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Non-Hodgkin's Lymphoma

Non-Hodgkin's lymphoma is a type of cancer that affects your lymphatic system. NHL can affect groups of lymph nodes in just one area of your body.

Your lymphatic system is the tissues and organs, including your bone marrow, spleen, thymus, and lymph nodes, that produce and store cells that fight infection and disease. These tissues and organs are connected by lymph vessels, which transport lymph fluid. Lymph fluid contains body fluid, fat and white blood cells called lymphocytes, which fight infection.

lymphatic system

There are two main types of lymphocyte: B cells (which produce antibodies) and T cells (which interact more directly with other cells and sometimes kill them, for example cells that are infected with a virus). These cells develop from stem cells - the most basic type of cell in your body.

 

 

NHL is a type of cancer that affects your lymphatic system. NHL can affect groups of lymph nodes in just one area of your body. However, the cancerous cells can spread through your lymphatic system to lymph nodes in other parts of your body where they may form secondary tumours. The cells may also spread to other parts of your body through your blood and may grow and form secondary tumours in other organs.

Around 400 people are diagnosed with NHL in Hong Kong every year. It accounts for about three in every 100 cancers diagnosed.

Types of non-Hodgkin's lymphoma

There are many different types of NHL. The two main types are:

  • low grade - these NHLs grow slowly and may need little or no treatment for months or years
  • high grade - these NHLs grow faster and may need immediate treatment because they progress very quickly, but they are more likely to be cured than low grade NHLs

NHL is also defined by the type of lymphocyte affected (B cells or T cells) and the exact form of cells involved. B cell NHLs are more common than T cell NHLs.

Your doctor will explain which type of NHL you have and how it will be treated, as this can vary considerably.

 

The first symptom of NHL is often swelling, usually of a gland in your neck, armpit or groin. It's usually painless. Other symptoms commonly include:

  • excessive sweating - particularly at night
  • recurrent high temperatures
  • unexplained weight loss
  • shortness of breath
  • a cough or difficulty breathing

These symptoms aren't always due to NHL but if you have them, visit your GP.

The causes of NHL aren't understood at present, but there are certain factors that can make it more likely, including the following.

  • A weakened immune system - such as if you have HIV/AIDS, or are taking medicines that suppress your immune system.
  • Age - NHL is more common in people over 50.
  • A virus such as the Epstein-Barr virus (glandular fever) or the human T cell lymphoma virus 1 (HTLV1).
  • Helicobacter pylori bacteria - this can cause a type of NHL in your stomach, called Mucosa-Associated Lymphoid Tissue (MALT) lymphoma.
  • Previous treatment for cancer.
  • Coeliac disease - this can slightly increase your risk of developing a type of NHL called Enteropathy Associated T Cell Lymphoma.

Your GP will ask about your symptoms and examine you. He or she may also ask about your medical history and take a blood test.

If your GP thinks you have NHL, he or she will refer you to a hospital specialist for further tests, which may include the following.

  • A biopsy - this is a small sample of tissue, which is taken from your lymph node. The sample will be sent to a laboratory for testing.
  • A CT scan, to see whether NHL has spread to other parts of your body.
  • A bone marrow biopsy, to check whether NHL has spread to your bone marrow.

Not all NHLs require treatment immediately - low grade NHLs may need little or no treatment for months or years. Your treatment will depend on the type of NHL you have and whether or not it has spread. The main types of treatment are chemotherapy, radiotherapy and monoclonal antibody therapy.

A team of professionals will help you through your treatment. This team may include a nurse specialist, a haematologist (a doctor who specialises in treating conditions of the blood), a haemo-oncologist (a doctor who specialises in the treatment of blood cancers such as NHL), a radiotherapist (a doctor who specialises in treating conditions using radiation) and a counsellor.

After treatment you will have regular check ups with your doctor to see if there are any signs of the cancer coming back.

 

Chemotherapy

Chemotherapy uses medicines to destroy cancer cells. The medicines will usually be injected into your arm, but you may need to take tablets or capsules instead. A combination of medicines may be given to you over a number of days - this is often followed by a break in treatment for a few weeks. The treatment cycle will then be restarted. The breaks between treatments allow your body to recover from the side-effects of the medicines.

You may be given steroid medicines (eg prednisolone) as part of your chemotherapy treatment.

You may need very high doses of chemotherapy if standard chemotherapy hasn't been successful or if the NHL has come back. If this happens, you may need to have a stem cell transplant to help you to produce healthy blood cells after you have had the high dose treatment. Stem cells are the most basic type of cells, from which all other types of cells in your body develop.

 

Radiotherapy

Radiotherapy uses radiation to destroy cancer cells. A beam of radiation is targeted on the cancerous cells, which shrinks the cancer. You will usually only have radiotherapy if the cancer is in one or two lymph node areas. It may be given alongside chemotherapy.

