Adult Non-Hodgkin Lymphoma Treatment (PDQ®)

Non-Hodgkin lymphoma is a disease in which malignant (cancer) cells form in the lymph system. Non-Hodgkin lymphoma is a type of cancer that ... Skiptomaincontent Español 1-800-4-CANCER LiveChat Publications Dictionary Home CancerTypes Lymphoma Patient Lymphoma Patient AdultHodgkinLymphomaTreatment AdultNHLTreatment AIDS-RelatedLymphomaTreatment MycosisFungoides(IncludingSézarySyndrome)Treatment PrimaryCNSLymphomaTreatment ChildhoodHodgkinLymphomaTreatment ChildhoodNHLTreatment HealthProfessional AdultHodgkinLymphomaTreatment AdultNHLTreatment AIDS-RelatedLymphomaTreatment MycosisFungoides(IncludingSézarySyndrome)Treatment PrimaryCNSLymphomaTreatment ChildhoodHodgkinLymphomaTreatment ChildhoodNHLTreatment ResearchAdvances ResearchArticles AdultNon-HodgkinLymphomaTreatment(PDQ®)–PatientVersion OnThisPage GeneralInformationAboutAdultNon-HodgkinLymphoma StagesofAdultNon-HodgkinLymphoma TreatmentOptionOverview TreatmentofIndolentNon-HodgkinLymphoma TreatmentofAggressiveNon-HodgkinLymphoma TreatmentofLymphoblasticLymphoma TreatmentofBurkittLymphoma TreatmentofRecurrentNon-HodgkinLymphoma TreatmentofNon-HodgkinLymphomaDuringPregnancy ToLearnMoreAboutAdultNon-HodgkinLymphoma AboutThisPDQSummary GeneralInformationAboutAdultNon-HodgkinLymphoma GotoHealthProfessionalVersionKeyPointsNon-Hodgkinlymphomaisadiseaseinwhichmalignant (cancer)cellsforminthelymphsystem.Non-Hodgkinlymphomacanbeindolentoraggressive.Olderage,beingmale,andhavingaweakenedimmunesystemcanincreasetheriskof adultnon-Hodgkinlymphoma.Signsandsymptomsofadultnon-Hodgkinlymphomaincludeswollenlymphnodes,fever, drenchingnightsweats,weightloss,andfatigue.Teststhatexaminethelymphsystemandotherpartsofthebodyareusedtodiagnoseandstageadultnon-Hodgkinlymphoma.Certainfactorsaffectprognosis(chance ofrecovery)andtreatmentoptions.Non-Hodgkinlymphomaisadiseaseinwhichmalignant (cancer)cellsforminthelymphsystem.Non-Hodgkinlymphomaisatypeof cancerthatformsinthelymphsystem.Thelymphsystemispartoftheimmunesystem.Ithelpsprotectthebodyfrominfectionanddisease.Thelymphsystemismadeupofthefollowing:Lymph:Colorless,wateryfluidthattravelsthroughthelymphvesselsandcarrieslymphocytes(whitebloodcells).Therearethreetypesoflymphocytes:Blymphocytesthatmakeantibodiestohelpfightinfection.AlsocalledBcells.Mosttypesofnon-HodgkinlymphomabegininBlymphocytes.TlymphocytesthathelpBlymphocytesmaketheantibodiesthathelpfightinfection.AlsocalledTcells.Naturalkillercellsthatattackcancercellsandviruses.AlsocalledNKcells.Lymphvessels:Anetworkofthintubesthatcollectlymphfromdifferentpartsofthebodyandreturnittothebloodstream.Lymphnodes:Small,bean-shapedstructuresthatfilterlymphandstorewhitebloodcellsthathelpfightinfectionanddisease.Lymphnodesarefoundalonganetworkoflymphvesselsthroughoutthebody.Groupsoflymphnodesarefoundintheneck,underarm,mediastinum,abdomen,pelvis,andgroin.Spleen:Anorganthatmakeslymphocytes,storesredbloodcellsandlymphocytes,filterstheblood,anddestroysoldbloodcells.Thespleenisontheleftsideoftheabdomennearthestomach.Thymus:AnorganinwhichTlymphocytesmatureandmultiply.Thethymusisinthechestbehindthebreastbone.Tonsils:Twosmallmassesoflymphtissueatthebackofthethroat.Thereisonetonsiloneachsideofthethroat.Bonemarrow:Thesoft,spongytissueinthecenterofcertainbones,suchasthehipboneandbreastbone.Whitebloodcells,redbloodcells,andplateletsaremadeinthebonemarrow.EnlargeAnatomyofthelymphsystem,showingthelymphvesselsandlymphorgansincludinglymphnodes,tonsils,thymus,spleen,andbonemarrow.Lymph(clearfluid)andlymphocytestravelthroughthelymphvesselsandintothelymphnodeswherethelymphocytesdestroyharmfulsubstances.Thelymphentersthebloodthroughalargeveinneartheheart.Lymphtissueisalsofoundinotherpartsofthebodysuchastheliningofthedigestivetract,bronchus,andskin.Cancercanspreadtothe liverandlungs.Therearetwogeneraltypesoflymphomas:Hodgkinlymphomaandnon-Hodgkinlymphoma.Thissummaryisaboutthetreatmentofadultnon-Hodgkinlymphoma,includingduringpregnancy.Non-Hodgkinlymphomacanbeindolentoraggressive.Non-Hodgkinlymphomagrowsandspreadsatdifferentratesandcanbeindolentoraggressive.Indolentlymphomatendstogrowandspreadslowly,andhasfewsignsandsymptoms.Aggressivelymphomagrowsandspreadsquickly,andhassignsandsymptomsthatcanbesevere.Thetreatmentsforindolentandaggressivelymphomaaredifferent.Thissummaryisaboutthefollowingtypesofnon-Hodgkinlymphoma:Indolentnon-HodgkinlymphomasFollicularlymphoma.Follicularlymphomaisthemostcommontypeofindolentnon-Hodgkinlymphoma.Itisaveryslow-growingtypeofnon-HodgkinlymphomathatbeginsinBlymphocytes.Itaffectsthelymphnodesandmayspreadtothebonemarroworspleen.Mostpatientswithfollicularlymphomaareage50yearsandolderwhentheyarediagnosed.Follicularlymphomamaygoawaywithouttreatment.Thepatientiscloselywatchedforsignsorsymptomsthatthediseasehascomeback.Treatmentisneededifsignsorsymptomsoccurafterthecancerdisappearedorafterinitialcancertreatment.Sometimesfollicularlymphomacanbecomeamoreaggressivetypeoflymphoma,suchasdiffuselargeB-celllymphoma.Lymphoplasmacyticlymphoma.Inmostcasesoflymphoplasmacyticlymphoma,BlymphocytesthatareturningintoplasmacellsmakelargeamountsofaproteincalledmonoclonalimmunoglobulinM(IgM)antibody.HighlevelsofIgMantibodyinthebloodcausethebloodplasmatothicken.Thismaycausesignsorsymptomssuchastroubleseeingorhearing,heartproblems,shortnessofbreath,headache,dizziness,andnumbnessortinglingofthehandsandfeet.Sometimestherearenosignsorsymptomsoflymphoplasmacyticlymphoma.Itmaybefoundwhenabloodtestisdoneforanotherreason.Lymphoplasmacyticlymphomaoftenspreadstothebonemarrow,lymphnodes,andspleen.PatientswithlymphoplasmacyticlymphomashouldbecheckedforhepatitisCvirusinfection.ItisalsocalledWaldenströmmacroglobulinemia.Marginalzonelymphoma.Thistypeofnon-HodgkinlymphomabeginsinBlymphocytesinapartoflymphtissuecalledthemarginalzone.Theprognosismaybeworseforpatientsaged70yearsorolder,thosewithstageIIIorstageIVdisease,andthosewithhighlactatedehydrogenase(LDH)levels.Therearefivedifferenttypesofmarginalzonelymphoma.Theyaregroupedbythetypeoftissuewherethelymphomaformed:Nodalmarginalzonelymphoma.Nodalmarginalzonelymphomaformsinlymphnodes.Thistypeofnon-Hodgkinlymphomaisrare.ItisalsocalledmonocytoidB-celllymphoma.Gastricmucosa-associatedlymphoidtissue(MALT)lymphoma.GastricMALTlymphomausuallybeginsinthestomach.Thistypeofmarginalzonelymphomaformsincellsinthemucosathathelpmakeantibodies.PatientswithgastricMALTlymphomamayalsohaveHelicobactergastritisoranautoimmunedisease,suchasHashimotothyroiditisorSjögrensyndrome.ExtragastricMALTlymphoma.ExtragastricMALTlymphomabeginsoutsideofthestomachinalmosteverypartofthebodyincludingotherpartsofthegastrointestinaltract,salivaryglands,thyroid,lung,skin,andaroundtheeye.Thistypeofmarginalzonelymphomaformsincellsinthemucosathathelpmakeantibodies.ExtragastricMALTlymphomamaycomebackmanyyearsaftertreatment.Mediterraneanabdominallymphoma.ThisisatypeofMALTlymphomathatoccursinyoungadultsineasternMediterraneancountries.ItoftenformsintheabdomenandpatientsmayalsobeinfectedwithbacteriacalledCampylobacterjejuni.Thistypeoflymphomaisalsocalledimmunoproliferativesmallintestinaldisease.Splenicmarginalzonelymphoma.Thistypeofmarginalzonelymphomabeginsinthespleenandmayspreadtotheperipheralbloodandbonemarrow.Themostcommonsignofthistypeofsplenicmarginalzonelymphomaisaspleenthatislargerthannormal.Primarycutaneousanaplasticlargecelllymphoma.Thistypeofnon-Hodgkinlymphomaisintheskinonly.Itcanbeabenign(notcancer)nodulethatmaygoawayonitsownoritcanspreadtomanyplacesontheskinandneedtreatment.Aggressivenon-HodgkinlymphomasDiffuselargeB-celllymphoma.DiffuselargeB-celllymphomaisthemostcommontypeofnon-Hodgkinlymphoma.Itgrowsquicklyinthelymphnodesandoftenthespleen,liver,bonemarrow,orotherorgansarealsoaffected.SignsandsymptomsofdiffuselargeB-celllymphomamayincludefever,drenchingnightsweats,andweightloss.ThesearealsocalledBsymptoms.PrimarymediastinallargeB-celllymphoma.Thistypeofnon-HodgkinlymphomaisatypeofdiffuselargeB-celllymphoma.Itismarkedbytheovergrowthoffibrous(scar-like)lymphtissue.Atumormostoftenformsbehindthebreastbone.Itmaypressontheairwaysandcausecoughingandtroublebreathing.MostpatientswithprimarymediastinallargeB-celllymphomaarewomenwhoareage30to40years.Follicularlargecelllymphoma,stageIII.Follicularlargecelllymphoma,stageIII,isaveryraretypeofnon-Hodgkinlymphoma.TreatmentofthistypeoffollicularlymphomaismoreliketreatmentofaggressiveNHLthanofindolentNHL.Anaplasticlargecelllymphoma.Anaplasticlargecelllymphomaisatypeofnon-HodgkinlymphomathatusuallybeginsinTlymphocytes.ThecancercellsalsohaveamarkercalledCD30onthesurfaceofthecell.Therearetwotypesofanaplasticlargecelllymphoma:Cutaneousanaplasticlargecelllymphoma.Thistypeofanaplasticlargecelllymphomamostlyaffectstheskin,butotherpartsofthebodymayalsobeaffected.Signsofcutaneousanaplasticlargecelllymphomaincludeoneormorebumpsorulcersontheskin.Thistypeoflymphomaisrareandindolent.Systemicanaplasticlargecelllymphoma.Thistypeofanaplasticlargecelllymphomabeginsinthelymphnodesandmayaffectotherpartsofthebody.Thistypeoflymphomaismoreaggressive.Patientsmayhavealotofanaplasticlymphomakinase(ALK)proteininsidethelymphomacells.ThesepatientshaveabetterprognosisthanpatientswhodonothaveextraALKprotein.Systemicanaplasticlargecelllymphomaismorecommoninchildrenthanadults.Formoreinformation,seeChildhoodNon-HodgkinLymphomaTreatment.ExtranodalNK-/T-celllymphoma.ExtranodalNK-/T-celllymphomausuallybeginsintheareaaroundthenose.Itmayalsoaffecttheparanasalsinus(hollowspacesinthebonesaroundthenose),roofofthemouth,trachea,skin,stomach,andintestines.MostcasesofextranodalNK-/T-celllymphomahaveEpstein-Barrvirusinthetumorcells.Sometimeshemophagocyticsyndromeoccurs(aseriousconditioninwhichtherearetoomanyactivehistiocytesandTcellsthatcausesevereinflammationinthebody).Treatmenttosuppresstheimmunesystemisneeded.Thistypeofnon-HodgkinlymphomaisnotcommonintheUnitedStates.Lymphomatoidgranulomatosis.Lymphomatoidgranulomatosismostlyaffectsthelungs.Itmayalsoaffecttheparanasalsinuses(hollowspacesinthebonesaroundthenose),skin,kidneys,andcentralnervoussystem.Inlymphomatoidgranulomatosis,cancerinvadesthebloodvesselsandkillstissue.Becausethecancermayspreadtothebrain,intrathecalchemotherapyorradiationtherapytothebrainisgiven.AngioimmunoblasticT-celllymphoma.Thistypeofnon-HodgkinlymphomabeginsinTcells.Swollenlymphnodesareacommonsign.Othersignsmayincludeaskinrash,fever,weightloss,ordrenchingnightsweats.Theremayalsobehighlevelsofgammaglobulin(antibodies)intheblood.Patientsmayalsohaveopportunisticinfectionsbecausetheirimmunesystemsareweakened.PeripheralT-celllymphoma.PeripheralT-celllymphomabeginsinmatureTlymphocytes.ThistypeofTlymphocytematuresinthethymusglandandtravelstootherlymphaticsitesinthebodysuchasthelymphnodes,bonemarrow,andspleen.TherearethreesubtypesofperipheralT-celllymphoma:HepatosplenicT-celllymphoma.ThisisanuncommontypeofperipheralT-celllymphomathatoccursmostlyinyoungmen.ItbeginsintheliverandspleenandthecancercellsalsohaveaT-cellreceptorcalledgamma/deltaonthesurfaceofthecell.Subcutaneouspanniculitis-likeT-celllymphoma.Subcutaneouspanniculitis-likeT-celllymphomabeginsintheskinormucosa.Itmayoccurwithhemophagocyticsyndrome(aseriousconditioninwhichtherearetoomanyactivehistiocytesandTcellsthatcausesevereinflammationinthebody).Treatmenttosuppresstheimmunesystemisneeded.Enteropathy-typeintestinalT-celllymphoma.ThistypeofperipheralT-celllymphomaoccursinthesmallbowelofpatientswithuntreatedceliacdisease(animmuneresponsetoglutenthatcausesmalnutrition).Patientswhoarediagnosedwithceliacdiseaseinchildhoodandstayonagluten-freedietrarelydevelopenteropathy-typeintestinalT-celllymphoma.IntravascularlargeB-celllymphoma.Thistypeofnon-Hodgkinlymphomaaffectsbloodvessels,especiallythesmallbloodvesselsinthebrain,kidney,lung,andskin.SignsandsymptomsofintravascularlargeB-celllymphomaarecausedbyblockedbloodvessels.Itisalsocalledintravascularlymphomatosis.Burkittlymphoma.BurkittlymphomaisatypeofB-cellnon-Hodgkinlymphomathatgrowsandspreadsveryquickly.Itmayaffectthejaw,bonesoftheface,bowel,kidneys,ovaries,orotherorgans.TherearethreemaintypesofBurkittlymphoma(endemic,sporadic,andimmunodeficiencyrelated).EndemicBurkittlymphomacommonlyoccursinAfricaandislinkedtotheEpstein-Barrvirus,andsporadicBurkittlymphomaoccursthroughouttheworld.Immunodeficiency-relatedBurkittlymphomaismostoftenseeninpatientswhohaveAIDS.Burkittlymphomamayspreadtothebrainandspinalcordandtreatmenttopreventitsspreadmaybegiven.Burkittlymphomaoccursmostofteninchildrenandyoungadults.Formoreinformation,seeChildhoodNon-HodgkinLymphomaTreatment.Burkittlymphomaisalsocalleddiffusesmallnoncleaved-celllymphoma.Lymphoblasticlymphoma.LymphoblasticlymphomamaybegininTcellsorBcells,butitusuallybeginsinTcells.Inthistypeofnon-Hodgkinlymphoma,therearetoomanylymphoblasts(immaturewhitebloodcells)inthelymphnodesandthethymusgland.Theselymphoblastsmayspreadtootherplacesinthebody,suchasthebonemarrow,brain,andspinalcord.Lymphoblasticlymphomaismostcommoninteenagersandyoungadults.Itisalotlikeacutelymphoblasticleukemia(lymphoblastsaremostlyfoundinthebonemarrowandblood).Formoreinformation,seeAdultAcuteLymphoblasticLeukemiaTreatment.AdultT-cellleukemia/lymphoma.AdultT-cellleukemia/lymphomaiscausedbythehumanT-cellleukemiavirustype1(HTLV-1).Signsincludeboneandskinlesions,highbloodcalciumlevels,andlymphnodes,spleen,andliverthatarelargerthannormal.Mantlecelllymphoma.MantlecelllymphomaisatypeofB-cellnon-Hodgkinlymphomathatusuallyoccursinmiddle-agedorolderadults.Itbeginsinthelymphnodesandspreadstothespleen,bonemarrow,blood,andsometimestheesophagus,stomach,andintestines.Patientswithmantlecelllymphomahavetoomuchofaproteincalledcyclin-D1oracertaingenechangeinthelymphomacells.Insomepatientswhodonothavesignsorsymptomsoflymphoma,delayingthestartoftreatmentdoesnotaffecttheprognosis.Posttransplantationlymphoproliferativedisorder.Thisdiseaseoccursinpatientswhohavehadaheart,lung,liver,kidney,orpancreastransplantandneedlifelongimmunosuppressivetherapy.MostposttransplantlymphoproliferativedisordersaffecttheBcellsandhaveEpstein-Barrvirusinthecells.Lymphoproliferativedisordersareoftentreatedlikecancer.Truehistiocyticlymphoma.Thisisarare,veryaggressivetypeoflymphoma.ItisnotknownwhetheritbeginsinBcellsorTcells.Itdoesnotrespondwelltotreatmentwithstandardchemotherapy.Primaryeffusionlymphoma.PrimaryeffusionlymphomabeginsinBcellsthatarefoundinanareawherethereisalargebuild-upoffluid,suchastheareasbetweentheliningofthelungandchestwall(pleuraleffusion),thesacaroundtheheartandtheheart(pericardialeffusion),orintheabdominalcavity.Thereisusuallynotumorthatcanbeseen.ThistypeoflymphomaoftenoccursinpatientswhoareinfectedwithHIV.Plasmablasticlymphoma.PlasmablasticlymphomaisatypeoflargeB-cellnon-Hodgkinlymphomathatisveryaggressive.ItismostoftenseeninpatientswithHIVinfection.Olderage,beingmale,andhavingaweakenedimmunesystemcanincreasetheriskof