Early symptoms of non-Hodgkin lymphoma

Hodgkin lymphoma

There are very few specific early symptoms of non-Hodgkin lymphoma (NHL) which makes diagnosing this condition difficult. As a matter of fact, the symptoms depend on where cancer begins and the organ involved. For example, a stretched belly or pain in the back or abdomen are signs of a tumor in the abdomen, and chest pain, difficulty breathing, or other respiratory problems are signs of a tumor in the center of the chest that puts pressure on the trachea. Similarly, lymphoma affecting the brain can cause headache, trouble thinking, weakness in parts of the body, changes in personality, and sometimes seizures, and lymphoma in the skin can cause itchy, red or purple lumps or nodules underneath the skin.

However, there are other, more general symptoms of NHL, including:

·         Enlarged lymph nodes in the abdomen, groin, neck, or underarms.

·         Enlarged spleen or liver.

·         Unexplained fever.

·         Unintentional weight loss.

·         Night sweats.

·         Intermittent fever and chills.

·         Fatigue.

·         A feeling of fullness after a small meal.

·         Anemia.

Non-Hodgkin lymphoma starts when cells in the lymphatic system grow out of control to the point that they form a tumor. Lymphatic tissue is all over the body so NHL can appear almost anywhere; more often than not it does so in the lymph nodes, liver, spleen, or bone marrow, though it can also affect the stomach, intestines, skin, thyroid gland, brain, and any other part of the body. The type and subtype of lymphoma depends on the lymphatic system cells involved.











B-lymphocytes (B cells)

·         Diffuse large B-cell lymphoma

·         Follicular lymphoma

·         Mantle cell lymphoma

·         Small lymphocytic lymphoma

·         Mediastinal large B-cell lymphoma

·         Splenic marginal zone B-cell lymphoma

·         Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue

·         Nodal marginal zone B-cell lymphoma

·         Lymphoplasmacytic lymphoma

·         Primary effusion lymphoma

·         Burkitt lymphoma/Burkitt cell leukemia

About 90% of people with lymphoma have B-cell lymphoma.






T-lymphocytes (T cells)

·         Anaplastic large cell lymphoma, primary cutaneous type.

·         Anaplastic large cell lymphoma, systemic type.

·         Peripheral T-cell lymphoma, NOS.

·         Angioimmunoblastic T-cell lymphoma.

·         Precursor T-lymphoblastic lymphoma/leukemia (precursor T-cell acute lymphoblastic leukemia).

·         Adult T-cell lymphoma/leukemia (human T-cell lymphotropic virus type I positive).

·         Extranodal NK/T-cell lymphoma, nasal type.

·         Enteropathy-associated T-cell lymphoma.

·         Gamma/delta hepatosplenic T-cell lymphoma.

·         Subcutaneous panniculitis-like T-cell lymphoma.

·         Mycosis fungoides.

About 10% of people with lymphoma have T-cell lymphoma.







Natural killer cells (NK cells)

Less than 1% of people with lymphoma have NK-cell lymphoma.


Generally speaking, NHL is more common in men than in women. Conversely, some specific types are more common in women. The same can be said of age. While the most common forms occur in people aged 60-70, certain types are more commonly seen in younger people. The takeaway here is that NHL, not unlike the majority of cancers, can affect just about anyone. Other risk factors are:

·         Bacterial infections (Helicobacter pylori).

·         Viruses (Epstein-Barr, hepatitis C).

·         Immune deficiency disorders (HIV/AIDS).

·         Autoimmune disorders (rheumatoid arthritis, Sjogren syndrome.)

·         Chemical exposure to pesticides and petrochemicals.

·         Previous radiation therapy and chemotherapy for Hodgkin disease.

People with the above risk factors seldom develop NHL, but they and their physicians should nonetheless be aware of the possibility. As it turns out, most lymphomas are detected when a patient has a lump that won’t go away, have developed some of the early symptoms of non-Hodgkin lymphoma, or don’t feel well and go for a medical checkup. If the doctor believes lymphoma is a possibility, he or she will perform a physical exam with particular emphasis on the lymph nodes, spleen, and liver. If the lymph nodes are enlarged and an infection is ruled out, the physician will likely order the usual battery of lab and imaging tests and biopsies. Additionally, he or she may order certain molecular and genetic tests such as the following:

·         Flow cytometry

Commonly used to classify lymphoma cells according to the substances on their surfaces, it can help determine if the lymph node is enlarged because of NHL, other cancer, or a non-cancerous condition.

