Non-Hodgkin lymphoma (NHL) is a blood cancer with more than 60 subtypes. It is one of the most common cancers in the U.S. It happens when a type of white blood cell called a lymphocyte changes and grows out of control.
Each year at Fred Hutchinson Cancer Center, we care for more than 3,000 patients with NHL — including more than 60 rare subtypes. We provide all standard therapies. Our experts are national leaders in NHL research and have developed many of these approaches.
Diagnosing NHL involves a series of blood tests and then a lymph node biopsy, which shows if you have cancer. The biopsy gives details about the type and subtype of cancer you have.
At Fred Hutch, our experts check and confirm your subtype. Knowing your subtype is important, because each behaves differently and requires a different type of treatment.
Finding out your subtype can be a challenge. Hematopathologists (lab experts who look at samples of your blood under a microscope) can recognize which subtype you have by carefully studying your blood. At Fred Hutch, our hematopathologists are very experienced in identifying exact NHL subtypes.
Staging means finding out how far NHL has spread in your lymph system or other parts of your body. Accurate staging helps your physician predict which treatments are most likely to control your disease or put it into remission.
Physicians use Roman numerals I (one), II (two), III (three) and IV (four) to name the stages of NHL. Stage I is the least advanced, and stage IV is the most advanced. All stages can be treated.
Your physician may add a letter to your stage to reflect details about your disease:
To diagnose the stage of your NHL, you need imaging tests and blood tests.
Imaging tests show which lymph nodes are bigger than normal, if other organs are affected and if you have any large tumors.
Blood tests check for lymphoma cells in your blood. They also check for other substances (like proteins) that can tell physicians how severe your disease is, if your organs are working well and how urgently you need treatment.
You will probably also have tests to check whether lymphoma is in your bone marrow.
Imaging tests to stage NHL include:
Blood tests to assess NHL may include:
After numbing the area so there is no pain, a physician uses a hollow needle to take a sample of marrow (bone marrow aspiration) and a small piece of bone (bone marrow biopsy). A pathologist checks these samples for signs of cancer.
Other Tests You Might Need
Your physician recommends other tests based on your NHL subtype and your signs and symptoms. For example, if you have a type of lymphoma that affects the digestive tract, you may need an endoscopy to check your esophagus, stomach or small intestine. You may need a colonoscopy to check your large intestine. If it seems like lymphoma is affecting your brain or spinal cord, you may need a lumbar puncture.
There are more treatment options today than ever before to control NHL or put it into remission.
This is an aggressive subtype of B-cell NHL found mostly in young men. The average age at diagnosis is 30. In the U.S., the disease usually starts as a large tumor in the belly. It can also start in the testicles, ovaries or other organs. Patients are usually treated with chemotherapy. More than half of patients go into complete remission.
CLL and SLL are closely related. They are a subtype of B-cell NHL.
Along with common NHL symptoms, CLL/SLL may cause shortness of breath, anemia, bruising and frequent infections.
Both CLL and SLL tend to be slow-growing, but each patient’s version of these conditions can vary significantly. You and your physician may decide to monitor the disease, but not to treat it. This is called watchful waiting. If you do need active treatment, it could include oral therapy, chemotherapy, antibody therapy, blood or marrow transplant or clinical trial therapy.
Learn more about CLL
This is also known as lymphoma of the skin. It mainly affects lymphocytes in the skin but may involve lymph nodes, blood and other organs.
It is nearly always slow-growing. Almost half of people with this disease have a recurrence after responding to treatment at first.
Treatment may focus on:
Learn more about CBCL
DLBCL is the most common subtype of NHL. It is also a subtype of B-cell NHL. DLBCL makes up about 30 percent of NHL cases in the U.S.