adultnon-Hodgkinlymphoma.Anythingthatincreasesyourriskofgettingadiseaseiscalledariskfactor.Havingariskfactordoesnotmeanthatyouwillgetcancer;nothavingriskfactorsdoesn’tmeanthatyouwillnotgetcancer.Talkwithyourdoctorifyouthinkyoumaybeatrisk.Theseandotherriskfactorsmayincreasetheriskofcertaintypesofadult non-Hodgkinlymphoma:Beingolder,male,orWhite.Havingoneofthefollowingmedicalconditionsthatweakenstheimmunesystem:Aninheritedimmunedisorder(suchashypogammaglobulinemiaorWiskott-Aldrichsyndrome).Anautoimmunedisease(suchasrheumatoidarthritis,psoriasis,orSjögrensyndrome).HIV/AIDS.HumanT-lymphotrophicvirustypeIorEpstein-Barrvirusinfection.Helicobacterpyloriinfection.Takingimmunosuppressantdrugsafteranorgantransplant.Signsandsymptomsofadultnon-Hodgkinlymphomaincludeswollenlymphnodes,fever, drenchingnightsweats,weightloss,andfatigue.Thesesignsandsymptomsmaybecausedbyadultnon-Hodgkin lymphomaorbyotherconditions.Checkwithyourdoctorifyouhaveanyofthe following:Swellinginthelymphnodesintheneck,underarm, groin,orstomach.Feverfornoknownreason.Drenchingnightsweats.Feelingverytired.Weightlossfornoknownreason.Skinrashoritchyskin.Paininthechest,abdomen,orbonesfornoknownreason.Whenfever,drenchingnightsweats,andweightlossoccurtogether,thisgroupofsymptomsiscalledBsymptoms.Othersignsandsymptomsofadultnon-Hodgkinlymphomamayoccuranddependonthefollowing: Wherethecancerformsinthebody.Thesizeofthetumor.Howfastthetumorgrows. Teststhatexaminethelymphsystemandotherpartsofthebodyareusedtodiagnoseandstageadultnon-Hodgkinlymphoma.Thefollowingtestsandproceduresmaybeused:Physicalexamandhealthhistory:Anexamofthebodytocheckgeneralsignsofhealth,includingcheckingforsignsofdisease,suchaslumpsoranythingelsethatseemsunusual.Ahistoryofthepatient’shealth,includingfever,drenchingnightsweats,andweightloss,healthhabits,andpastillnessesandtreatmentswillalsobetaken.Completebloodcount(CBC):Aprocedureinwhichasampleofbloodisdrawnandcheckedforthefollowing:Thenumberofredbloodcells,whitebloodcells,andplatelets.Theamountofhemoglobin(theproteinthatcarriesoxygen)intheredbloodcells.Theportionofthesamplemadeupofredbloodcells.EnlargeCompletebloodcount(CBC).Bloodiscollectedbyinsertinganeedleintoaveinandallowingthebloodtoflowintoatube.Thebloodsampleissenttothelaboratoryandtheredbloodcells,whitebloodcells,andplateletsarecounted.TheCBCisusedtotestfor,diagnose,andmonitormanydifferentconditions.Bloodchemistrystudies:Aprocedureinwhichabloodsampleischeckedtomeasuretheamountsofcertainsubstancesreleasedintothebloodby organsandtissuesinthebody.Anunusual(higherorlowerthannormal)amountofasubstancecanbeasign ofdisease.LDHtest:Aprocedureinwhichabloodsampleischeckedtomeasuretheamountoflacticdehydrogenase.AnincreasedamountofLDHinthebloodmaybeasignoftissuedamage,lymphoma,orotherdiseases.HepatitisBandhepatitisCtest:AprocedureinwhichasampleofbloodischeckedtomeasuretheamountsofhepatitisBvirus-specificantigensand/orantibodiesandtheamountsofhepatitisCvirus-specificantibodies.Theseantigensorantibodiesarecalledmarkers.DifferentmarkersorcombinationsofmarkersareusedtodeterminewhetherapatienthasahepatitisBorCinfection,hashadapriorinfectionorvaccination,orissusceptibletoinfection.PatientswhohavebeentreatedforhepatitisBvirusinthepastneedcontinuedmonitoringtocheckifithasreactivated.KnowingwhetherapersonhashepatitisBorCmayhelpplantreatment.HIVtest:AtesttomeasurethelevelofHIVantibodiesinasampleofblood.Antibodiesaremadebythebodywhenitisinvadedbyaforeignsubstance.AhighlevelofHIVantibodiesmaymeanthebodyhasbeeninfectedwithHIV.CTscan(CATscan): Aprocedurethatmakesaseriesofdetailedpicturesofareasinsidethebody,suchastheneck,chest,abdomen,pelvis,andlymphnodes,takenfromdifferentangles.Thepicturesaremadebyacomputerlinkedtoanx-raymachine.Adyemaybeinjectedintoaveinorswallowedtohelptheorgansortissuesshowupmoreclearly.Thisprocedureisalsocalledcomputedtomography,computerizedtomography,orcomputerizedaxialtomography.PETscan(positron emissiontomographyscan):Aproceduretofindmalignanttumorcellsinthebody.Asmallamountofradioactiveglucose(sugar)isinjectedintoavein.ThePETscannerrotatesaroundthebodyandmakesapictureofwhereglucoseisbeingusedinthebody.Malignanttumorcellsshowupbrighterinthepicturebecausetheyaremoreactiveandtakeupmoreglucosethannormalcellsdo.Bonemarrowaspirationandbiopsy:Theremovalofbonemarrowandasmallpieceofbonebyinsertinganeedleintothehipboneorbreastbone.Apathologistviewsthebonemarrowandboneunderamicroscopetolookforsignsofcancer.EnlargeBonemarrowaspirationandbiopsy.Afterasmallareaofskinisnumbed,abonemarrowneedleisinsertedintothepatient’shipbone.Samplesofblood,bone,andbonemarrowareremovedforexaminationunderamicroscope.Lymphnodebiopsy:The removalofallorpartofalymphnode.Apathologistviewsthetissueunderamicroscopetocheckforcancercells.Oneofthefollowingtypesofbiopsiesmaybedone:Excisional biopsy:Theremovalofanentirelymphnode.Incisional biopsy:Theremovalofpartofalymphnode.Corebiopsy:Theremovalofpartofalymphnodeusingawideneedle.Ifcancerisfound,thefollowingtestsmaybedonetostudythecancercells: Immunohistochemistry:Alaboratorytestthatusesantibodiestocheckforcertainantigens(markers)inasampleofapatient’stissue.Theantibodiesareusuallylinkedtoanenzymeorafluorescentdye.Aftertheantibodiesbindtoaspecificantigeninthetissuesample,theenzymeordyeisactivated,andtheantigencanthenbeseenunderamicroscope.Thistypeoftestisusedtohelpdiagnosecancerandtohelptellonetypeofcancerfromanothertypeofcancer.Cytogeneticanalysis:Alaboratorytestinwhichthechromosomesofcellsinasampleofbloodorbonemarrowarecountedandcheckedforanychanges,suchasbroken,missing,rearranged,orextrachromosomes.Changesincertainchromosomesmaybeasignofcancer.Cytogeneticanalysisisusedtohelpdiagnosecancer,plantreatment,orfindouthowwelltreatmentisworking.Immunophenotyping:Alaboratorytestthatusesantibodiestoidentifycancercellsbasedonthetypesofantigensormarkersonthesurfaceofthecells.Thistestisusedtohelpdiagnosespecifictypesoflymphoma.FISH(fluorescenceinsituhybridization):Alaboratorytestusedtolookatandcountgenesorchromosomesincellsandtissues.PiecesofDNAthatcontainfluorescentdyesaremadeinthelaboratoryandaddedtoasampleofapatient’scellsortissues.WhenthesedyedpiecesofDNAattachtocertaingenesorareasofchromosomesinthesample,theylightupwhenviewedunderafluorescentmicroscope.TheFISHtestisusedtohelpdiagnosecancerandhelpplantreatment.Othertestsandproceduresmaybedonedependingonthesignsandsymptomsseenandwherethecancerformsinthebody.Certainfactorsaffectprognosis(chance