Mesothelioma Info

Non-Hodgkin's lymphoma (NHL) is a type of cancer that affects the lymph system. A lymphoma is a cancer that originates in the lymphatic system, which is part of the body's immune system. The lymphatic system contains tiny vessels similar to blood vessels that transport lymph, a colorless fluid made of cells that fight infection, throughout the body. Lymphomas occur when cells in the lymph system are injured, become abnormal, and begin to multiply continuously. This proliferation makes it difficult for the body to produce healthy cells to protect against infection.
Because lymphoid tissue is found in many parts of the body (e.g., groin, spleen, thymus, tonsils, bone marrow, chest, neck, and abdomen), non-Hodgkin's lymphoma (NHL) can start anywhere and spread to any other part of the body, including the liver, bone marrow, spleen, and nose.
Non-Hodgkin's lymphoma can progress either slowly or aggressively. Lymphomas that grow slowly and produce fewer symptoms than more aggressive tumors are called indolent lymphomas. Aggressive lymphomas--also called intermediate- and high-grade lymphomas—grow and spread at an accelerated rate, and are associated with more severe symptoms. The prognosis for patients with Non-Hodgkin's lymphoma is based on whether the tumors are indolent or aggressive.
Lymphomas account for approximately 5% of all cases of cancer in the U.S. About 50,000 new cases of NHL occur annually in the U.S. The disease is becoming more common, possibly because of its link to human immunodeficiency virus (HIV). People who have autoimmune diseases like HIV or immune deficiencies are at risk for developing NHL because their immune systems are compromised, making it hard for them to fight off cancer cells. In addition, 3 out of 10,000 people receiving an organ transplant or who have a suppressed immune system will develop lymphoma. NHL is more common in men, Caucasians, and people who are over 50 years of age.
Treatment for patients with NHL depends on the number and location of tumors. Treatment usually involves radiation therapy, chemotherapy, or a combination of both. Treatment may also involve surgery, immunotherapy, and bone marrow transplantation.
Treatment for NHL is determined by the stage of the condition. Patients with highly aggressive or non-responsive disease are treated with more intensive therapy. In a few cases of NHL, high-dose chemotherapy, bone marrow transplantation, biological therapies, or surgery may be needed.
Causes

While there are some known risk factors for NHL, there are no known direct causes.
Symptoms

A painless swelling of the lymph nodes is the most common sign of NHL. The lymph nodes in the groin, abdomen, neck, or armpit are most commonly affected. A lump can be felt on either side of the neck, in the groin, in the armpit, or above the collarbone. Because enlarged lymph nodes are also a sign of infection, a doctor may observe them for a period of weeks to see if they change in size.
Abdominal swelling can occur in the abdomen because of fluid collection or swollen lymph nodes. This abdominal swelling may also cause constipation.
Other symptoms of NHL include:

• Enlarged lymph nodes
• Fever
• Excessive sweating or night sweats
• Weight loss; loss of appetite
• Fatigue
• Weakness
• Bone/flank pain
• Severe itchiness
• Coughing, shortness of breath, suffocation
• Constant tiredness
• Red patches on the skin
• Enlarged spleen

Patients experiencing general symptoms such as weight loss, night sweats, and fever (referred to as B symptoms ) may have an increased number of cancer cells. While these symptoms do not necessarily mean that a patient has NHL, patients who have been diagnosed with NHL and are experiencing B symptoms typically have more advanced disease and a poorer prognosis.
Risk Factors

A malfunction in the immune system may trigger an infection that predisposes people to NHL. As the body's defenses are altered, the risk of infection increases. People with particular infections such as HIV are at high risk for developing lymphoma.
Infections that are associated with NHL are:

• HIV
• human T-cell leukemia or lymphoma virus
• Epstein-Barr virus
• H. pylori infection
• Tuberculosis
• Kaposi's sarcoma-associated herpesvirus (KSHV)

Exposure to large amounts of chemicals or radiation may predispose people to NHL. Exposure to large quantities of chemicals (e.g., weed killers, pesticides, chemotherapy) or high levels of radiation (e.g., radiation therapy, nuclear reactor accidents) may increase your risk for NHL. Ironically, although chemotherapy and radiation therapy are used to treat cancer, they also predispose patients to NHL for 10 years after treatment.
Advancing age and gender may predispose people to NHL. The chances of developing NHL increase as one ages. NHL is more common in men than in women.
Diagnosis

Non-Hodgkin's lymphoma is diagnosed based on the cell types present as well as the extent to which the disease has spread throughout the body. A tissue sample (biopsy) from a lymph node is the most useful method for diagnosis, as it can be examined under a microscope to look for cancer cells. Based on how the tumor cells appear under a microscope, the pathologist estimates the potential of the cells to grow and spread. Doctors use information from the biopsy to “stage” cancer calls, or determine the extent of the disease by what parts of the body are affected. In order to stage a tumor, doctors consider:

• The number and location of the lymph nodes that have cancer cells
• The location of the affected lymph nodes: above, below, or on both sides of the diaphragm
• The presence of cancer cells in the bone marrow, spleen, or organs outside the lymphatic system

Your physician will ask about B symptoms, such as fever, night sweats, and weight loss. He or she will also carefully examine enlarged lymph nodes in your neck, armpits, or groin. Your physician will ask you about your medical history and conduct a physical examination to detect lymph node enlargement. As swelling of lymph nodes may indicate infection and not necessarily NHL, the physician may watch the swelling for a period of weeks before sending you for more testing.
Your physician may order scans, such as x-rays, computed tomography (CT scan), and MRI (which is the most sensitive imaging test) to detect the size and location of lymphomas throughout the body.
Table 1. Stages and Grades of Tumors and Treatment Options for Patients with NHL

Stage Grade Location NHL Treatment Comment I Low Only one lymph node or one area/organ outside the lymph nodes Radiation and/or chemotherapy depending on location Stage I often put into remission or alleviated I Intermediate Only one lymph node or one area/organ outside the lymph nodes Radiation and/or chemotherapy I High Only one lymph node or one area/organ outside the lymph nodes Aggressive chemotherapy; some radiation Treatment depends on cell type II Low Two or more lymph nodes in similar areas of the body, or one lymph node and area outside the lymph nodes Radiation and/or chemotherapy Treatment and remission or alleviation rates for stage II are 30% to 75% II Intermediate Two or more lymph nodes in similar areas of the body, or one affected lymph node and area outside the lymph nodes Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies II High Two or more lymph nodes in similar areas of the body, or one lymph node and area outside the lymph nodes Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies Treatment depends on cell type III Low Multiple areas of the body adjacent to lymph tissue, particularly to an area or organ near the lymph nodes or spleen Radiation and/or chemotherapy Standard therapies are not very effective III Intermediate Multiple areas of the body adjacent to lymph tissue, particularly to an area or organ near the lymph nodes or spleen Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies III High Multiple areas of the body adjacent to lymph tissue, particularly to an area or organ near the lymph nodes or spleen Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies IV Low Many areas of the body near and far from the lymph system Chemotherapy with or without radiation; bone marrow transplantation Patients without symptoms may not be treated, only monitored IV Intermediate Many areas of the body near and far from the lymph system Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies IV High Many areas of the body near and far from the lymph system Radiation and/or chemotherapy; surgery + chemotherapy; bone marrow or PBSC transplantation; new combination therapies Treatment depends on cell type
PBSC; peripheral blood stem cell
Prevention and Screening

Though it is difficult to prevent non-Hodgkins lymphoma, it is possible to lower the risk of certain infections, such as tuberculosis and HIV, that increase the likelihood of developing lymphoma. HIV patients should talk to their providers about their risk for developing NHL and any steps that can be taken to help lower that risk.
Treatment

Urgent Care

If you have NHL and have been prescribed chemotherapy, you may need to be hospitalized for treatment. Although chemotherapy is often given in a doctor's office or clinic, sometimes patients are hospitalized for a short time to receive treatment.
Swollen lymph nodes in the thymus gland, which is located in the neck, may produce life-threatening symptoms. Swollen lymph nodes in the thymus can block bloodflow inside the chest, or block airflow through the trachea. Blocked blood vessels cause the head and arms to swell, which can cause brain damage. Blockage of the trachea may cause shortness or breath, coughing, or suffocation. If you start to experience any of these symptoms, seek immediate medical attention.
Cancer patients are also at risk for other emergencies that arise either from the cancer or from the treatment. Severe complications can arise when the lymphoma produces too many white cells, called hyperleukocytosis. Other complications can include severe anemia, blood clots, excess calcium levels in the blood, liver disease and blockages in the intestine. All patients should be monitored carefully for these complications by their doctors. If you have NHL and you feel weak, dizzy, light-headed or you notice weakness in one part of your body, you should notify your doctor immediately. Self Care

If you are undergoing chemotherapy, take steps to avoid infection: wash your hands thoroughly, avoid uncooked fruit or other germ-carrying foods, and avoid contact with children or other individuals suspected of having an infection. Patients receiving anticancer drugs are more likely to get an infection because of the alterations such drugs cause in the immune system. Children are more likely than adults to carry infections; however, taking precautions to avoid exposure to germs minimizes the risk for infection. For example, a surgical mask, sterile gown, and/or surgical gloves may be worn to minimize exposure.
Eat a healthy diet.
Patients undergoing anticancer treatment need to make every effort to get enough calories and protein in their diet to help them regain strength, increase energy, and prevent weight loss.
Drug Therapy

Your doctor is the best source of information on the drug treatment choices available to you.
Other Therapies

