Lymphoma is usually classified into either Non-Hodgkin Lymphoma (NHL) or Hodgkin lymphoma (HL; previously known as Hodgkin’s Disease). There are many similarities of presentation between NHL and HL, but under the microscope, they have very different appearances. They behave differently in how they advance and spread, and while they both commonly need chemotherapy treatment, the types of therapy used for NHL and HL are different.
This is a cancerous condition of white blood cells called lymphocytes. It is the 5th commonest cancer in the UK, and for reasons that are not clear, NHL seems to be increasingly common. The typical patient presents with painless lymph gland swellings which grow over a period of weeks to months. They may notice these in their neck, armpits or groin. Sometimes patients are more unwell with their lymphoma, and develop night sweats, weight loss and marked fatigue. When lymph glands cannot be felt, the diagnosis might be delayed, particularly if the clinical picture is not typical of lymphoma.
When patients present with swollen glands to their GP, the GP may choose to refer to surgical colleagues for biopsies, to establish the cause of the swollen lymph glands. There are, of course, many causes of swollen lymph glands, including normal reactions to infections, and it may be appropriate for a period of observation prior to referral. Increasingly our radiology colleagues take biopsies with the help of ultrasound guidance, which can speed up the diagnostic pathway for our patients.
If the biopsies indicate NHL, it is very important to accurately classify the subtype. There are over 60 different types, which behave very differently and require different treatments. We therefore insist that wherever possible, our patients have their pathology reviewed by our expert colleagues at The Cambridge University Hospitals Haemato-Oncology Diagnostic Service, prior to planning therapy. For overseas patients, this does mean patients may need to ask their laboratory to send us their diagnostic biopsy material prior to first consultation.
Prior to treatment, patients usually require staging investigations to establish how extensive the disease is at presentation and what the prognostic profile looks like. This typically means a CT or PET / CT scan, a bone marrow biopsy, and a range of blood tests. With the pathology details, the staging information and the prognostic scores, we can then go through all treatment options with patients to ensure we put the right treatment package together for that individual patient.
For the more indolent non-hodgkin lymphomas, it may be that patients can be managed with either local radiotherapy or close observation, termed ‘watch and wait’. For the more advanced indolent lymphomas or more aggressive lymphomas, it is very likely that chemotherapy treatment will be required. This may be combined with specific antibody therapy and is likely to require multiple sessions of treatment termed ‘cycles’. Most lymphoma chemotherapy can be given as an outpatient on our Nuffield Oncology Day Unit, but occasional inpatient treatment is delivered on the Newton Ward, here at the Nuffield. After initial treatment with 6 to 8 cycles of chemotherapy, some patients may benefit from maintenance therapy, usually with antibody infusions.
The majority of NHL patients respond well to treatment, and depending on the type of lymphoma, many patients will be cured of their illness with a single block of chemotherapy treatment. Some types of lymphoma are, however, never actually cured, and they will relapse at some stage. Usually they respond to further treatment, allowing another period of remission. We keep a close eye on our patients throughout treatment and the intervening remission periods. Many patients continue to enjoy a good quality of life, even when on treatment, as the side effects of treatment are much better managed with modern anti-sickness drugs and other supportive care measures.
Hodgkin Lymphoma is one of the more common cancers of young people, although it can also affect older patients. It is a cancer of white blood cells called B lymphocytes that grow in lymph glands, hence the typical presentation of swollen lymph nodes, often in the neck or arm pit. The glands are usually painless, growing over weeks to months. Patients may have a cough or shortness of breath, as HL commonly causes enlargement of glands in the middle of the chest (the mediastinum). Patients may also have prominent systemic symptoms such as night sweats, weight loss, fevers and fatigue. These are known as B-symptoms.
Patients require a lymph node biopsy to prove the diagnosis. This is typically done by one of our surgical colleagues, but increasingly biopsies are performed by radiologists using ultrasound to guide a core needle biopsy. This has the advantage of speed and no requirement for a general anaesthetic, but from time to time, we have to send patients back to a surgeon for a full excision biopsy, particularly where there is doubt over the diagnosis from a smaller core biopsy.
Having proven the diagnosis, a priority is to stage patients, usually with a PET / CT scan and sometimes a bone marrow biopsy, to define exactly the extent of the Hodgkin Lymphoma. Blood tests help us to assign a prognostic score, and with all the information together, we can go through treatment options with the patient in some detail.
There are a number of debates amongst doctors who treat Hodgkin Lymphoma. If you get Hodgkin Lymphoma doctors from Germany, UK, US and Canada together, you can be sure there will be 4 opinions on the optimal management! However, the good news for most young patients with HL is that the clear majority of them will be cured by the different strategies that are available. Often, the factors that influence the choice of one therapy over another are the patient’s view on a particular set of treatment-related side effects.
Standard treatment usually involves chemotherapy with our without radiotherapy after the chemotherapy has completed. With patients who present with early stage disease we may be able to avoid radiotherapy, but this requires detailed discussion to make sure we plan the right treatment for the individual. For patients who present with advanced stage disease, there is much debate as to whether patients are better served with either ABVD or escalated BEACOPP chemotherapy schedules. There are clear pros and cons with each regime, and we go to great lengths to make sure our patients are informed about their options. This will ensure we help them make the best decision for their particular circumstances.
Whatever treatment options are chosen, the majority if not all of the care is delivered as an out-patient, with regular trips up to the Nuffield oncology unit for review and treatment. We keep a close eye on patients as they move through their treatment programme, and we are pleased to say that the vast majority of our young Hodgkin Lymphoma patients are cured by their first round of treatment. If a patient is unlucky enough to suffer a relapse of their disease, there are many treatments available, including bone marrow / stem cell transplant which have a good chance of curing their disease. We have growing experience with the very promising new Hodgkin Lymphoma drug, brentuximab vedotin, having treated a number of patients in our NHS and Nuffield practice.