·         Cytogenetics

Checks the chromosomes in the lymphoma cells for abnormalities.

·         Fluorescent in situ hybridization (FISH)

Employs a special dye to look for chromosome changes small enough that they can escape cytogenetic testing.

·         Polymerase chain reaction (PCR)

Can find gene changes too small for a microscope, even in a limited sample.


Once NHL is diagnosed, there are three factors that need to be established before proceeding to treatment; stage, prognosis, and functional status.




·         The tumor is in one lymph node area or lymphoid organ; or,

·         It has spread one area or organ outside the lymphatic system.


·         The tumor is in two or more clusters of lymph nodes on the same side of the diaphragm; or,

·         It extends to a nearby organ and may affect other groups of lymph nodes on the same side of the diaphragm.


·         The tumor is in lymph node regions on both sides of the diaphragm; or,

·         It may have spread to a nearby organ, into the spleen, or both.


·         The tumor has metastasized outside the lymphatic system into a distant organ; or,

·         It has spread to the bone marrow, liver, brain, or spinal cord, or to the pleura.


Each stage may be divided into A or B. The B is added if the patient has any of these symptoms:

·         Loss of more than 10% of body weight over the past 6 months without dieting.

·         Fever of unknown origin of at least 101.5 F.

·         Drenching night sweats.

The prognosis is a forecast of the patient’s chances of survival and it is based on five different factors:

  1. Age.
  2. Stage.
  3. Spread.
  4. Performance status.
  5. Blood level of lactate dehydrogenase (LDH).


International Prognostic Index

Good factors

Bad factors

Risk groups

  1. Age 60 or below
  2. Stage I or II
  3. No lymphoma outside lymph nodes or lymphoma only in one area outside lymph nodes
  4. Patient is able to function normally
  5. Normal LDH level
  1. Age above 60
  2. Stage III or IV
  3. Lymphoma is in more than one organ outside lymph nodes
  4. Patient requires plenty of help with everyday activities.
  5. High LDH

Low (0-1 poor bad factors)

Low intermediate (2 bad factors)

High intermediate (3 bad factors)

High (4-5 bad factors)


Fast-growing lymphomas that have received more modern treatments:

Very good (no bad factors)

Good (1-2 bad factors)

Poor (3 or more bad factors).


Another prognosis tool that is intimately related to performance status is used to determine how well – or how badly – a patient can function and undertake everyday activities.

Functional status

Eastern Cooperative Oncology Group


Karnofsky Performance Scales

Fully active and able to perform pre-lymphoma activities.



Restricted physically arduous activity, ambulatory, can do work of a mild or sedentary nature.


Ambulatory and capable of self-care, unable to perform any work activities.


Limited self-care, bed- or chair-ridden for over 50% of waking hours.


Fully disabled, completely bed- or chair-ridden.








Near death.


Very sick.


Severely disabled.




Needs significant assistance.


Occasional assistance.


Cares for self but not able to perform normal activity or active work.


Normal activity with effort.


Normal activity, minor symptoms.


No evidence of disease.


Treatment per se also depends on whether the lymphoma is slow-growing (indolent NHL) or fast-growing (aggressive NHL). People with indolent NHL are monitored closely and only treated when the early symptoms of non-Hodgkin lymphoma appear or when the cancer begins to change. Stage I or II indolent lymphoma can be eliminated with radiation therapy, but most people with this type of NHL are diagnosed at later stages of the disease – there are effective treatments for these stages as well but the lymphoma may come back and require further treatment.

Aggressive lymphoma may grow more rapidly and so treatment is started without delay. This type of NHL generally requires more intensive chemotherapy – sometimes accompanied by radiation therapy. Non-Hodgkin lymphoma is not necessarily either indolent or aggressive; some subtypes have characteristics of both.