 

Monoclonal antibodies

Monoclonal antibodies are medicines that are designed to recognise and target markers that are commonly carried by cancer cells. Rituximab is a monoclonal antibody that is used to treat B cell NHLs. Rituximab is usually given in combination with chemotherapy.

Getting enough vitamin D may reduce your risk of developing a number of cancers, including NHL – although more research needs to be done to be certain. Vitamin D is also well known to be important for bone health.

Vitamin D is produced naturally by your body when your skin is exposed to sunlight and can also be obtained from some foods, such as oily fish.

You may get enough vitamin D during summer by spending frequent short spells in the sun without wearing sunscreen (the exact time you need is different for everyone, but is typically only a few minutes in the middle of the day). However, do not let your skin redden. If you don't get much sun exposure and particularly during winter months, taking up to 25 micrograms of vitamin D a day (two high-strength 12.5 microgram capsules) can help to make sure you get enough.

Always read the patient information leaflet that comes with your supplements and if you are pregnant or breastfeeding, ask your pharmacist or GP for advice first. Talk to your GP before taking vitamin D supplements if you are taking diuretics for high blood pressure or have a history of kidney stones or kidney failure.

Question: Where do the cells for a stem cell transplant come from?

Answer: The cells are usually taken from your own blood, before you have high dose chemotherapy.

 

Explanation: Stem cells are the most basic type of cell, from which all other cells in your body develop.

You may need a stem cell transplant if you have very high doses of chemotherapy to treat non-Hodgkin's lymphoma. This is to provide you with healthy blood cells after the treatment, because high dose chemotherapy may destroy your bone marrow, where your blood cells are produced.

The stem cells are usually taken from your blood after you have had standard chemotherapy treatment. You will be given daily injections of growth factor, which will increase the number of stem cells in your blood. The stem cells will then be collected through a tube in your arm and they will be stored. They will be put back in your body through a drip after you have had high dose chemotherapy treatment. This is known as an autologous stem cell transplant.

Less often, stem cells for a transplant are taken from your bone marrow. This is known as an autologous bone marrow transplant. A doctor will pass a needle through your skin into several places in your hip bone (pelvis) to collect cells from your bone marrow into a syringe. You will be given either a general anaesthetic (which means that you will be asleep during the procedure) or a local anaesthetic and sedation before the procedure.

In some circumstances you may need a stem cell or bone marrow transplant from another person. This is called an allogeneic transplant. Ideally it will be taken from a sibling (brother or sister) as their cells are most likely to closely match your own. You may need to have this type of transplant if NHL is affecting your bone marrow or if it has returned after a previous stem cell transplant of your own cells.

 

Question:How will a stem cell transplant affect me long-term?

 

Answer: A stem cell transplant affects everyone differently and the length of time it takes to recover varies.

 

Explanation: Your immune system (the system that defends your body against infection and other harmful substances) won't be very strong after a stem cell transplant and you will be more susceptible to infections.

Your doctor may give you antibiotics and mouthwashes to help prevent you getting an infection. There are also things you can do to help stop yourself getting an infection. For example, it's important to make sure that the environment around you is clean and free of germs. You also need to be aware of people who may pass on infections to you - try to stay away from people with coughs, colds and other infections.

You will probably feel tired after a stem cell transplant and may have some problems eating. It can take about a year for you to get back to your normal activities. You may also develop anaemia and have a sore mouth and mouth ulcers.

Some people need to have a stem cell or bone marrow transplant from another person. This is called an allogeneic transplant. If you have this type of transplant there is a chance that you could develop a condition called Graft versus host disease. This happens when the white blood cells of the donor attack the tissues of your body. It causes symptoms including diarrhoea, weight loss and rashes. You will be given medicines to prevent this.

 

Question: Will I still be able to have children after treatment for non-Hodgkin's lymphoma?

 

Answer: Many people have healthy children after they have been treated for NHL. However, certain treatments can reduce your chances of having children or cause infertility. Ask your doctor whether your treatment will affect your chance of having children.

 

Explanation: NHL is commonly treated with chemotherapy. Some chemotherapy medicines can cause infertility. If you want to have children in the future, your doctor may be able to use alternative medicines that don't have this effect. However, this depends on the type of NHL you have and whether or not it has spread. Ask your doctor about your treatment and whether it can affect your chances of having children.

If your treatment may affect your fertility, it's sometimes possible for you to store your eggs or sperm before you start treatment, so that you're able to have children in future. Your doctor will be able to give you more information on this.

Being told that you may be infertile and unable to have children can be very difficult to cope with. Try talking about your feelings with your partner, family or close friends as this may help you come to terms with how you're feeling. Some people find it helpful to talk to a trained counsellor.

 

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    • Pearce SHS, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ 2010;340: 142-47.
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    • Hodgkin's lymphoma symptoms and treatment. Cancer Research UK.www.cancerresearchuk.org/cancer-info/cancerstats/types/hodgkinslymphoma/treatment/, accessed 1 March 2010
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