OVERVIEW

What is lymphoma?

Lymphoma is a malignant tumor of the immune system that originates in lymph nodes and lymphatic tissues. Based on histopathological changes, it can be divided into two main types: Hodgkin lymphoma and non-Hodgkin lymphoma.

What is non-Hodgkin lymphoma?

Hodgkin lymphoma and non-Hodgkin lymphoma are classifications in tumor pathology. All lymphomas other than Hodgkin lymphoma fall under non-Hodgkin lymphoma.

Based on pathological examination results, doctors further categorize non-Hodgkin lymphoma into three main groups: precursor lymphoid neoplasms, mature B-cell neoplasms, and mature T-cell and NK-cell neoplasms.

Different types of lymphoma correspond to different treatment plans.

SYMPTOMS

Where can non-Hodgkin lymphoma occur?

Non-Hodgkin lymphoma can occur anywhere in the body, with the most common sites being lymph nodes. These include palpable enlarged lymph nodes in the neck, armpits, above the collarbone, or groin (near the upper thigh), as well as deeper lymph nodes that cannot be felt, such as those in the mediastinum or retroperitoneum.

Additionally, non-Hodgkin lymphoma can develop in lymphoid tissues outside the lymph nodes, such as the tonsils, spleen, bone marrow, nasopharynx, gastrointestinal tract, bones, or skin. Sometimes, there may be no visible changes or obvious symptoms, yet the disease has already been silently progressing internally.

What are the earliest symptoms of non-Hodgkin lymphoma?

In non-Hodgkin lymphoma, painless enlarged lymph nodes are the most common initial clinical manifestation. Systemic symptoms are more often seen in advanced stages. However, since non-Hodgkin lymphoma can also occur in any lymphoid tissue outside the lymph nodes, symptoms can vary widely.

What are the systemic symptoms of non-Hodgkin lymphoma?

• Persistent fever ≥ 38°C (100.4°F) for more than three days without an infectious cause;
• Unintentional weight loss of more than 10% within six months;
• Night sweats (sweating after falling asleep).

When non-Hodgkin lymphoma appears in the nasal cavity, symptoms like nasal congestion or nosebleeds may occur. If it affects the gastrointestinal tract, abdominal pain or diarrhea may develop.

Is non-Hodgkin lymphoma classified into early and late stages? How is it staged?

It is divided into stages I to IV:

• Stage I: The tumor is confined to one lymph node region;
• Stage II: The tumor involves two or more lymph node regions on the same side of the diaphragm;
• Stage III: The tumor involves lymph node regions on both sides of the diaphragm;
• Stage IV: Involvement of the liver, bone marrow, or widespread extranodal disease;
• Subclassification E: Localized extranodal disease.

The spleen is considered a lymph node region, and staging also considers the presence or absence of systemic symptoms.

In simple terms, stages I to IV correspond to early to advanced disease. Different stages of the same disease may require different treatment approaches and have varying prognoses.

CAUSES

What causes non-Hodgkin's lymphoma?

The exact etiology and pathogenesis of non-Hodgkin's lymphoma remain unclear, but current research suggests associations with the following factors:

• Infections: Epstein-Barr virus (EBV), retroviruses, human herpesvirus-8 (HHV-8), Helicobacter pylori, hepatitis B and C viruses, etc.
• Immune dysfunction: Genetic mutations leading to immunodeficiency, AIDS-related lymphoma, autoimmune diseases, etc.
• Environmental and occupational exposures: Pesticides, herbicides, prolonged contact with leather, dyes, radiation, etc.

Is non-Hodgkin's lymphoma hereditary?

There is currently no strong evidence suggesting that non-Hodgkin's lymphoma is hereditary, so patients need not be overly concerned.

DIAGNOSIS

Diagnosis and Staging of Non-Hodgkin Lymphoma: What Tests Are Needed?

