Non-Hodgkin's Lymphoma

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Questions to Ask Your Doctor About Your Cancer
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Non-Hodgkin's Lymphoma Treatment

Treatment for non-Hodgkin's lymphoma (NHL) depends on the type, location, grade, and stage of disease, as well as the patient's age and overall health.

Localized, early-stage NHL
If the patient is diagnosed with localized, slow-growing, early stage (Stages 1 or 2) NHL, radiation therapy is the main form of treatment.

Nonlocalized, late-stage NHL
If the patient has nonlocalized, slow-growing, late stage (Stages 3 or 4) NHL, the treatment plan is not so well defined. Because of the unhurried growth of such tumors, chemotherapy and radiotherapy - which selectively destroy rapidly-dividing cells - cannot eliminate all of the patient's cancer cells. Therefore, these tumors usually are not "curable." In spite of this, treatment options may include single agent chemotherapy, or combination chemotherapy, or chemotherapy plus radiation therapy.

In addition, some physicians and patients may choose to delay treatment until symptoms appear, especially with elderly patients or in those who have significant health problems. Yet, recent findings suggest that the patient's survival is improved when treatment is begun soon after diagnosis.

Waldenstrom's macroglobulinemia
If the patient is diagnosed with a slow-growing NHL that is associated with Waldenstrom's macroglobulinemia - a condition in which too much of the antibody immunoglobulin M [IgM] is produced - the physician may recommend plasmapheresis before treatment of the NHL with chemotherapy. Plasmapheresis involves separating the plasma and its components, including IgM, from the blood, with eventual re-transfusion into the patient.

Aggressive, early-stage NHL
Patients who have aggressive, intermediate-grade NHLs in early stages (Stages 1 or 2) usually are treated with combination chemotherapy, or radiation therapy plus chemotherapy. If the individual has health problems that do not permit the use of chemotherapy, radiation therapy may be used alone.

Aggressive, late-stage NHL
Patients who have aggressive, intermediate-grade NHLs in late stages (Stages 3 or 4) may be treated with combination chemotherapy (plus radiation therapy for individuals with bulky tumors), or high-dose chemotherapy with stem cell transplantation.

In addition, patients may be given growth factors to aid the recovery of bone marrow cells and prevent infections after chemotherapy treatment.

Highly aggressive NHL
Patients who have highly aggressive, high-grade NHLs such as Burkitt's lymphoma, Burkitt's-like lymphoma, and lymphoblastic lymphoma are treated with intrathecal chemotherapy - chemotherapy injected directly into the spinal fluid - to prevent the spread of cancer to the brain and central nervous system (CNS).

Unfortunately, some patients may have certain conditions or characteristics that make them less responsive to such treatment. In these cases, the oncologist may recommend high-dose chemotherapy with stem cell transplantation or biological therapies.

Patients with acute T-cell leukemia/lymphoma generally have a poor prognosis. New antiviral drugs for HIV (human immunodeficiency virus) infection have shown some activity against this lymphoma. This is because HIV is related to HTLV-1 (human T-cell leukemia/lymphoma virus) - the virus that is associated with human T-cell lymphoma.

Central Nervous System NHL
Some people - particularly those with immune system disorders caused by AIDS or the anti-rejection medications used for organ transplants - develop lymphomas that arise in the central nervous system (CNS). Such primary CNS lymphomas (PCNSL) initially may benefit from treatment with prednisone, or radiation therapy. Without radiation therapy, all patients with AIDS-related lymphoma develop progressive disease. Unfortunately, though, CNS lymphoma tends to recur within a short period of time (e.g., 1 to 2 years).

The majority of patients with AIDS-related PCNSL are diagnosed with immunoblastic or large cell lymphoma. Researchers currently are examining alternative forms of treatment for PCNSL. Individuals with a better performance status, no history of infection, and lower stages of NHL, may be able to tolerate more aggressive treatments, including systemic chemotherapy.