ofrecovery)andtreatmentoptions.Theprognosisandtreatmentoptionsdependonthefollowing:Thepatient'ssignsandsymptoms,includingwhetherornottheyhaveBsymptoms(feverfornoknownreason,weightlossfornoknownreason,ordrenchingnightsweats).Thestageofthecancer(thesizeofthecancertumorsandwhetherthecancerhasspreadtootherpartsofthebodyorlymphnodes).Thetypeofnon-Hodgkinlymphoma.Theamountoflactatedehydrogenase(LDH)intheblood.Whethertherearecertainchangesinthegenes.Thepatient’sage,sex,and generalhealth.Whetherthelymphomaisnewlydiagnosed,continuestogrowduringtreatment,orhasrecurred(comeback).Fornon-Hodgkinlymphomaduringpregnancy,treatmentoptionsalsodependon:Thewishesofthepatient.Whichtrimesterofpregnancythepatientisin.Whetherthebabycanbedeliveredearly.Sometypesofnon-Hodgkinlymphomaspreadmorequicklythan othersdo.Mostnon-Hodgkinlymphomasthatoccurduringpregnancyare aggressive.Delayingtreatment ofaggressivelymphomauntilafterthebabyisbornmaylessenthemother'schanceofsurvival.Immediate treatmentisoftenrecommended,evenduringpregnancy. StagesofAdultNon-HodgkinLymphoma KeyPointsAfteradultnon-Hodgkinlymphomahasbeendiagnosed,testsaredonetofindout whethercancercellshavespreadwithinthelymph systemortootherpartsofthebody. Therearethreewaysthatcancerspreadsinthebody.Thefollowingstagesareusedforadultnon-Hodgkin lymphoma:StageIStageIIStageIIIStageIVAdultnon-Hodgkinlymphomasmaybegroupedfortreatmentaccordingtowhetherthecancerisindolentoraggressive,whetheraffectedlymphnodesarenexttoeachotherinthebody,andwhetherthecancerisnewlydiagnosedorrecurrent.Adultnon-Hodgkinlymphomacanrecur(comeback)afterithasbeentreated.Afteradultnon-Hodgkinlymphomahasbeendiagnosed,testsaredonetofindout whethercancercellshavespreadwithinthelymph systemortootherpartsofthebody. Theprocessusedtofindoutthetypeofcancerandifcancercells havespreadwithinthelymphsystemortootherpartsofthebodyiscalledstaging.The informationgatheredfromthestagingprocessdeterminesthestageofthe disease.Itisimportanttoknowthestageofthediseaseinordertoplantreatment.Theresultsofthetestsandproceduresdonetodiagnosenon-Hodgkinlymphomaareusedtohelpmakedecisionsabouttreatment.Thefollowingtestsandproceduresmayalsobeusedinthestaging process:MRI(magnetic resonanceimaging)withgadolinium:Aprocedurethatusesamagnet,radiowaves,andacomputertomakeaseriesofdetailedpicturesofareasinsidethebody,suchasthebrainandspinalcord.Asubstancecalledgadoliniumisinjectedintothepatientthroughavein.Thegadoliniumcollectsaroundthecancercellssotheyshowupbrighterinthepicture.Thisprocedureisalsocallednuclearmagneticresonanceimaging(NMRI).Lumbarpuncture:Aprocedureusedtocollectcerebrospinalfluid(CSF)fromthespinalcolumn.ThisisdonebyplacinganeedlebetweentwobonesinthespineandintotheCSFaroundthespinalcordandremovingasampleofthefluid.ThesampleofCSFischeckedunderamicroscopeforsignsthatthecancerhasspreadtothebrainandspinalcord.ThisprocedureisalsocalledanLPorspinaltap.EnlargeLumbarpuncture.Apatientliesinacurledpositiononatable.Afterasmallareaonthelowerbackisnumbed,aspinalneedle(along,thinneedle)isinsertedintothelowerpartofthespinalcolumntoremovecerebrospinalfluid(CSF,showninblue).Thefluidmaybesenttoalaboratoryfortesting.Forpregnantwomenwithnon-Hodgkinlymphoma,stagingtestsandproceduresthatprotecttheunbornbabyfromtheharmsofradiationareused.ThesetestsandproceduresincludeMRI(withoutcontrast),lumbarpuncture,andultrasound.Therearethreewaysthatcancerspreadsinthebody.Cancercanspreadthroughtissue,thelymphsystem,andtheblood:Tissue.Thecancerspreadsfromwhereitbeganbygrowingintonearbyareas. Lymphsystem.Thecancerspreadsfromwhereitbeganbygettingintothelymphsystem.Thecancertravelsthroughthelymphvesselstootherpartsofthebody. Blood.Thecancerspreadsfromwhereitbeganbygettingintotheblood.Thecancertravelsthroughthebloodvesselstootherpartsofthebody. Thefollowingstagesareusedforadultnon-Hodgkin lymphoma:StageIEnlargeStageIadultlymphoma.Cancerisfoundinoneormorelymphnodesinagroupoflymphnodesor,inrarecases,cancerisfoundintheWaldeyer’sring,thymus,orspleen.InstageIE(notshown),cancerhasspreadtooneareaoutsidethelymphsystem.StageIadultnon-HodgkinlymphomaisdividedintostagesIandIE.InstageI,cancerisfoundinoneofthefollowingplacesinthelymphsystem:Oneormorelymphnodesinagroupoflymphnodes.Waldeyer'sring.Thymus.Spleen.InstageIE,cancerisfoundinoneareaoutsidethelymphsystem.StageIIStageIIadultnon-HodgkinlymphomaisdividedintostagesIIandIIE.InstageII,cancerisfoundintwoormoregroupsoflymphnodesthatareeitherabovethediaphragmorbelowthediaphragm.EnlargeStageIIadultlymphoma.Cancerisfoundintwoormoregroupsoflymphnodesthatareeitherabovethediaphragmorbelowthediaphragm.InstageIIE,cancerhasspreadfromagroupoflymphnodestoanearbyareathatisoutsidethelymphsystem.Cancermayhavespreadtootherlymphnodegroupsonthesamesideofthediaphragm. EnlargeStageIIEadultlymphoma.Cancerhasspreadfromagroupoflymphnodestoanearbyareathatisoutsidethelymphsystem.Cancermayhavespreadtootherlymphnodegroupsonthesamesideofthediaphragm.InstageII,thetermbulkydiseasereferstoalargertumormass.Thesizeofthetumormassthatisreferredtoasbulkydiseasevariesbasedonthetypeoflymphoma. StageIIIEnlargeStageIIIadultlymphoma.Cancerisfoundingroupsoflymphnodesbothaboveandbelowthediaphragm;orinagroupoflymphnodesabovethediaphragmandinthespleen.InstageIIIadultnon-Hodgkinlymphoma,cancerisfound:ingroupsoflymphnodesbothaboveandbelowthediaphragm;orinlymphnodesabovethediaphragmandinthespleen.StageIVEnlargeStageIVadultlymphoma.Cancer(a)hasspreadthroughoutoneormoreorgansoutsidethelymphsystem;or(b)isfoundintwoormoregroupsoflymphnodesthatareeitherabovethediaphragmorbelowthediaphragmandinoneorganthatisoutsidethelymphsystemandnotneartheaffectedlymphnodes;or(c)isfoundingroupsoflymphnodesabovethediaphragmandbelowthediaphragmandinanyorganthatisoutsidethelymphsystem;or(d)isfoundintheliver,bonemarrow,morethanoneplaceinthelung,orcerebrospinalfluid(CSF).Thecancerhasnotspreaddirectlyintotheliver,bonemarrow,lung,orCSFfromnearbylymphnodes.InstageIVadultnon-Hodgkinlymphoma,cancer:hasspreadthroughoutoneormoreorgansoutsidethelymphsystem;orisfoundintwoormoregroupsoflymphnodesthatareeitherabovethediaphragmorbelowthediaphragmandinoneorganthatisoutsidethelymphsystemandnotneartheaffectedlymphnodes;orisfoundingroupsoflymphnodesbothaboveandbelowthediaphragmandinanyorganthatisoutsidethelymphsystem;orisfoundintheliver,bonemarrow,morethanoneplaceinthelung,orcerebrospinalfluid(CSF).Thecancerhasnotspreaddirectlyintotheliver,bonemarrow,lung,orCSFfromnearbylymphnodes. Adultnon-Hodgkinlymphomasmaybegroupedfortreatmentaccordingtowhetherthecancerisindolentoraggressive,whetheraffectedlymphnodesarenexttoeachotherinthebody,andwhetherthecancerisnewlydiagnosedorrecurrent.Formoreinformationonthetypesofindolent(slow-growing)andaggressive(fast-growing)non-Hodgkinlymphoma,seetheGeneralInformationsection.Non-Hodgkinlymphomacanalsobedescribedascontiguousornoncontiguous:Contiguouslymphomas:Lymphomasinwhichthelymphnodeswithcancerarenext