• Blood tests: In addition to routine tests such as complete blood count and liver/kidney function, lactate dehydrogenase, blood β₂-microglobulin, EB virus, hepatitis B "two-and-a-half" panel, and tests for hepatitis B, hepatitis C, and HIV are required.
• Imaging tests: Lymph node ultrasound, chest/abdominal/pelvic CT, and positron emission tomography/computed tomography (PET/CT) are necessary. If PET/CT is unavailable, contrast-enhanced CT can be used as an alternative. Due to the complexity of non-Hodgkin lymphoma and individual patient differences, doctors may also recommend additional tests such as brain MRI when necessary.
• Other tests: Lymph node biopsy, bone marrow aspiration, and bone marrow biopsy are also required.

Why Is a Lymph Node Biopsy Needed for Non-Hodgkin Lymphoma?

A lymph node biopsy is highly accurate and serves as the "gold standard" for diagnosing lymphoma.

Why Are Bone Marrow Aspiration and Biopsy Necessary for Non-Hodgkin Lymphoma?

Bone marrow aspiration (including biopsy) aids in both diagnosis and staging of non-Hodgkin lymphoma, playing a crucial role in refining the diagnosis and guiding treatment.

Why Is PET/CT Needed for Non-Hodgkin Lymphoma, and Is It Harmful to the Body?

PET/CT is currently the best method for determining lymphoma staging and an essential tool for evaluating treatment efficacy.

The radiation exposure from one scan is comparable to a round-trip flight between China and the U.S., far below harmful levels. Residual radiation typically dissipates within a day and a half. If PET/CT is unavailable, contrast-enhanced CT can be used as an alternative.

TREATMENT

Which department should I see for non-Hodgkin's lymphoma?

If lymphoma is suspected, you should visit the oncology or hematology department of a regular hospital.

If initial symptoms appear in areas such as the skin—like skin lumps or hardening—you may first visit the relevant department (e.g., dermatology) for examination and then be referred.

What are the treatment options for non-Hodgkin's lymphoma?

• Chemotherapy: Chemotherapy is the primary treatment for non-Hodgkin's lymphoma.

• Biological agents: With rapid advancements in biologics, various monoclonal antibodies have entered the market, such as the well-known and widely used CD20 monoclonal antibody rituximab (Rituxan).

• Radiation therapy: For stage I and some favorable stage II non-Hodgkin's lymphoma, radiation is a common treatment to control and shrink lesions.

• Beyond these three methods, other options—like hematopoietic stem cell transplantation, surgical removal of lesions before chemo/radiation, and interferon therapy—may be considered based on individual cases.

Can surgery alone cure non-Hodgkin's lymphoma if only one lesion is found?

No. Non-Hodgkin's lymphoma is a systemic disease, so even a single lesion cannot be fully cured by surgical removal alone.

What is the purpose of surgical intervention in non-Hodgkin's lymphoma?

In most cases, surgery is performed to obtain biopsy samples for pathology—such as when mediastinal or retroperitoneal lymph nodes cannot be accessed via needle biopsy or when insufficient tissue is obtained. In some cases, surgery may be needed to relieve severe compression symptoms, but chemotherapy and/or radiation are still required afterward.

Does non-Hodgkin's lymphoma require long-term treatment?

Yes. Regardless of the subtype, treatment for non-Hodgkin's lymphoma is a long-term battle. For example, the standard (R)-CHOP regimen involves cycles every 3 weeks, typically totaling 6 cycles (± 2 additional cycles of (R)), meaning chemotherapy alone takes 18–24 weeks. Radiation may extend this further. Treatment plans vary by subtype and individual response, so patients and families should prepare mentally and financially for a prolonged process.

Why are frequent evaluations needed during treatment, and how often?

Non-Hodgkin's lymphoma is highly complex, with varying treatments even within subtypes. Regular assessments help adjust the approach. Evaluations typically follow guidelines but may be scheduled earlier if needed based on the patient’s response.

Why do treatment drugs differ for non-Hodgkin's lymphoma?

