Lymphoma and haematological (blood) cancer
Lymphoma is a cancer of the lymphoid tissue, which is part of the body’s immune (defensive) system. Lymphoma can affect any part of the body, but normally starts as a swelling of one or more lymph nodes (glands). If these swellings develop in the neck, armpits or groins then they are usually easy to feel, but lymph nodes are also found in deeper areas such as the chest and abdomen and swellings in these areas are more difficult to diagnose. It is important to remember that swellings of lymph nodes can occur for a number of reasons and that most are not due to cancer. Swellings of lymph nodes in the neck are particularly common in people who have throat infections and in young people with glandular fever.
Lymphoma can also present with more general symptoms such as fatigue, weight loss, heavy night sweats or chest, back or abdominal pain.
Types of lymphoma
There are two main types of lymphoma;
• Hodgkin’s lymphoma
• Non-Hodgkins lymphoma
Hodgkin’s lymphoma makes up around 20% of lymphoma cases. It can occur at any age, but is the type of lymphoma which is most common in teenagers and young adults. Most cases present with lymph node swelling and are more often early stage (stage 1 or 2 – see below).
Non-Hodgkin’s lymphoma (NHL) makes up around 80% of lymphoma cases. It can occur at any age, but is most common in late middle age and the elderly. NHL usually causes enlargement of lymph nodes, but is more likely than Hodgkin’s lymphoma to involve other parts of the body, such as the liver, lungs or bones. NHL can be divided into 2 main groups, high grade and low grade. High grade NHL is more likely to cause rapidly enlarging swellings and symptoms such as weight loss whereas low grade NHL is more likely to cause slowly enlarging lymph node swellings at several sites.
Making the diagnosis
You are most likely to have a scan at first to discover whether there is enlargement of lymph nodes or abnormality of any other part of the body. This may be an ultrasound scan, which is often used to look at one area of the body where there are symptoms. CT scans are very useful to investigate people with possible lymphoma, they can cover a wide area, from the neck to the groins, in one quick scan, and can look at deep areas of the body which are otherwise difficult to see. However, a biopsy is almost always needed to make a diagnosis of lymphoma.
Types of biopsy
Surgical biopsy – a small operation is performed to remove a piece of tissue. One advantage of this technique is that a larger sample is obtained (often a whole lymph node) which is the most accurate method of diagnosis, however it will leave a scar. It is usually performed as a day case, with general anaesthetic.
Ultrasound or CT guided biopsy – the scan is used to guide a hollow needle into the tissue to obtain a sample. This is usually performed with local anaesthetic and can be performed as an outpatient or day case. The sample is smaller than with a surgical biopsy, but is usually accurate for diagnosis. The procedure leaves a tiny scar which is usually hardly noticeable.
Bone marrow biopsy (trephine) – certain types of lymphoma can involve the bone marrow without causing any symptoms. Samples of bone marrow are usually taken from the iliac crest (the large bone at the back of the pelvis) using a hollow needle under local anaesthetic. This is usually done without a scan for guidance, but if CT scans show an abnormal area of bone then CT can be used to direct the needle. Bone marrow biopsy can be uncomfortable and is usually performed as a day case with sedation.
Staging of lymphoma
Lymphoma is staged as follows:
Stage 1 – lymphoma in one group of lymph nodes
Stage 2 – lymphoma in two or more groups of nodes, on one side of the diaphragm
Stage 3 – lymphoma in two or more groups of nodes, on both sides of the diaphragm
Stage 4 – lymphoma in tissues other than lymph nodes eg. In the liver, lungs or bones (occasionally if only one area of tissue is involved this can still be stage 1 or 2)
How is lymphoma staged?
A CT scan of the chest, abdomen and pelvis is usually performed when there is a suspected diagnosis of lymphoma and in most cases of low grade NHL this is enough for accurate staging.
In Hodgkin’s lymphoma and high grade NHL, a PET-CT scan is the most accurate scan for staging. This type of scan combines CT with an injection of a radioactive tracer (18F-FDG) which highlights areas of active lymphoma.
Why is accurate staging of lymphoma important?
Both the stage and the exact type of lymphoma have a major effect on what type of treatment is most suitable for each case.
What is the treatment?
Most patients with Hodgkin’s lymphoma or high grade NHL require treatment with chemotherapy alone (Hodgkin’s) or chemotherapy combined with an antibody drug (high grade NHL). The chemotherapy used is a combination of several drugs, which have a variety of side effects including a drop in white blood count which can lead to an increased risk of infection.
Occasionally, early stage lymphoma is treated with radiotherapy to the involved site alone, with no chemotherapy required.
Radiotherapy is also sometimes given at the end of chemotherapy, this is usually given when a swelling does not completely disappear after the initial treatment, to reinforce the effect of the chemotherapy.
Sometimes, particularly in low grade NHL, no treatment is needed when the diagnosis is first made. Swellings may remain stable or be slow growing and only need treatment when they become troublesome.
How is treatment monitored?
A CT or PET-CT scan is usually performed at the end of treatment to assess how well the tumour has shrunk and whether any further treatment is needed. In some cases, a CT or PET-CT scan is performed part way through the treatment and adjustments may be made according to the results.
What other tests may be necessary?
In some cases, MRI scans may be performed to examine a particular area in more detail. Examples of this are scans of the brain or spine if there are neurological symptoms or back pain.
Relapse of lymphoma
In most cases of Hodgkin’s disease and high grade NHL, the initial treatment is curative. However, in some cases the tumour will come back (relapse). If this happens, further chemotherapy is often necessary and in certain selected cases a bone marrow transplant provides the best chance of cure.
In low grade NHL, relapse is likely to occur at some point, although this may be many years after the initial diagnosis. The treatment will depend on what symptoms are being caused by the tumour.
How are decisions about treatment made?
All patients with lymphoma at The Christie Private Care are discussed in detail at a specialist lymphoma meeting called a MDTM (Multidisciplinary Team Meeting). Present at the meeting are Oncologists, a Haematologist, Radiologist, Histopathologist and Nurses, all with specialist expertise in treatment of lymphoma. The weekly specialist Lymphoma MDTM at The Christie has run for over 15 years and has great experience in the management of all types of lymphoma.