toeachother.Noncontiguouslymphomas:Lymphomasinwhichthelymphnodeswithcancer arenotnexttoeachother,butareonthesamesideofthe diaphragm.Adultnon-Hodgkinlymphomacanrecur(comeback)afterithasbeentreated.Thelymphomamaycomeback inthelymphsystemorinotherpartsofthebody.Indolentlymphomamaycomebackas aggressivelymphoma.Aggressive lymphomamaycomebackasindolentlymphoma. TreatmentOptionOverview KeyPointsTherearedifferenttypesoftreatmentforpatientswithnon-Hodgkinlymphoma.Patientswithnon-Hodgkinlymphomashouldhavetheirtreatment plannedbyateamofhealthcareproviderswhoareexpertsintreatinglymphomas.Treatmentforadultnon-Hodgkinlymphomamaycausesideeffects.Ninetypesofstandardtreatmentareused:Radiationtherapy ChemotherapyImmunotherapyTargetedtherapyPlasmapheresisWatchfulwaiting AntibiotictherapySurgeryStemcelltransplantNewtypesoftreatmentarebeingtestedinclinical trials.VaccinetherapyPatientsmaywanttothinkabouttakingpartinaclinicaltrial.Patientscanenterclinicaltrialsbefore,during,orafterstartingtheircancertreatment.Follow-uptestsmaybeneeded.Therearedifferenttypesoftreatmentforpatientswithnon-Hodgkinlymphoma.Differenttypesoftreatmentareavailableforpatientswithnon-Hodgkinlymphoma.Sometreatmentsarestandard(thecurrentlyusedtreatment),andsome arebeingtestedinclinicaltrials. Atreatmentclinicaltrialisaresearchstudymeanttohelp improvecurrenttreatmentsorobtaininformationonnewtreatmentsforpatients withcancer.Whenclinicaltrialsshowthatanewtreatmentisbetterthanthe standardtreatment,thenew treatmentmaybecomethestandardtreatment.Patientsmaywanttothinkabouttakingpartinaclinicaltrial.Someclinicaltrialsareopenonlytopatientswhohavenotstartedtreatment.Forpregnantwomenwithnon-Hodgkinlymphoma,treatmentiscarefullychosentoprotecttheunbornbaby.Treatmentdecisionsarebasedonthemother’swishes,thestageofthenon-Hodgkinlymphoma,andtheageoftheunbornbaby.Thetreatmentplanmaychangeasthesignsandsymptoms,cancer,andpregnancychange.Choosingthemostappropriatecancertreatmentisadecisionthatideallyinvolvesthepatient,family,andhealthcareteam. Patientswithnon-Hodgkinlymphomashouldhavetheirtreatment plannedbyateamofhealthcareproviderswhoareexpertsintreatinglymphomas.Treatmentwillbeoverseenbyamedical oncologist,adoctorwhospecializesintreatingcancer,orahematologist,adoctorwhospecializesintreatingbloodcancers.The medicaloncologistmayreferyoutootherhealthcareproviderswhohaveexperienceand areexpertsintreatingadultnon-Hodgkinlymphomaandwhospecializeincertain areasofmedicine.Thesemayincludethefollowingspecialists:Neurosurgeon.Neurologist.Radiation oncologist.Endocrinologist.Rehabilitationspecialist.Otheroncologyspecialists.Treatmentforadultnon-Hodgkinlymphomamaycausesideeffects.Forinformationaboutsideeffectsthatbeginduringtreatmentforcancer,seeourSideEffectspage.Sideeffectsfromcancertreatmentthatbeginaftertreatmentandcontinueformonthsoryearsarecalledlateeffects.Treatmentwithchemotherapy,radiationtherapy,orstemcelltransplantfornon-Hodgkinlymphomamayincreasetheriskoflateeffects.Lateeffectsofcancertreatmentmayincludethefollowing:Heartproblems.Infertility(inabilitytohavechildren).Lossofbonedensity.Neuropathy(nervedamagethatcausesnumbnessortroublewalking).Asecondcancer,suchas:Lungcancer.Braincancer.Kidneycancer.Bladdercancer.Melanoma.Hodgkinlymphoma.Myelodysplasticsyndrome.Acutemyeloidleukemia.Somelateeffectsmaybetreatedorcontrolled.Itisimportanttotalkwithyourdoctorabouttheeffectscancertreatmentcanhaveonyou.Regularfollow-uptocheckforlateeffectsisimportant.Ninetypesofstandardtreatmentareused:Radiationtherapy Radiationtherapyisacancertreatmentthatuseshigh-energyx-raysorothertypesofradiationtokillcancercellsorkeepthemfromgrowing.Externalradiationtherapyusesamachineoutsidethebodytosendradiationtowardtheareaofthebodywithcancer.Sometimestotal-bodyirradiationisgivenbeforeastemcelltransplant.Protonbeamradiationtherapyisatypeofhigh-energy,externalradiationtherapythatusesstreamsofprotons(tinyparticleswithapositivecharge)tokilltumorcells.Thistypeoftreatmentcanlowertheamountofradiationdamagetohealthytissuenearatumorsuchastheheartorbreast.Externalradiationtherapyisusedtotreatadultnon-Hodgkinlymphoma,andmayalsobeusedaspalliativetherapytorelievesymptomsandimprovequalityoflife.Forapregnantwomanwithnon-Hodgkinlymphoma,radiationtherapyshouldbegivenafterdelivery,ifpossible,toavoidanyrisktotheunbornbaby.Iftreatmentisneededrightaway,thewomanmaydecidetocontinuethepregnancyandreceiveradiationtherapy.Aleadshieldisusedtocoverthepregnantwoman'sabdomentohelpprotecttheunbornbabyfromradiationasmuchaspossible.ChemotherapyChemotherapyisacancertreatmentthatusesdrugstostopthegrowthofcancercells,eitherbykillingthecellsorbystoppingthemfromdividing.Whenchemotherapyistakenbymouthorinjectedintoaveinormuscle,thedrugsenterthebloodstreamandcanreachcancercellsthroughoutthebody(systemicchemotherapy).Whenchemotherapyisplaceddirectlyintothecerebrospinalfluid(intrathecalchemotherapy),anorgan,orabodycavitysuchastheabdomen,thedrugsmainlyaffectcancercellsinthoseareas(regionalchemotherapy).Combinationchemotherapyistreatmentusingtwoormoreanticancerdrugs.Steroiddrugsmaybeadded,tolessen inflammationandlowerthebody'simmuneresponse.Systemiccombinationchemotherapyisusedforthetreatmentofadultnon-Hodgkinlymphoma.Intrathecalchemotherapymayalsobeusedinthetreatmentoflymphomathatfirstformsinthetesticlesorsinuses(hollowareas)aroundthenose,diffuselargeB-celllymphoma,Burkittlymphoma,lymphoblasticlymphoma,andsomeaggressiveT-celllymphomas.Itisgiventolessenthechancethatlymphomacellswillspreadtothebrainandspinalcord.ThisiscalledCNSprophylaxis.EnlargeIntrathecalchemotherapy.Anticancerdrugsareinjectedintotheintrathecalspace,whichisthespacethatholdsthecerebrospinalfluid(CSF,showninblue).Therearetwodifferentwaystodothis.Oneway,showninthetoppartofthefigure,istoinjectthedrugsintoanOmmayareservoir(adome-shapedcontainerthatisplacedunderthescalpduringsurgery;itholdsthedrugsastheyflowthroughasmalltubeintothebrain).Theotherway,showninthebottompartofthefigure,istoinjectthedrugsdirectlyintotheCSFinthelowerpartofthespinalcolumn,afterasmallareaonthelowerbackisnumbed.Whenapregnantwomanistreatedwithchemotherapyfornon-Hodgkinlymphoma,theunbornbabycannotbeprotectedfrombeingexposedtochemotherapy.Somechemotherapyregimensmaycausebirthdefectsifgiveninthefirsttrimester.Formoreinformation,seeDrugsApprovedforNon-HodgkinLymphoma.ImmunotherapyImmunotherapyisatreatmentthatusesthepatient’simmunesystemtofightcancer.Substancesmadebythebodyormadeinalaboratoryareusedtoboost,direct,orrestorethebody’snaturaldefensesagainstcancer.Thiscancertreatmentisatypeofbiologictherapy.Immunomodulators:Lenalidomideisanimmunomodulatorusedtotreatadultnon-Hodgkinlymphoma.CART-celltherapy:Thepatient'sTcells(atypeofimmunesystemcell)arechangedsotheywillattackcertainproteinsonthesurfaceofcancercells.Tcellsaretakenfromthepatientandspecialreceptorsareaddedtotheirsurfaceinthelaboratory.Thechangedcellsarecalledchimericantigenreceptor(CAR)Tcells.TheCARTcellsaregrowninthelaboratoryandgiventothepatientbyinfusion.TheCARTcellsmultiplyinthepatient'sbloodandattackcancercells.CART-celltherapy(suchasaxicabtageneciloleucelortisagenlecleucel)isusedtotreatlargeB-celllymphomathathasnotrespondedtotreatment.CART-celltherapyisbeingstudiedtotreatmantlecelllymphomathathasrelapsedornotrespondedtotreatment.EnlargeCART-celltherapy.Atypeoftreatmentinwhichapatient’sTcells(atypeofimmunecell)arechangedinthelaboratorysotheywillbindtocancercellsandkillthem.Bloodfromaveininthepatient’sarmflowsthroughatubetoanapheresismachine(notshown),whichremovesthewhitebloodcells,includingtheTcells,andsendstherestofthebloodbacktothepatient.Then,thegeneforaspecialreceptorcalledachimericantigenreceptor(CAR)isinsertedintotheTcellsinthelaboratory.MillionsoftheCARTcellsaregrowninthelaboratoryandthengiventothepatientbyinfusion.TheCARTcellsareabletobindtoanantigenonthecancercellsandkillthem.Formoreinformation,seeDrugsApprovedforNon-HodgkinLymphoma.TargetedtherapyTargetedtherapyisatypeoftreatmentthatusesdrugsorothersubstancestoidentifyandattackspecificcancercells.Targetedtherapiesusuallycauselessharmtonormalcellsthanchemotherapyorradiationtherapydo.Monoclonal antibodytherapy,proteasomeinhibitortherapy,andkinaseinhibitortherapyaretypesoftargetedtherapyusedtotreatadultnon-Hodgkinlymphoma.Monoclonal antibodytherapy:Monoclonalantibodiesareimmunesystemproteinsmadeinthelaboratorytotreatmanydiseases,includingcancer.Asacancertreatment,theseantibodiescanattachtoaspecifictargetoncancercellsorothercellsthatmayhelpcancercellsgrow.Theantibodiesareabletothenkillthecancercells,blocktheirgrowth,orkeepthemfromspreading.Monoclonalantibodiesaregivenbyinfusion.Theymaybeusedaloneortocarrydrugs,toxins,orradioactivematerialdirectlytocancercells.Typesofmonoclonalantibodiesinclude:Rituximab,usedtotreatmanytypesofnon-Hodgkinlymphoma.Obinutuzumab,usedtotreatfollicularlymphoma.Mogamulizumab,usedtotreatcertaintypesofrelapsedorrefractoryT-celllymphoma.TafasitamabcombinedwithlenalidomidetotreatrelapsedorrefractorydiffuselargeB-celllymphoma.PembrolizumabtotreatprimarymediastinallargeB-celllymphoma.Polatuzumabvedotin,combinedwithbendamustineandrituximabtotreatrelapsedorrefractorydiffuselargeB-celllymphoma.Brentuximabvedotin,whichcontainsamonoclonalantibodythatbindstoaproteincalledCD30thatisfoundonsomelymphomacells.Italsocontainsananticancerdrugthatmayhelpkillcancercells.YttriumY90-ibritumomabtiuxetan,anexampleofaradiolabeledmonoclonalantibody.Howdomonoclonalantibodiesworktotreatcancer?Thisvideoshowshowmonoclonalantibodies,suchastrastuzumab,pembrolizumab,andrituximab,blockmoleculescancercellsneedtogrow,flagcancercellsfordestructionbythebody’simmunesystem,ordeliverharmfulsubstancestocancercells.Proteasomeinhibitortherapy:Thistreatmentblockstheactionofproteasomesincancercells.Proteasomesremoveproteinsnolongerneededbythecell.Whentheproteasomesareblocked,theproteinsbuildupinthecellandmaycausethecancercelltodie.BortezomiborixazomibisusedtodecreasehowmuchimmunoglobulinMisinthebloodaftercancertreatmentforlymphoplasmacyticlymphoma(Waldenströmmacroglobulinemia).Itisalsobeingstudiedtotreatrelapsedmantlecelllymphoma.Kinaseinhibitortherapy:Thistreatmentblockscertainproteins,whichmayhelpkeeplymphomacellsfromgrowingandmaykillthem.Kinaseinhibitortherapiesinclude:Copanlisib,whichblocksP13Kproteinsandmayhelpkeeplymphomacellsfromgrowing.Thisisusedtotreatfollicularnon-Hodgkinlymphomasthathaverelapsed(comeback)orhavenotgottenbetteraftertreatmentwithatleasttwoothertherapies.Ibrutinib,acalabrutinib,andzanubrutinib,whicharetypesofBrutontyrosinekinaseinhibitortherapy.Theyareusedtotreatmantlecelllymphoma.Ibrutinibandacalabrutinibarealsousedtotreatlymphoplasmacyticlymphoma,andzanubrutinibisbeingstudiedtotreatit.Histonemethyltransferaseinhibitortherapy:Tazemetostatisusedtotreatfollicularlymphomathathascomebackorhasnotgottenbetterwithothertreatment.Itisusedinadultswhosecancerhasacertainmutation(change)intheEZH2genethathasalreadybeentreatedwithatleasttwootheranticancertherapies.B-celllymphoma-2(BCL-2)inhibitortherapy:Venetoclaxmaybeusedtotreatmantlecelllymphoma.ItblockstheactionofaproteincalledBCL-2andmayhelpkillcancercells.Formoreinformation,seeDrugsApprovedforNon-HodgkinLymphoma.PlasmapheresisIfthebloodbecomesthickwithextraantibodyproteinsandaffectscirculation,plasmapheresisisdonetoremoveextraplasmaandantibodyproteinsfromtheblood.Inthisprocedure,bloodisremovedfromthepatientandsentthroughamachinethatseparatestheplasma(theliquidpartoftheblood)fromthebloodcells.Thepatient'splasmacontainstheunneededantibodiesandisnotreturnedtothepatient.Thenormalbloodcellsarereturnedtothebloodstreamalongwithdonatedplasmaoraplasmareplacement.Plasmapheresisdoesnotkeepnewantibodiesfromforming.Watchfulwaiting Watchfulwaitingis closelymonitoringapatient’sconditionwithoutgivinganytreatmentuntil signsorsymptomsappearorchange.AntibiotictherapyAntibiotictherapyisatreatmentthatusesdrugstotreatinfectionsandcancercausedbybacteriaandothermicroorganisms.Formoreinformation,seeDrugsApprovedforNon-HodgkinLymphoma.SurgerySurgerymaybeusedtoremovethelymphomaincertainpatientswithindolentoraggressivenon-Hodgkinlymphoma.Thetypeofsurgeryuseddependsonwherethelymphomaformedinthebody:Localexcisionforcertainpatientswithmucosa-associatedlymphoidtissue(MALT)lymphoma,PTLD,andsmallbowelT-celllymphoma.Splenectomyforpatientswithmarginalzonelymphomaofthespleen.Patientswhohaveaheart,lung,liver,kidney,orpancreastransplantusuallyneedtotakedrugstosuppresstheirimmunesystemfortherestoftheirlives.Long-termimmunosuppressionafteranorgantransplantcancauseacertaintypeofnon-Hodgkinlymphomacalledpost-transplantlymphoproliferativedisorder(PLTD).SmallbowelsurgeryisoftenneededtodiagnoseceliacdiseaseinadultswhodevelopatypeofT-celllymphoma.StemcelltransplantStemcelltransplantisamethodofgivinghighdosesofchemotherapyand/ortotal-bodyirradiationandthenreplacingblood-formingcellsdestroyedbythecancertreatment.Stemcells(immaturebloodcells)areremovedfromthebloodorbonemarrowofthepatient(autologoustransplant)oradonor(allogeneictransplant)andarefrozenandstored.Afterthechemotherapyand/orradiationtherapyiscompleted,thestoredstemcellsarethawedandgivenbacktothepatientthroughaninfusion.Thesereinfusedstemcellsgrowinto(andrestore)thebody’sbloodcells.EnlargeStemcelltransplant.(Step1):Bloodistakenfromaveininthearmofthedonor.Thepatientoranotherpersonmaybethedonor.Thebloodflowsthroughamachinethatremovesthestemcells.Thenthebloodisreturnedtothedonorthroughaveinintheotherarm.(Step2):Thepatientreceiveschemotherapytokillblood-formingcells.Thepatientmayreceiveradiationtherapy(notshown).