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Blood Cancer and Non-Hodgkins Lymphoma (NHL)
Treatment Options
Non-Hodgkin's Lymphoma Treatment
The treatment of non-Hodgkin's lymphoma (NHL) depends on the type, location, grade, and stage of disease, as well as personal factors such as the patient's age and overall health. Yet some general principles apply.
Localized, early-stage NHL
If the patient is diagnosed with localized, slow-growing, early stage (Stages 1 or 2) NHL, radiation therapy is the main form of treatment.
Nonlocalized, late-stage NHL
If the patient has nonlocalized, slow-growing, late stage (Stages 3 or 4) non-Hodgkin's lymphoma, the treatment plan is not so well defined. Because of the unhurried growth of such tumors, chemotherapy and radiotherapy - which selectively destroy rapidly-dividing cells - cannot eliminate all of the patient's cancer cells. Therefore, these tumors usually are not "curable." In spite of this, treatment options may include single agent chemotherapy, or combination chemotherapy, or chemotherapy plus radiation therapy.
In addition, some physicians and patients may choose to delay treatment until symptoms appear, especially with elderly patients or in those who have significant health problems. Yet recent findings suggest that the patient's survival is improved when treatment is begun soon after diagnosis.
Waldenstrom's macroglobulinemia
If the patient is diagnosed with a slow-growing non-Hodgkin's lymphoma that is associated with Waldenstrom's macroglobulinemia - a condition in which too much of the antibody immunoglobulin M [IgM] is produced - the physician may recommend plasmapheresis before treatment of the NHL with chemotherapy. Plasmapheresis involves separating the plasma and its components, including IgM, from the blood, with eventual re-transfusion into the patient.
Aggressive, early-stage NHL
People with aggressive, intermediate-grade NHLs in early stages (Stages 1 or 2) usually are treated with combination chemotherapy, or radiation therapy plus chemotherapy.
If the individual has health problems that do not permit the use of chemotherapy, radiation therapy may be used alone.
Aggressive, late-stage NHL
People with aggressive, intermediate-grade NHLs in late stages (Stages 3 or 4) may be treated with combination chemotherapy (plus radiation therapy for individuals with bulky tumors), or high-dose chemotherapy with stem cell transplantation.
In addition, patients may be given growth factors to aid the recovery of bone marrow cells and prevent infections after chemotherapy treatment.
Highly aggressive NHL
Patients with highly aggressive, high-grade NHLs such as Burkitt's lymphoma, Burkitt's-like lymphoma, and lymphoblastic lymphoma are treated with intrathecal chemotherapy - chemotherapy injected directly into the spinal fluid - to prevent the spread of cancer to the brain and central nervous system (CNS).
Unfortunately, some patients may have certain conditions or characteristics that make them less responsive to such treatment. In these cases, the oncologist may recommend high-dose chemotherapy with stem cell transplantation or biological therapies.
Patients with acute T-cell leukemia/lymphoma generally have a poor prognosis. Yet new antiviral drugs for HIV (human immunodeficiency virus) infection have shown some activity against this lymphoma. This is because HIV is related to HTLV-1 (human T-cell leukemia/lymphoma virus) - the virus that is associated with human T-cell lymphoma.
Gastric (stomach) NHL
It is now known that gastric NHLs are associated with Helicobacter pylori - the bacteria that are responsible for stomach ulcers. The infection and inflammation caused by these bacteria are believed to spur an abnormal immune system response by stomach lymphocytes. In some individuals, this response may lead to the development of a gastric non-Hodgkin's lymphoma. Treatment of low-grade gastric NHL with antibiotics (e.g., ampicillin and metronidazole) may shrink and/or completely rid the stomach of tumor.
Yet, if gastric non-Hodgkin's lymphoma returns, chemotherapy, radiation therapy, and/or surgical resection (cutting away) of the tumor may be necessary. The choice of therapy depends upon the type of non-Hodgkin's lymphoma. Slow-growing, mucosa-associated lymphoid tissue (MALT) tumors will be treated differently from more aggressive, high-grade lymphomas.
Cutaneous (skin) NHL
Lymphoma that arises in the skin is known as primary cutaneous (skin) lymphoma. Cutaneous lymphomas include cutaneous T-cell lymphoma (CTCL; also known as mycosis fungoides) Sézary syndrome, and other T-cell and B-cell lymphomas. The management of these tumors - which are primarily T-cell in type - differs from the treatment of most other NHLs. A biopsy may be required to confirm a diagnosis of cutaneous lymphoma, which can produce symptoms such as redness, thickening, generalized plaques (patches), or nodules (knot-like lumps).
CTCL may be treated by a variety of methods that directly involve the skin. These include:
• Topical (applied to the skin) chemotherapy
• Electron beam radiation therapy (radiation of the skin surface), a form of radiation that does not penetrate too deeply and thereby does not damage organs below the skin
• Psoralen plus ultraviolet light (PUVA) therapy - Psoralen is a drug that can make cells light-sensitive. It is taken orally, and then the patient's skin is exposed to ultraviolet light. During PUVA therapy, CTCL cells take up psoralen and are selectively killed by light exposure.
If NHL has spread to the lymph nodes and other organs beyond the skin, other treatments will be required, such as systemic chemotherapy or biological therapies with substances such as interferon, monoclonal antibodies, cis-retinoic acid (a chemical relative of vitamin A), or other new compounds, such as cytotoxic fusion protein, a protein that binds to cancers cells and causes them to die.
Extranodal NHL
"Primary extranodal non-Hodgkin's lymphoma" refers to a lymphoma that arises outside of the lymph nodes in an organ that is considered to be the major site of disease. Typical locations for extranodal NHLs are the sinuses, thyroid, tonsil, salivary gland, eye/eye socket, breast, testis, kidney, lung, stomach, and bowel. Surgery has a controversial role in the management of extranodal NHL. In general, such cancers are not cured by surgery alone, although resection of the tumor may be helpful if the disease remains confined. If the extranodal NHL has spread to other locations, the physician may recommend treatment by chemotherapy, with/without radiation therapy.
Recurrent NHL
Low-grade NHLs that come back after a remission (a period in which cancer is not detectable) usually are treated with chemotherapy, or chemotherapy plus radiation therapy.
Unfortunately, up to one-third of all low-grade non-Hodgkin's lymphomas will change into aggressive lymphomas. In such cases, the cancer becomes fast-growing and endangers the patient's life. Therefore, treatment of transformed NHLs usually consists of combination chemotherapy, or high-dose chemotherapy with stem cell transplantation.
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