Understanding non-hodgkin lymphoma

In his latest online article, Professor Graham Collins gives us his insight into non-Hodgkin lymphoma. He talks about the early signs and symptoms, the different types, how they are diagnosed, treatment options, side effects, prevention, risk factors and what role do the targeted therapies play in the management of non-Hodgkin lymphoma.

What are the early signs and symptoms of non-Hodgkin lymphoma?

The initial indicators of non-Hodgkin lymphoma typically manifest as an enlarged, painless lump, commonly detected in the neck, armpit, or groin. This lump, often described as rubbery or similar to marbles, signifies an enlarged lymph gland. However, there are diverse ways through which individuals may present symptoms. Enlarged lymph glands in less palpable areas, such as the abdomen, might cause vague discomfort. For instance, a lump in the abdominal region could obstruct bile outflow, leading to jaundice. In some cases, chest discomfort, cough, or breathlessness may result from enlarged lymph nodes in the chest. Additionally, people may not exhibit lump-related symptoms but instead present with systemic manifestations like night sweats, profound fatigue, unexplained weight loss, or an inexplicable fever. In essence, the presence of a lump or the occurrence of systemic symptoms may indicate non-Hodgkin lymphoma.

What are the different types of non-Hodgkin lymphoma and how are they diagnosed?

There are different types of non-Hodgkin lymphoma, and it can be confusing for someone just diagnosed when they look it up online. In simple terms, non-Hodgkin lymphoma falls into two main categories: high grade (aggressive) and low grade (indolent).

High grade lymphomas, like diffuse large B cell lymphoma, grow quickly. Patients with this type can get sick fast, and some end up needing emergency treatment. On the other hand, low grade lymphomas are often discovered when someone notices a lump. They usually feel fine, visit their family doctor, have a biopsy, and find out its low-grade lymphoma. For low grade lymphoma, the common approach is to keep an eye on it without immediate treatment, a method known as "watch and wait."

Treatment approaches differ for high- and low-grade non-Hodgkin lymphomas. High grade lymphomas are treated promptly, and the good news is that treatments often work well, curing about two-thirds of patients. Low grade lymphomas also respond well to treatments, leading to remission for many years, but complete cure is less common. In summary, high- and low-grade non-Hodgkin lymphomas are distinct conditions with different management strategies.

What are the treatment options for non-Hodgkin lymphoma and what are the side effects?

There are various treatment possibilities for non-Hodgkin lymphoma, and the choice depends on several factors. First, it hinges on the specific type and subtype of non-Hodgkin lymphoma the patient has. Additionally, the stage of the disease, indicating where in the body it is located, is a crucial consideration. Finally, the patient's individual factors, such as overall health and ability to tolerate intensive treatment, play a role.

For high-grade non-Hodgkin lymphoma, a common approach involves combinations of chemotherapy drugs, often paired with an antibody treatment called rituximab. The goal is to achieve a cure. Typically, patients undergo several cycles of chemotherapy, administered every three weeks for around six cycles. This regimen aims to completely eliminate the lymphoma, achieving a cure in approximately 60 to 70 percent of cases. If the lymphoma returns, further chemotherapy may be coupled with advanced treatments like CAR T cell therapy, where genetically modified immune cells target and destroy the lymphoma.

Stem cell transplantation is another intensive option for some patients. For indolent or low-grade non-Hodgkin lymphomas, treatment may still involve chemotherapy with antibody treatments, but it tends to be less intense and better tolerated. In cases of early-stage, low-grade disease affecting a specific site, low doses of radiotherapy can be highly effective, potentially leading to long remissions or cures.

As for low-grade lymphomas, especially in relapse situations, non-chemotherapy options like targeted treatments such as ibrutinib or acalabrutinib are becoming more prevalent. These are oral medications taken daily, offering targeted effects with fewer side effects on non-affected tissues in the body.

How can non-Hodgkin lymphoma be prevented and what are the risk factors associated with it?

We don't really know what causes most cases of non-Hodgkin lymphoma. Despite a lot of research, the reasons remain unclear. Unlike some cancers linked to smoking or alcohol, non-Hodgkin lymphoma doesn't seem to be associated with these factors. Even things like sunlight exposure, which are linked to certain cancers, don't play a role in non-Hodgkin lymphoma.

In some specific cases, like gastric malt lymphoma affecting the stomach, a bacteria called H. pylori has been found to cause it. For these cases, antibiotics can be an effective treatment, without the need for chemotherapy or radiotherapy.

There are some risk factors to consider, though. People with weakened immune systems, like those with HIV, organ transplant recipients, or those with autoimmune conditions, have a higher risk of developing non-Hodgkin lymphoma.

As for prevention, it's challenging since we don't know the causes. The focus is on early diagnosis, recognising symptoms like lumps or night sweats, fever, and unintentional weight loss. Seeking medical help early is important, as it's easier to treat the disease when it's diagnosed at an earlier stage. While we can't prevent non-Hodgkin lymphoma, catching it early significantly improves the chances of successful treatment.

What role do the targeted therapies, play in management on non-Hodgkin lymphoma, and how have these treatments evolved in the recent years?

Non-Hodgkin lymphoma treatment has seen significant progress. First-line therapy usually involves a mix of chemotherapy and monoclonal antibodies. But when lymphomas come back, more focused treatments step in. For instance, pills like ibrutinib or acalabrutinib work well for specific types.

Immunotherapy has also made a difference. There's an approach using bispecific antibodies, which help the immune system target and eliminate lymphoma cells. This method is proving effective for both high-grade and low-grade non-Hodgkin lymphomas.

Another immunotherapy method, called CAR T therapy, involves modifying T cells to recognise and attack lymphoma cells. While promising, there are some downsides, like temporary side effects and potential long-term immune system effects.

Despite challenges, these advancements have significantly improved outcomes, especially for high-risk patients with relapsed non-Hodgkin lymphoma.

Professor Graham Collins is an esteemed haematologist with over 20 years of experience. You can schedule an appointment with Professor Collins on his Top Doctors profile.