(Step3):Thepatientreceivesstemcellsthroughacatheterplacedintoabloodvesselinthechest.Newtypesoftreatmentarebeingtestedinclinical trials.Thissummarysectiondescribestreatmentsthatarebeingstudiedin clinicaltrials.Itmaynotmentioneverynewtreatmentbeingstudied. Informationaboutclinicaltrialsisavailablefromthe NCIwebsite.VaccinetherapyVaccinetherapyisacancertreatmentthatusesasubstanceorgroupofsubstancestostimulatetheimmunesystemtofindthetumorandkillit.Patientsmaywanttothinkabouttakingpartinaclinicaltrial.Forsomepatients,takingpartinaclinicaltrialmaybethebesttreatmentchoice.Clinicaltrialsarepartofthecancerresearchprocess.Clinicaltrialsaredonetofindoutifnewcancertreatmentsaresafeandeffectiveorbetterthanthestandardtreatment.Manyoftoday'sstandardtreatmentsforcancerarebasedonearlierclinicaltrials.Patientswhotakepartinaclinicaltrialmayreceivethestandardtreatmentorbeamongthefirsttoreceiveanewtreatment.Patientswhotakepartinclinicaltrialsalsohelpimprovethewaycancerwillbetreatedinthefuture.Evenwhenclinicaltrialsdonotleadtoeffectivenewtreatments,theyoftenanswerimportantquestionsandhelpmoveresearchforward.Patientscanenterclinicaltrialsbefore,during,orafterstartingtheircancertreatment.Someclinicaltrialsonlyincludepatientswhohavenotyetreceivedtreatment.Othertrialstesttreatmentsforpatientswhosecancerhasnotgottenbetter.Therearealsoclinicaltrialsthattestnewwaystostopcancerfromrecurring(comingback)orreducethesideeffectsofcancertreatment.Clinicaltrialsaretakingplaceinmanypartsofthecountry.InformationaboutclinicaltrialssupportedbyNCIcanbefoundonNCI’sclinicaltrialssearchwebpage.ClinicaltrialssupportedbyotherorganizationscanbefoundontheClinicalTrials.govwebsite.Follow-uptestsmaybeneeded.Someoftheteststhatweredonetodiagnosethecancerortofindoutthestageofthecancermayberepeated.Sometestswillberepeatedinordertoseehowwellthetreatmentisworking.Decisionsaboutwhethertocontinue,change,orstoptreatmentmaybebasedontheresultsofthesetests.Someofthetestswillcontinuetobedonefromtimetotimeaftertreatmenthasended.Theresultsofthesetestscanshowifyourconditionhaschangedorifthecancerhasrecurred(comeback).Thesetestsaresometimescalledfollow-uptestsorcheck-ups. TreatmentofIndolentNon-HodgkinLymphoma Forinformationaboutthetreatmentslistedbelow,seetheTreatmentOptionOverviewsection.Treatmentofindolent stageIandindolent,contiguous stageIIadult non-Hodgkinlymphomamayinclude thefollowing:Radiationtherapy.Monoclonalantibodytherapy(rituximab)and/orchemotherapy.Watchfulwaiting.Ifthetumoristoolargetobetreatedwithradiationtherapy,thetreatmentoptionsforindolent,noncontiguousstageII,III,orIVadult non-Hodgkinlymphomawillbeused.Treatmentofindolent,noncontiguousstageII,III,orIVadult non-Hodgkinlymphomamayincludethefollowing:Watchfulwaitingforpatientswhodonothavesignsor symptoms.Monoclonal antibodytherapy(rituximab)withorwithoutchemotherapy.Lenalidomideandrituximab.Maintenancetherapywithrituximab.Monoclonalantibodytherapy(obinutuzumab)withorwithoutchemotherapy.PI3Kinhibitortherapy(copanlisib).EZH2inhibitortherapy(tazemetostat).Radiolabeledmonoclonalantibody therapy.Aclinicaltrialofhigh-dosechemotherapywithorwithout total-bodyirradiationorradiolabeledmonoclonalantibodytherapy,followedbyautologousorallogeneicstemcelltransplant.Aclinicaltrialofchemotherapywithorwithout vaccinetherapy.Aclinicaltrialofnewtypesofmonoclonalantibodies.Aclinicaltrialofradiationtherapythatincludesnearbylymphnodes,forpatientswhohavestageIIIdisease.Aclinicaltrialoflow-doseradiationtherapy,torelievesymptomsandimprovequalityoflife.Othertreatmentsforindolentnon-Hodgkinlymphomadependonthetypeofnon-Hodgkinlymphoma.Treatmentmayincludethefollowing:Forfollicularlymphoma,treatmentmaybewithinaclinicaltrialofnewmonoclonalantibodytherapy,newchemotherapyregimen,orastemcelltransplant.Forfollicularlymphomathathasrelapsed(comeback)orhasnotgottenbetteraftertreatment,therapymayincludeaPI3Kinhibitor(copanlisib).Forlymphoplasmacyticlymphoma(Waldenströmmacroglobulinemia),tyrosinekinaseinhibitortherapyand/orplasmapheresisorproteasomeinhibitortherapy(ifneededtomakethebloodthinner)isused.Othertreatmentsthatarelikethoseusedforfollicularlymphomamayalsobegiven.Forgastricmucosa-associatedlymphoidtissue(MALT)lymphoma,antibiotictherapytotreatHelicobacterpyloriinfectionisgivenfirst.Fortumorsthatdonotrespondtoantibiotictherapy,treatmentisradiationtherapy,surgery,orrituximabwithorwithoutchemotherapy.ForextragastricMALTlymphomaoftheeyeandMediterraneanabdominallymphoma,antibiotictherapyisusedtotreatinfection.Forsplenicmarginalzonelymphoma,rituximabwithorwithoutchemotherapyandB-cellreceptortherapyisusedasinitialtreatment.Ifthetumordoesnotrespondtotreatment,asplenectomymaybedone. TreatmentofAggressiveNon-HodgkinLymphoma Forinformationaboutthetreatmentslistedbelow,seetheTreatmentOptionOverviewsection.TreatmentofaggressivestageIandaggressive,contiguousstageIIadultnon-Hodgkinlymphomamayincludethefollowing:Monoclonalantibodytherapy(rituximab)andcombinationchemotherapy.Sometimesradiationtherapyisgivenlater.Aclinicaltrialofanewregimenofmonoclonalantibodytherapyandcombinationchemotherapy.Treatmentofaggressive,noncontiguousstageII,III,orIVadult non-Hodgkinlymphomamayincludethefollowing:Monoclonalantibodytherapy(rituximab)withcombinationchemotherapy.Combinationchemotherapy. Aclinicaltrialofmonoclonalantibodytherapywithcombinationchemotherapyfollowedbyradiationtherapy.Othertreatmentsdependonthetypeofaggressivenon-Hodgkinlymphoma.Treatmentmayincludethefollowing:ForextranodalNK-/T-celllymphoma,radiationtherapythatmaybegivenbefore,during,orafterchemotherapyandCNSprophylaxis.Formantlecelllymphoma,monoclonalantibodytherapywithcombinationchemotherapy,followedbystemcelltransplant.Monoclonalantibodytherapymaybegivenafterwardsasmaintenancetherapy(treatmentthatisgivenafterinitialtherapytohelpkeepcancerfromcomingback).Forposttransplantationlymphoproliferativedisorder,treatmentwithimmunosuppressivedrugsmaybestopped.Ifthisdoesnotworkorcannotbedone,monoclonalantibodytherapyaloneorwithchemotherapymaybegiven.Forcancerthathasnotspread,surgerytoremovethecancerorradiationtherapymaybeused.Forplasmablasticlymphoma,treatmentsarelikethoseusedforlymphoblasticlymphomaorBurkittlymphoma.Forinformationonthetreatmentoflymphoblasticlymphoma,seeTreatmentOptionsforLymphoblasticLymphomaandforinformationonthetreatmentofBurkittlymphoma,seeTreatmentOptionsforBurkittLymphoma. TreatmentofLymphoblasticLymphoma Forinformationaboutthetreatmentslistedbelow,seetheTreatmentOptionOverviewsection.Treatmentofadultlymphoblasticlymphomamayincludethe following:CombinationchemotherapyandCNSprophylaxis.Sometimesradiationtherapyisalsogiventoshrinkalargetumor.Targetedtherapywithamonoclonalantibodyalone(rituximab)orcombinedwithkinaseinhibitortherapy(ibrutinib).Aclinicaltrialofstemcelltransplantafterinitialtreatment. TreatmentofBurkittLymphoma Forinformationaboutthetreatmentslistedbelow,seetheTreatmentOptionOverviewsection.TreatmentofadultBurkittlymphoma mayincludethefollowing:Combinationchemotherapywithorwithoutmonoclonalantibodytherapy.CNSprophylaxis. TreatmentofRecurrentNon-HodgkinLymphoma Forinformationaboutthetreatmentslistedbelow,seetheTreatmentOptionOverviewsection.Treatmentofindolent, recurrentadult non-Hodgkinlymphomamayinclude thefollowing:Monoclonalantibody