If you have NHL, you may be treated with radiation therapy. Radiation therapy involves exposing cancer-infected areas to high-energy radiation. Radiation therapy can also be used to ease the symptoms associated with lymphoma in the internal organs, such as the brain and spinal cord. Radiation treatment—sometimes combined with chemotherapy—is usually given for three to four weeks, and it is often combined with chemotherapy to treat NHL.
If you currently are taking anticancer drugs or undergoing radiation therapy and your blood cell counts are low, you may need a blood transfusion. Platelet transfusions protect against bleeding; red cell transfusions are used to treat the fatigue associated with radiation therapy.
You may be prescribed a biological therapy, which can stimulate or restore the immune system's ability to fight infection and disease. Three of these therapies are interferon, anti-CD20 therapy, and radioimmunoconjugation therapy. Biological therapies can kill lymphoma cells, slow their growth, or activate the immune system to fight cancer cells more efficiently. These therapies can also lessen the side effects of some cancer treatments. Interferon, a hormone-like substance, is produced by the blood cells of the immune system to fight infection, and can cause some NHL tumors to shrink. Antibodies are also produced by the immune system to help combat infection, and can be designed specifically to attack the cancer cells. Anti-CD20 therapy is an antibody designed to attack a specific type of cancer cell. .
Radioimmunoconjugation therapy is also a biological therapy, but is different in that it is an antibody attached to a radioactive element. Therefore, radioimmunoconjugation provides highly targeted radiation therapy only to the cancer cells.
If you relapse, your doctor may recommend bone marrow transplantation. Patients who relapse and are still sensitive to anticancer drugs usually receive bone marrow or blood cell transplantation. Bone marrow or blood cells can be retrieved either from the patient or from a relative whose basic cell type is identical. The goal of transplantation is to replace the blood-forming cells that have been destroyed by cancer treatment. Therefore, transplantation is done after chemotherapy. This helps the patient to produce healthy blood cells that are needed to fight infection.
Joining a support group may be help you cope with NHL. Patients with non-Hodgkin's lymphoma disease often have concerns about such things as holding their jobs, caring for their families, treatments, hospital stays, and meeting expenses. Because support from friends and family may not be enough, some patients benefit from discussing their concerns with other cancer patients.
Surgery

If the doctor suspects that you have NHL, he or she may suggest surgery to obtain a tissue sample to confirm the diagnosis. Removing the entire lymph node or a small part of a larger tumor requires surgery. If the node is near the skin surface, local anesthesia is used. If the node or tumor is inside the chest or abdomen, the surgeon will use general anesthesia.
If the lymphoma starts in an organ, such as the thyroid gland or the stomach, and has not progressed, you may need surgical treatment. Surgery is rarely used to treat NHL; however, it can be useful in particular cases. For example, removing a bulky tumor from the stomach can be useful before starting chemotheapy.
Alternative Medicine

Consider alternative therapies (in addition to standard cancer treatment) to relieve pain, reduce side effects, and enhance your emotional, physical, and spiritual well-being. Always consult your doctor before starting any alternative therapy to make sure it will not be harmful to you.
Special Circumstances

If you are pregnant, discuss treatment options for NHL with your doctor. Data are sparse regarding the long-term effects of anticancer drugs on children who were exposed in utero. For some patients, early delivery, if feasible, may be the best option to avoid exposing the fetus to radiation and anticancer drugs.
Prognosis

Early-stage, indolent, or low-grade NHL may be put in remission or alleviated effectively with radiation therapy. Indolent NHL responds both to treatment with radiation and anticancer drugs. Thirty percent of patients with NHL can be cured with effective treatment.
More aggressive NHL may be put into remission or alleviated with an intensive combination of anticancer drugs and/or bone marrow or PBSC transplantation. Thirty to sixty percent of patients with aggressive NHL can attain complete remission. In addition, a combination of anticancer therapy and therapy with an antibody that is used for treating a particular type of lymphoma—may increase survival of these patients.
The overall survival rate of patients with NHL varies depending on stage and grade, and ranges from 20% to 95%. Patients who have HIV and the develop NHL have a poorer prognosis than the general population. The survival rate depends on the person's age, general health, response to treatment, and grade and stage of the NHL. Thus, a definite prognosis is difficult. Patients with lymphoma at higher stages and grades have a poorer prognosis than other patients, and patients over 60 years of age have a poorer outcome than younger patients.
Relapses usually occur within the first two years after treatment, and are more common in patients with advanced-stage NHL. Patients who have a relapse can be successfully re-treated. Patients with relapsed NHL who receive bone marrow or blood cell transplantation in combination with anticancer drugs have a 20% to 60% survival rate at two and five years after treatment, repectively. Bone marrow or blood cell transplantation procedures are usually used for patients who have relapsed lymphoma and are still sensitive to anticancer drugs. These procedures predispose a patient to leukemia and death because high doses of anticancer drugs and radiation are administered as a component of transplantation therapy.
Follow-up

Schedule a visit with your physician every three months after treatment. You will need to follow up with a physician for several years. Regular follow-up visits are necessary to discuss changes in your health. During your appointment, the doctor will take a general medical history and conduct a physical examination, paying careful attention to the size and firmness of the lymph nodes.
Report any new symptoms to your doctor immediately. New symptoms may be caused by side effects of treatment or recurrent cancer.