Treatment is personalized based on disease specifics and staging. For example, rituximab is used if CD20 is positive, but not all cases express this marker. Drug costs may also influence choices.

Is chemotherapy for non-Hodgkin's lymphoma given through hand veins?

No. Due to the toxicity and long duration of treatment, peripheral veins (e.g., hand veins) would be damaged. Instead, central venous access (PICC or PORT) is used to protect veins and reduce discomfort.

What is a PICC line for non-Hodgkin's lymphoma patients?

A PICC (peripherally inserted central catheter) is a long, flexible tube inserted via an arm vein to deliver drugs near the heart. It requires weekly care and activity restrictions (e.g., no heavy lifting, careful showering).

What is a PORT for non-Hodgkin's lymphoma patients?

A PORT (implantable venous access port) is a device placed under the skin to deliver drugs to central veins. It requires monthly maintenance but allows normal activities.

Why is hepatitis B testing needed before treatment?

Chemotherapy or immunosuppressants (e.g., rituximab) can reactivate hepatitis B, worsening outcomes. HBV DNA, liver function, and serology are checked before and during treatment.

Should hepatitis B medication continue after lymphoma treatment?

If baseline HBV DNA was <2000 IU/mL, antiviral therapy should continue for 6–12 months post-chemotherapy. Decisions depend on individual factors; consult your doctor before stopping.

How long can someone live with non-Hodgkin's lymphoma?

Survival varies by subtype and stage. Prognostic factors include tumor stage, gene expression, and international prognostic index. Discuss specifics with your doctor.

How often should follow-ups occur after treatment?

For the first 5 years, check-ups every 3–6 months are typical, adjusted as needed. After 5 years, frequency depends on the patient’s condition.

Can non-Hodgkin's lymphoma recur after treatment?

Yes. Despite improved therapies, some patients relapse or develop resistance. Regular follow-ups help detect recurrence early.

How to manage severe vomiting during chemotherapy?

Antiemetics are used preventively, but patients should also adjust diet and mindset to minimize nausea, which typically peaks 1–6 hours post-treatment.

What is the estimated cost of non-Hodgkin's lymphoma treatment?

Initial diagnosis (including PET/CT, often not covered by insurance) may exceed ¥10,000. Treatment costs vary widely—biologics or epigenetic drugs can cost tens of thousands per cycle.

DIET & LIFESTYLE

Are there any dietary requirements for non-Hodgkin's lymphoma?

There are usually no special requirements, but adjustments should be made based on the actual situation. For example, when non-Hodgkin's lymphoma occurs in the gastrointestinal tract and causes severe symptoms like diarrhea or bloody stools, hypoalbuminemia may develop. In such cases, a high-quality protein diet can be provided to improve nutrition.

Can non-Hodgkin's lymphoma patients continue with normal work and study?

Non-Hodgkin's lymphoma has many subtypes. For some indolent lymphomas that do not yet meet treatment criteria, patients can still live normally, work, and study, but should avoid fatigue and infections. If it is a subtype requiring urgent treatment, the patient must focus "full-time" on treatment.

What should non-Hodgkin's lymphoma patients do if they still want to have children?

If a patient is diagnosed with non-Hodgkin's lymphoma and requires immediate treatment but is not pregnant and still wishes to have children, they may choose to freeze sperm or eggs before chemotherapy.

If a patient is diagnosed with non-Hodgkin's lymphoma during pregnancy and requires treatment, termination of pregnancy is necessary if it is in the first trimester. For later stages of pregnancy, the decision should be made jointly with the clinician, considering the specific chemotherapy plan, the patient's condition, and their wishes.

PREVENTION

Can Non-Hodgkin's Lymphoma Be Prevented?

Since the exact cause and pathogenesis of non-Hodgkin's lymphoma are not fully understood, there are no specific preventive measures. It is advisable to maintain adequate rest, balance work and leisure, engage in moderate exercise, avoid infections as much as possible, and minimize prolonged or excessive exposure to herbicides, radiation, pesticides, leather, etc.