therapy(rituximaborobinutuzumab)withorwithoutchemotherapy.Lenalidomideandrituximab.PI3Kinhibitortherapy(copanlisib).EZH2inhibitortherapy(tazemetostat).Radiationtherapyaspalliativetherapytorelievesymptomsandimprovequalityoflife.Chemotherapywithoneormoredrugs.Radiolabeledmonoclonalantibodytherapy.CART-celltherapy.Stemcelltransplant.Treatmentofaggressive, recurrentadultnon-Hodgkinlymphomamayincludethefollowing:CART-celltherapywithaxicabtageneciloleucelforprimaryrefractorydiseaseorrelapsewithin1year.Bonemarrowtransplantorstemcelltransplantconsolidationtherapy.CART-celltherapyforrelapseafterautologousstemcelltransplant.Tafasitamabpluslenalidomide.Rituximabpluslenalidomide.Polatuzumabvedotinplusrituximabandbendamustine.Loncastuximabtesirine.Chemotherapywithorwithoutstemcelltransplant.ForcertainT-celllymphomas,monoclonalantibodytherapywithmogamulizumab.Monoclonalantibodytherapywithorwithoutcombinationchemotherapyfollowedbyautologousstemcelltransplant.Radiationtherapyas palliativetherapytorelievesymptomsandimprovequalityof life.Radiolabeledmonoclonalantibodytherapy.Formantlecelllymphoma,treatmentmayincludethefollowing:Brutontyrosinekinaseinhibitortherapy.Rituximabwithorwithoutatyrosinekinaseinhibitor(ibrutinib).Lenalidomide.Aclinicaltrialoflenalidomidewithmonoclonalantibodytherapy.Aclinicaltrialcomparinglenalidomidetoothertherapy.Aclinicaltrialofproteasomeinhibitortherapy(bortezomib).FordiffuselargeB-celllymphoma,treatmentmayincludethefollowing:Tafasitamabpluslenalidomide.Polatuzumabvedotin,combinedwithbendamustineandrituximab.Aclinicaltrialofautologousorallogeneicstemcelltransplant.Treatmentofindolent lymphomathatcomesbackasaggressivelymphomadependsonthetypeofnon-Hodgkinlymphomaandmayincluderadiationtherapyaspalliativetherapytorelievesymptomsandimprovequalityoflife.Treatmentofaggressivelymphomathatcomesbackasindolentlymphomamayincludechemotherapy. TreatmentofNon-HodgkinLymphomaDuringPregnancy InThisSectionIndolentNon-HodgkinLymphomaDuringPregnancyAggressiveNon-HodgkinLymphomaDuringPregnancyForinformationaboutthetreatmentslistedbelow,seetheTreatmentOptionOverviewsection.IndolentNon-HodgkinLymphomaDuringPregnancy Womenwhohave indolent(slow-growing) non-Hodgkinlymphomaduringpregnancymaybetreatedwithwatchfulwaitinguntilaftertheygivebirth.(SeetheTreatmentOptionsforIndolentNon-HodgkinLymphomasectionformoreinformation.)AggressiveNon-HodgkinLymphomaDuringPregnancyTreatmentofaggressive non-Hodgkinlymphomaduringpregnancymayincludethefollowing:Treatmentgivenrightawaybasedonthetypeofnon-Hodgkinlymphomatoincreasethemother'schanceofsurvival.Treatmentmayincludecombinationchemotherapyandrituximab.Earlydeliveryofthebabyfollowedbytreatmentbasedonthetypeofnon-Hodgkinlymphoma.Ifinthefirsttrimesterofpregnancy,medicaloncologistsmayadviseendingthepregnancysothattreatmentmaybegin.Treatmentdependsonthetypeofnon-Hodgkinlymphoma. ToLearnMoreAboutAdultNon-HodgkinLymphoma FormoreinformationfromtheNationalCancerInstituteaboutadultnon-Hodgkinlymphoma,seethefollowing:Non-HodgkinLymphomaHomePageDrugsApprovedforNon-HodgkinLymphomaTargetedCancerTherapiesImmunotherapytoTreatCancerForgeneralcancerinformationandotherresourcesfromtheNationalCancerInstitute,seethefollowing:AboutCancerStagingChemotherapyandYou:SupportforPeopleWithCancerRadiationTherapyandYou:SupportforPeopleWithCancerCopingwithCancerQuestionstoAskYourDoctoraboutCancerForSurvivorsandCaregivers AboutThisPDQSummary AboutPDQPhysicianDataQuery(PDQ)istheNationalCancerInstitute's(NCI's)comprehensivecancerinformationdatabase.ThePDQdatabasecontainssummariesofthelatestpublishedinformationoncancerprevention,detection,genetics,treatment,supportivecare,andcomplementaryandalternativemedicine.Mostsummariescomeintwoversions.Thehealthprofessionalversionshavedetailedinformationwrittenintechnicallanguage.Thepatientversionsarewrittenineasy-to-understand,nontechnicallanguage.BothversionshavecancerinformationthatisaccurateanduptodateandmostversionsarealsoavailableinSpanish.PDQisaserviceoftheNCI.TheNCIispartoftheNationalInstitutesofHealth(NIH).NIHisthefederalgovernment’scenterofbiomedicalresearch.ThePDQsummariesarebasedonanindependentreviewofthemedicalliterature.TheyarenotpolicystatementsoftheNCIortheNIH.PurposeofThisSummaryThisPDQcancerinformationsummaryhascurrentinformationaboutthetreatmentofadultnon-Hodgkinlymphoma.Itismeanttoinformandhelppatients,families,andcaregivers.Itdoesnotgiveformalguidelinesorrecommendationsformakingdecisionsabouthealthcare.ReviewersandUpdatesEditorialBoardswritethePDQcancerinformationsummariesandkeepthemuptodate.TheseBoardsaremadeupofexpertsincancertreatmentandotherspecialtiesrelatedtocancer.Thesummariesarereviewedregularlyandchangesaremadewhenthereisnewinformation.Thedateoneachsummary("Updated")isthedateofthemostrecentchange. Theinformationinthispatientsummarywastakenfromthehealthprofessionalversion,whichisreviewedregularlyandupdatedasneeded,bythePDQAdultTreatmentEditorialBoard. ClinicalTrialInformationAclinicaltrialisastudytoanswerascientificquestion,suchaswhetheronetreatmentisbetterthananother.Trialsarebasedonpaststudiesandwhathasbeenlearnedinthelaboratory.Eachtrialanswerscertainscientificquestionsinordertofindnewandbetterwaystohelpcancerpatients.Duringtreatmentclinicaltrials,informationiscollectedabouttheeffectsofanewtreatmentandhowwellitworks.Ifaclinicaltrialshowsthatanewtreatmentisbetterthanonecurrentlybeingused,thenewtreatmentmaybecome"standard."Patientsmaywanttothinkabouttakingpartinaclinicaltrial.Someclinicaltrialsareopenonlytopatientswhohavenotstartedtreatment. ClinicaltrialscanbefoundonlineatNCI'swebsite.Formoreinformation,calltheCancerInformationService(CIS),NCI'scontactcenter,at1-800-4-CANCER(1-800-422-6237). PermissiontoUseThisSummaryPDQisaregisteredtrademark.ThecontentofPDQdocumentscanbeusedfreelyastext.ItcannotbeidentifiedasanNCIPDQcancerinformationsummaryunlessthewholesummaryisshownanditisupdatedregularly.However,auserwouldbeallowedtowriteasentencesuchas“NCI’sPDQcancerinformationsummaryaboutbreastcancerpreventionstatestherisksinthefollowingway:[includeexcerptfromthesummary].” ThebestwaytocitethisPDQsummaryis:PDQ®AdultTreatmentEditorialBoard.PDQAdultNon-HodgkinLymphomaTreatment.Bethesda,MD:NationalCancerInstitute.Updated.Availableat:https://www.cancer.gov/types/lymphoma/patient/adult-nhl-treatment-pdq.Accessed.[PMID:26389337]Imagesinthissummaryareusedwithpermissionoftheauthor(s),artist,and/orpublisherforuseinthePDQsummariesonly.IfyouwanttouseanimagefromaPDQsummaryandyouarenotusingthewholesummary,youmustgetpermissionfromtheowner.ItcannotbegivenbytheNationalCancerInstitute.Informationaboutusingtheimagesinthissummary,alongwithmanyotherimagesrelatedtocancercanbefoundinVisualsOnline.VisualsOnlineisacollectionofmorethan3,000scientificimages. DisclaimerTheinformationinthesesummariesshouldnotbeusedtomakedecisionsaboutinsurancereimbursement.MoreinformationoninsurancecoverageisavailableonCancer.govontheManagingCancerCarepage.ContactUsMoreinformationaboutcontactingusorreceivinghelpwiththeCancer.govwebsitecanbefoundonourContactUsforHelppage.QuestionscanalsobesubmittedtoCancer.govthroughthewebsite’sE-mailUs.