, but generally, they are very effective for most lymphomas. The different types of treatment are applied and sometimes we do need more than one treatment.

Certain types of lymphoma have a history of waxing and waning; being treated, then going away, and coming back again. That may be measured in years and, actually in decades for some of the indolent lymphomas. Whereas the more aggressive ones are curable. The more indolent ones we generally term 'incurable', which sounds dramatic but actually that statement 'incurable, if a patient is well without the disease causing symptoms or problems, and either not needing treatment or responding to treatment for years or even decades, then whilst technically incurable, it may not impact our quality of life and hopefully enable them to function very well and hopefully forget about people like me between appointments. 

If you've concerns surrounding Hodgkin's lymphoma, lymphomas or other haematology conditions, arrange a consultation with Dr Wrench via his Top Doctors profile.