DLBCL advances quickly. Treatment usually starts right away with chemotherapy and the antibody therapy called rituximab. After the first treatment, about two-thirds of patients will go into long-term remission. In some people, the disease does not respond to treatment (refractory disease), or it gets better but then gets worse (relapsed disease). Then, options include high-dose chemotherapy plus a blood or marrow transplant or cellular immunotherapies, such as axicabtagene ciloleucel (Yescarta®), tisagenlecleucel (Kymriah®) and lisocabtagene maraleucel (Breyanzi®).
Follicular means the cells tend to come from a central part (B-cell follicle) of the lymph node. This subtype of B-cell NHL is often slow-growing. It makes up about 20 percent of NHLs and affects many lymph nodes throughout the body as well as the bone marrow. About 30 percent of the time, it turns into aggressive diffuse B-cell lymphoma.
Since it typically grows slowly, you and your physician may decide to monitor the disease, but not treat it. This is known as watchful waiting.
If you do need active treatment, it could include chemotherapy, radiation therapy or immunotherapy. Many patients go into long-term remission after treatment. For most people, the disease gets better but then gets worse (relapsed disease) or does not respond to treatment (refractory disease). Then, options include cellular immunotherapies, such as axicabtagene ciloleucel (Yescarta®) and lisocabtagene maraleucel (Breyanzi®); high-dose chemotherapy plus a blood or marrow transplant; or treatments that are being tested in clinical trials.
This is a subtype of B-cell NHL that gets its name from the way the cells look. They have very thin structures on their surface that make them look hairy. The disease is rare, with fewer than 1,000 people diagnosed in the U.S. each year.
It is slow-growing. Treatment may not be needed in the early stages. Some patients need a blood transfusion from time to time. If your spleen becomes enlarged or your blood counts drop, your options may include surgery to remove the spleen and chemotherapy.
In this subtype of B-cell NHL, abnormal lymphocytes build up, forming nodules around the body, most often the lungs. The nodules damage or destroy blood vessels in the area. This subtype is linked to infection with Epstein-Barr virus, which causes mononucleosis (often called mono).
If the disease has a low impact on your health, you and your physician may decide to monitor the disease, but not treat it. This is called watchful waiting. If you do need active treatment, options include interferon, corticosteroids, chemotherapy and the antibody therapy called rituximab.
MCL typically affects men between the ages of 50 and 70. By the time it is diagnosed, it has often already spread throughout the body. It may be in the lymph nodes, bone marrow, blood, digestive tract and spleen.
This B-cell NHL subtype can be hard to label as either slow-growing or fast-growing. Physicians often approach MCL as fast-growing (aggressive) because it is hard to treat, and most patients will develop symptoms in weeks to months.
Treatment may include chemotherapy combined with immunotherapy or clinical trial therapy. Brexucabtagene autoleucel (Tecartus®), available at SCCA, is an FDA-approved cellular immunotherapy treatment for patients with relapsed (the disease gets better but then gets worse) or refractory (does not respond to treatment) MCL. Blood or marrow transplant is an option for some people. Many treatments are being studied in clinical trials.
Extranodal marginal zone B-cell lymphoma (mucosa-associated lymphoid tissue lymphoma, MALT)
This starts outside the lymph nodes. Usually, it is only in the area where it began. Gastric MALT develops in the stomach. It may be linked with an infection. Antibiotics for the infection are usually the first treatment, and they often put the cancer into complete remission. If the cancer relapses (gets better but then gets worse), physicians may use immunotherapy, chemotherapy, radiation therapy or surgery. Non-gastric MALT develops in the lungs, skin, thyroid, salivary glands and tissues near the eye. Treatment depends on where the disease is. It usually involves surgery or radiation therapy.
Nodal marginal zone B-cell lymphoma
This disease, found mainly in women, usually stays in the lymph nodes. Lymphoma cells may also be in the bone marrow. Treatment often begins with watchful waiting. If you need active treatment, options include radiation therapy and chemotherapy.
