Hematologic Malignancies Program

Non-Hodgkin's Lymphoma

Stages and Treatments

If a patient has non-Hodgkin's lymphoma, the doctor will do more tests to find out if cancer cells have spread from where the cancer started to other parts of the body. This process is called staging. In order to plan a patient's treatment, the doctor needs to know the stage of the disease.

A doctor may determine the stage of the disease by examining the patient, doing blood and bone marrow tests, and taking x-rays called computed tomographic (CT or CAT) scans that produce an image of the inside of the body. This type of staging is called clinical staging.

In some cases, the doctor may need to do an operation called a laparotomy to determine the stage of the cancer. During this operation, the doctor cuts into the abdomen and carefully looks at the organs inside to see if they contain cancer. The doctor will cut out (biopsy) small pieces of tissue during the operation and look at them under a microscope to see whether they contain cancer. This type of staging is called pathologic staging. Pathologic staging is usually done only when it is needed to help the doctor plan treatment.

A number of factors are important in determining the stage of non-Hodgkin's lymphoma as well as the patient's chances of recovering from the disease. These include the patient's age and responsiveness to treatment, the size of the tumor, and the number of places the tumor has spread outside of the lymph nodes.

The following stages are used to describe non-Hodgkin's lymphoma:

Stage I: Cancer is found in only one lymph node area or in only one area or organ outside of the lymph nodes.

Stage II: Either of the following may be true:

Cancer is found in two or more lymph node areas on the same side of the diaphragm (the thin muscle under the lungs that helps us breathe).
Cancer is found in only one area or organ outside of the lymph nodes and in the lymph nodes around it. Other lymph node areas on the same side of the diaphragm may also have cancer.

In contiguous stage II cancer, the positive lymph node areas are next to one another; in non-contiguous stage II, the positive lymph nodes are not next to each other, but are still on the same side of the diaphragm.

Stage III: Cancer is found in lymph node areas on both sides of the diaphragm. The cancer may also have spread to an area or organ near the lymph node areas and/or to the spleen.

Stage IV: Either of the following may be true:

Cancer has spread in more than one spot to an organ or organs outside the lymph system. Cancer cells may or may not be found in the lymph nodes near these organs.
Cancer has spread to only one organ outside the lymph system, but lymph nodes far away from that organ are involved.

Recurrent: Recurrent disease means that the cancer has come back after it has been treated. It may come back in the area where it first started or in another part of the body.

Treatment Options

There are three primary treatment options for patients with non-Hodgkin's lymphoma:

radiation therapy
chemotherapy
biological therapy

Bone marrow transplantation is being tested in clinical trials.

Radiation Therapy

Radiation therapy is the use of high-energy x-rays to kill cancer cells and shrink tumors. Radiation for non-Hodgkin's lymphoma usually comes from a machine outside the body (external-beam radiation therapy). Radiation therapy given to the neck, chest, and lymph nodes under the arms is called radiation therapy to a mantle field. Radiation therapy given to the mantle field and to the lymph nodes in the upper abdomen, the spleen, and the lymph nodes in the pelvis is called total nodal irradiation. Radiation given to the brain to keep the cancer cells from growing there is called cranial irradiation. Radiation therapy may be used alone or in addition to chemotherapy.

The most common side effects of radiation therapy are tiredness, skin reactions in the treated areas (such as a rash or redness), and loss of appetite. Radiation therapy may also cause a decrease in the number of white blood cells that help protect the body against infection. Most of these side effects can be treated or controlled and in most cases they are not permanent.

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Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Most anticancer drugs are injected into a vein (IV) or a muscle; some are given by mouth. Chemotherapy is a systemic treatment, meaning that the drugs flow through the bloodstream to nearly every part of the body to kill cancerous cells. It is generally given in cycles; a treatment period is followed by a recovery period, then another treatment period, and so on. To treat certain types of non-Hodgkin's lymphoma that spread to the brain, chemotherapy may be put into the fluid that surrounds the brain through a needle in the brain or back (intrathecal chemotherapy).

Chemotherapy drugs generally fight rapidly dividing cells in the body. Cells that divide rapidly include both the targeted cancer cells and healthy cells in the blood, digestive tract, and hair follicles. Depending on which anticancer drugs a patient receives, he or she may experience symptoms when healthy cells are damaged along with the cancer cells. If healthy blood cells are destroyed by chemotherapy, the patient may be more susceptible to infections, bruising or bleeding, and fatigue. When cells in the hair roots or digestive tract are affected by anticancer drugs, the patient may have hair loss, nausea, vomiting, or mouth sores. Not all chemotherapy patients develop all of these side effects, and the symptoms usually go away during the recovery period or after the treatments are done. Doctors can prescribe medicines and other treatments to control most of the symptoms.

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Biological Therapy

Biological therapy tries to help the body fight cancer or infections. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. Biological treatment is sometimes called biological response modifier (BRM) therapy.

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Bone Marrow Transplant

A bone marrow transplant is a treatment in which a patient's diseased bone marrow is replaced with healthy bone marrow. A bone marrow transplant using marrow from a relative or person not related to the patient is called an allogeneic bone marrow transplant. The transplant includes the following steps:

First, all of the bone marrow in the patient's body is destroyed with high doses of chemotherapy with or without radiation therapy.
Healthy marrow is then taken from another person (a donor) whose tissue is the same or almost the same as that of the patient. The donor may be a twin (the best match), a brother or sister, or a person who is not related.
The healthy marrow from the donor is then given to the patient through a needle in the vein, and the new marrow replaces the original marrow that was destroyed.

Another type of bone marrow transplant, called an autologous bone marrow transplant, is conducted in the following steps:

First, bone marrow is taken from the patient and treated with drugs to kill any cancer cells.
The treated marrow taken from the patient is then frozen and saved
Next, high-dose chemotherapy is given to the patient with or without radiation therapy to destroy all of the remaining marrow.
The frozen, treated marrow is then thawed and given back to the patient through a needle in a vein to replace the marrow that was destroyed.

Another type of autologous transplant is called a peripheral blood stem cell transplant. The patient's blood is passed through a machine that removes the stem cells (immature cells from which all blood cells develop) and then returns the blood to the patient. This procedure is called leukapheresis and usually takes three or four hours to complete. The stem cells are treated with drugs to kill any cancer cells and then frozen until they are transplanted to the patient. This procedure may be done alone or with an autologous bone marrow transplant.

Patients have a greater chance of recovery if they are treated in a hospital that does more than five bone marrow transplants a year.

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This page was last updated on: March 3, 2008.