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Lymphoma

Lymphoma is a cancer of lymphatic system. It is a heterogeneous group of disease and can be classified into two main types: Hodgkin’s lymphoma and Non-Hodgkin’s lymphoma. Non-Hodgkin's lymphoma is more common in Hong Kong and neighboring areas in Asia. It is also one of the “top 10 cancer killers” in Hong Kong.

(Special thanks to Dr. Lei Ieng Kit, Kenny, Consultant, Department of Clinical Oncology, Prince of Wales Hospital for reviewing the information of this page.)

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The human body is filled with a lymphatic network comprising lymph ducts and lymph glands through which the lymphocytes  are circulated to organs and tissues of the body to fight against infection.

However, when malignant changes occur in lymph cells, these lymph cells will multiply continuously  and gather in the lymph gland, forming tumor, and spread to bone marrow, liver and other organs. This form of cancer, originated from the lymphatic system, is called “lymphoma”.

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Lymphoma is a heterogeneous group of disease. There are two main types: the Hodgkin's lymphoma and non-Hodgkin's lymphoma. They can be further classified based on the clinical manifestation and pathological features of individual tumor, including 5 subtypes of Hodgkin’s lymphoma and more than 30 subtypes of non-Hodgkin’s lymphoma. Non-Hodgkin’s lymphoma can be broadly grouped into indolent non-Hodgkin’s lymphoma and aggressive non-Hodgkin’s lymphoma according to clinical features and growth rate.

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The causes of lymphoma are not fully understood yet. Recent studies have shown that certain risk factors increase the chance of developing lymphoma. These risk factors include genetic changes, certain infections (e.g. infection by Human Immunodeficiency virus), radiation, chemicals and diseases of the immune system (such as rheumatoid arthritis, AIDS and immunosuppressive agents used (drugs for suppressing the immune system) after organ transplantation).
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Painless swelling of lymph gland, is the most common symptom in patients with lymphoma. The swelling usually occurs in the neck, armpits and groin (area where the lower abdomen and laps meet) and gradually spread to lymph gland, bone marrow of other parts of the body and other organs.

Other symptoms such as fever, excessive sweating, loss of appetite, weight loss, persistent itchy skin and fatigue are also commonly seen. If lymphoma cells have already spread to bone marrow and affected blood production , patient may have  anemia, bruising and frequent infection.

However, these symptoms can also occur in other diseases and may not be due to lymphoma. Therefore, if swelling persists in one or more lymph glands or there is persistence of symptoms, patient should seek advice from doctors as soon as possible.

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Swelling of lymph gland is a common symptom for lymphoma. However, infections  of head and neck regions (such as tonsillitis), pulmonary tuberculosis or malignant tumors spreading from other sites can also cause swelling of lymph gland in the neck and it may make it difficult to establish the diagnosis.

In addition to thorough history and physical examination , assessment of the affected lymph gland through lymph gland biopsy is the only way to determine if the swelling  is benign or malignant.

Once the diagnosis of lymphoma is confirmed, patient needs further testing to check his/her general health, how far the lymphoma has spread, and the prognosis. The testing includes blood tests, X-ray, computerised tomography (CT) scan and bone marrow examination. 

When the testing is complete, it should be possible to determine the stage of lymphoma. The stage of lymphoma can be I, II, III, or IV depending on how far the lymphoma has spread.

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Treatments for lymphoma include chemotherapy, immunotherapy, radioimmunotherapy or radiotherapy. Doctor shall decide the appropriate treatment plan for patients according to their general health, specific subtype of lymphoma and the stage of lymphoma. In special situations, doctor may use bone marrow or peripheral blood stem cell transplantation or enroll the patients to clinical trials.
 
Chemotherapy is a widely used treatment for lymphoma. It kills the cancer cells by receiving oral or intravenous injection of anti-cancer drugs. However, chemotherapy can also damage healthy cells and tissues, causing a number of side effects and  discomfort.
 
Radiotherapy is the use high-energy radiation produced from an X-ray machine to kill cancer cells on the affected area. It can be given alone or along side with chemotherapy for better treatment outcome and reduction of side effects. 
 
Apart from the traditional radiotherapy and chemotherapy, “immunotherapy” has become an important treatment for lymphoma. Immunotherapy is the use cells or antibodies of the immunity system to treat cancer. Since majority of B-cell type non-Hodgkin’s lymphomas bears an antigen, CD20, on the cell surface, immunotherapy or radioimmunotherapy drugs that are specifically designed to target this CD20 surface antigen have been developed. They include Rituximab (MabThera), Tositumomab (Bexxar) and Ibritumomab (Zevalin). Rituximab is a monoclonal antibody that can recognize and attach itself onto the surface CD20 antigen of B-cell lymphoma. It then stimulates immune response to kill the lymphoma cells. Ritxumab is effective and has little side effects for treatment of indolent lymphoma. It can also combine with chemotherapy to treat aggressive B-cell lymphomas and has been shown to improve treatment outcome. Tositumomab and Ibritumomab are “radioimmunotherapy” drugs produced by combining an anti-CD20 monoclonal antibody with radioactive chemicals, I-131[ Iodine-131﹞and Y-90 ﹝Yttrium-90﹞ respectively. They bind with the CD20 antigen on surface B-cell lymphoma cells and kill the lymphoma cells with the radiation energy released from the radioactive chemicals. These are major breakthroughs in the treatment of lymphoma in recent years.
 
Bone marrow or peripheral blood stem cell transplantation in lymphoma is the use of high dose chemotherapy and/or radiotherapy followed by re-infusion of  bone marrow or peripheral blood stem cells from the patients themselves or donated by their close families. However, the risk of this treatment is relatively high, thus it is usually used on selected patients with recurrence cancer.
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Prior to treatment, doctor will discuss and explain the details of the procedures, treatment plans, and their possible side effects and complications to patient. . As treatment begins, patient may be unwell because of side effects However, not all patients will experience the same level of side effects. The complications may also vary depending on the treatment approach and types of anti-cancer drug used.

Side effects of chemotherapy include loss of appetite, nausea, mouth ulcers, loss of hair, diarrhea and infection associated with low white blood cells counts. However, many of these complications are temporary. They will disappear once treatment has finished  Doctor will apply other drugs to ease the discomfort. Common side effects of radiotherapy include fatigue and skin rash on the treatment area. Other side effects of radiotherapy vary depending on the parts of the body under treatment.

Therefore, proper nursing care and nutrition are very important. Patient needs balanced diet, appropriate exercise and rest. Patient also needs to pay attention to his/her personal hygiene during the course of treatment. Room, clothing and appliances should always be tidied up and kept clean. Do not eat food that is not cooked thoroughly. Minimize visits to crowed public areas and avoid contact with friends and family who have flu or other infection.

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When people learn they have lymphoma, no matter how strong they are, they always feel anxious and helpless. No doubt that patient needs to rely on doctor and medicine to fight against disease. However, care, support and encouragement from friends and families are equally important. Patient should talk to families and friends and let them know his/her feelings, needs and progress.
 
Also, there are many associations and organizations in the community providing further information and support to patients with cancer. All these will be of great help during the whole course of treatment.
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