Splenic marginal zone B-cell lymphoma
This subtype of NHL, found in the bone marrow, blood and spleen, is rare. It is typically found in men and has been linked with hepatitis C. Treatment may include watchful waiting unless symptoms become a problem. If you need active treatment, options include surgery to remove the spleen, radiation therapy to the spleen, immunotherapy and chemotherapy.
This rare B-cell NHL subtype is more common in people with immune system diseases, such as HIV/AIDS. It often involves the brain (primary brain lymphoma) and may be found in and around the spinal cord and eyes (primary intraocular lymphoma).
Over time, it spreads throughout the central nervous system (brain and spinal cord). The symptoms are different from other lymphomas. Symptoms may include headaches, confusion, vision problems, facial paralysis and seizures.
Patients with this subtype may start treatment by taking corticosteroids to control symptoms and reduce swelling. Other treatments include chemotherapy, radiation therapy and sometimes a blood or marrow transplant.
Waldenström macroglobulinemia (WM) cells grow mainly in your bone marrow. There, they can crowd out the normal, healthy blood cells that your body needs (white blood cells, red blood cells and platelets). WM cells also make large amounts of an antibody called immunoglobulin M. This can build up around your body, causing other symptoms.
Treatment for WM is different from treatment for other types of lymphoma, and there is no one standard treatment. It is important to be treated at a specialized center, where physicians who are experts in WM can match your treatment to your situation.
Learn more about Waldenström macroglobulinemia
There are three types of this rare, aggressive T-cell lymphoma:
Both ALK+ and ALK- are treated as aggressive lymphomas. Patients with ALK+ ALCL tend to have excellent outcomes with the standard chemotherapy known as CHOP (cyclophosphamide, doxorubicin hydrochloride, vincristine and prednisone). In 2011, the drug brentuximab vedotin (Adcetris®) was approved for patients with both ALK+ and ALK- relapsed or refractory systemic ALCL.
AITL is an aggressive subtype. It is typically diagnosed at stage III or IV. People with AITL usually have fever, night sweats, weight loss, skin rashes and autoimmune disorders, and they often get infections. The causes of AITL are unknown, but it has been linked with Epstein-Barr virus. To start, treatment usually involves steroids. It often progresses and may be treated with the standard T-cell NHL treatments — chemotherapy or other medicine-based options — as well as radiation therapy.
This subtype is more common in parts of Asia and South America. It is linked with Epstein-Barr virus, which causes mononucleosis (often called mono). It often involves the upper airways, such as the nose and upper throat. It can also invade the skin and gastrointestinal tract. This is the only peripheral T-cell lymphoma subtype for which radiation therapy is the main treatment.
This extremely rare subtype affects the intestines. It happens mainly in middle-aged men who are sensitive to gluten, the main protein in wheat flour. It develops when celiac sprue (gluten-sensitive enteropathy) progresses to cancer. There is no standard treatment. Treatments can include surgery to remove the damaged part of the intestine, chemotherapy and a blood or marrow transplant. A gluten-free diet might prevent this lymphoma.
This extremely rare, aggressive disease starts in the liver or spleen. It can cause fever, abdominal pain, weakness and swelling of the liver and spleen. It happens mainly in children, young men and people whose immune system is suppressed (usually because of an organ transplant). There is no standard treatment. One option is chemotherapy using the medicine anthracycline. This causes a short-term response in most patients. Complete remission is rare. Physicians typically recommend a blood or marrow transplant using a donor’s stem cells (allogeneic transplant) the first time a patient goes into remission.
People with this rare, aggressive disease usually have small bumps or lesions under their skin. It is most common in people age 30 to 50. Sometimes it is linked with lupus. The standard treatment is chemotherapy combined with other medicines.
Physicians use this name for T-cell lymphomas that do not fit easily into any of the other subtypes of peripheral T-cell lymphoma. These lymphomas tend to be widespread and aggressive. Most people diagnosed are in their 60s. Most patients are treated with chemotherapy.