Gastric (stomach) NHL
It is now known that gastric NHLs are associated with Helicobacter pylori - the bacteria that are responsible for stomach ulcers. The infection and inflammation caused by these bacteria are believed to spur an abnormal immune system response by stomach lymphocytes. In some individuals, this response may lead to the development of a gastric NHL. Treatment of low-grade gastric NHL with antibiotics (e.g., ampicillin, metronidazole) may shrink and/or completely rid the stomach of tumor.

Yet, if gastric NHL returns, chemotherapy, radiation therapy, and/or surgical resection (cutting away) of the tumor may be necessary. The choice of therapy depends upon the type of NHL. Slow-growing, mucosa-associated lymphoid tissue (MALT) tumors will be treated differently from more aggressive, high-grade lymphomas.

Cutaneous (skin) NHL
Lymphoma that arises in the skin is known as primary cutaneous (skin) lymphoma. Cutaneous lymphomas include cutaneous T-cell lymphoma (CTCL; also known as mycosis fungoides) Sézary syndrome, and other T-cell and B-cell lymphomas. The management of these tumors - which are primarily T-cell in type - differs from the treatment of most other NHLs. A biopsy may be required to confirm a diagnosis of cutaneous lymphoma, which can produce symptoms such as redness, thickening, generalized plaques (patches), or nodules (knot-like lumps).

CTCL may be treated by a variety of methods that directly involve the skin. These include:

• Topical (applied to the skin) chemotherapy
• Electron beam radiation therapy (radiation of the skin surface), a form of radiation that does not penetrate too deeply and thereby does not damage organs below the skin
• Psoralen plus ultraviolet light (PUVA) therapy - Psoralen is a drug that can make cells light-sensitive. It is taken orally, and then the patient's skin is exposed to ultraviolet light. During PUVA therapy, CTCL cells take up psoralen and are selectively killed by light exposure.

If NHL has spread to the lymph nodes and other organs beyond the skin, other treatments will be required, such as systemic chemotherapy or biological therapies with substances such as interferon, monoclonal antibodies, cis-retinoic acid (a chemical relative of vitamin A), or other new compounds, such as cytotoxic fusion protein, a protein that binds to cancers cells and causes them to die.

Extranodal NHL
"Primary extranodal NHL" refers to a lymphoma that arises outside of the lymph nodes in an organ that is considered to be the major site of disease. Typical locations for extranodal NHLs are the sinuses, thyroid, tonsil, salivary gland, eye/eye socket, breast, testis, kidney, lung, stomach, and bowel. Surgery has a controversial role in the management of extranodal NHL. In general, such cancers are not cured by surgery alone, although resection of the tumor may be helpful if the disease remains confined. If the extranodal NHL has spread to other locations, the physician may recommend treatment by chemotherapy, with/without radiation therapy.

Recurrent NHL
Low-grade NHLs that come back after a remission (a period in which cancer is not detectable) usually are treated with chemotherapy, or chemotherapy plus radiation therapy.

Unfortunately, up to one-third of all low-grade NHLs will change into aggressive lymphomas. In such cases, the cancer becomes fast-growing and endangers the patient's life. Therefore, treatment of transformed NHLs usually consists of combination chemotherapy, or high-dose chemotherapy with stem cell transplantation.

For more information on therapies for the Non-Hodgkin's Lymphomas, please speak with your physician. Open communication leads to improved care. Ask questions and become more informed about your condition. Participation in your health care is essential; become an informed consumer.

Clinical Trials
Many advances are being made in the treatment of NHL. However, continued advances in the field depend upon the participation of patients in clinical trials. Through the use of clinical trials improved treatment outcomes and the development of more risk appropriate strategies can be secured. It is possible participation in a clinical trial may help you and the next unfortunate individual who will be diagnosed in the future. Please consider any clinical trial, which your physician may discuss with you. If clinical trial participation is not discussed, please ask your physician if there any trials for which you may be eligible for participation.

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