This disease affects NK cells and causes skin lesions. It is rare in the U.S. and more common in Asia and parts of Latin America. It usually happens to older adults and is linked with Epstein-Barr virus. The main treatment is chemotherapy and sometimes radiation therapy. Because this condition is likely to relapse (get better but then get worse), clinical trials or referral for blood or bone marrow transplant are often considered.
There are many resources online for learning about your disease. We've compiled a list of trusted sources to help you get started.
If you or yur caregiver are seeking additional information and resources, Fred Hutch Patient and Family Resource Center is available to help connect you with what you need.
Our list of online resources provides accurate health information from reliable and reputable sources, like the National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO).
American Cancer Society (ACS): Non-Hodgkin Lymphoma
Easy-to-read articles on a wide range of NHL topics, from diagnosis and treatment to finding support and living well after treatment ends. This group has cancer information specialists to answer questions by phone 24 hours a day, 7 days a week. From the American Cancer Society.
American Cancer Society (ACS): Lymphoma of the Skin
Easy-to-read articles on a wide range of cutaneous lymphoma topics, from diagnosis and treatment to finding support and living well after treatment ends. This group has cancer information specialists to answer questions by phone 24 hours a day, 7 days a week.
American Cancer Society (ACS): Waldenström Macroglobulinemia
Easy-to-read articles on a wide range of Waldenström macroglobulinemia topics, from diagnosis and treatment to finding support and living well after treatment ends. This group has cancer information specialists to answer questions by phone 24 hours a day, 7 days a week. From the American Cancer Society. From the American Cancer Society.
CancerCare: Treatment Update on Blood Cancers
Booklet written each year for patients about the research discussed at that year’s annual meeting of the American Society of Hematology. It’s a source to help you learn about the latest advances in NHL care so you can talk about them with your physician. From CancerCare.
CancerCare: Coping with Non-Hodgkin lymphoma
Two pages of practical tips. This handout is geared towards orienting you if you recently got an NHL diagnosis. It touches briefly on many important topics, like finding out which type of NHL you have, keeping your health records organized and seeking support.
Cutaneous Lymphoma Foundation
A website aimed at patients and families that explains many forms of cutaneous lymphoma (including T-cell and B-cell types). CLF has a library of online patient resources to help you understand your care, live with the disease and find support.
International Waldenström’s Macroglobulinemia Foundation (IWMF)
A website for patients as well as physicians and researchers. Patient articles cover details of the disease, like how it is diagnosed and treated and how to live with it. The support section helps patients and families connect with others facing the same disease. There is a library of stories by patients about their experiences.
Leukemia & Lymphoma Society: Know Your NHL Subtype
Brief handout about why it matters that you and your physician know which subtype of NHL you have. It includes a small card where your physician can write your subtype for you, in case it’s hard to say or to remember. From the Leukemia & Lymphoma Society.
Leukemia & Lymphoma Society: Cutaneous T-Cell Lymphoma
Longer booklet for people who want to go into more depth about cutaneous T-cell lymphoma treatment, side effects and new approaches being studied. This piece includes details about mycosis fungoides and Sézary syndrome.
Leukemia & Lymphoma Society: Waldenström Macroglobulinemia
Longer booklet for people who want to go into more depth about Waldenström macroglobulinemia signs and symptoms, diagnosis, treatment, side effects and new approaches being studied. From the Leukemia & Lymphoma Society.
National Cancer Institute (NCI): Lymphoma
Overview of NHL diagnosis, staging and treatment. The focus is on treatment options, including which options are used for slow-growing or fast-growing NHL. The “Coping With Cancer” section offers helpful advice for both patients and caregivers.
National Cancer Institute (NCI): Mycosis Fungoides (Including Sézary Syndrome) Treatment
Overview of diagnosis, staging and treatment for mycosis fungoides and Sézary syndrome. The focus is on treatment options, including which options are used for different stages.