Non-Hodgkin Lymphoma Overview

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Early Detection, Diagnosis, and Staging TOPICS

How is non-Hodgkin lymphoma found?

At this time, no special tests are advised to find non-Hodgkin lymphoma (NHL) early. The best course of action is to pay attention to any possible symptoms of this disease.

People with medical problems that increase the risk of NHL, such as a weakened immune system, HIV infection, autoimmune disease, or earlier treatment for cancer, should see their doctors regularly and let them know if any new problems occur.

Signs and symptoms of non-Hodgkin lymphoma

NHL may cause many different signs and symptoms, depending on where it is in the body. Sometimes it doesn't cause any symptoms until it has grown quite large.

Swollen lymph nodes: A lump under the skin, especially on the sides of the neck, in the groin, in the underarm areas, or above the collar bone, could be a swollen lymph node. Usually, swollen lymph nodes are caused by infections, but they can be a sign of lymphoma.

Lymphoma in the belly (abdomen): Lymphomas here may cause the abdomen to become swollen and tender. This may be because of swollen lymph nodes, but it can also be caused by fluid build-up.

Lymphoma can cause the spleen to enlarge and press on the stomach. This can cause a person to feel full after eating only a small amount of food.

When lymphoma is in the intestines or causes swelling near the intestines, bowel movements may be blocked, which can lead to belly pain, nausea, or vomiting. Lymphoma in the intestines can also cause holes in the intestine wall (called perforations). This allows the contents of the intestines to leak out, leading to serious infection and severe pain with nausea and vomiting.

Lymphomas of the stomach often cause pain in the stomach, nausea, and reduced appetite.

Lymphoma in the chest: If the disease starts in the thymus (a small organ behind the breast bone) or lymph nodes in the chest, pressure on the windpipe (trachea) can cause coughing, shortness of breath, or pain. The tumor can press on the large vein (the superior vena cava, or SVC) that carries blood from the head and arms back to the heart. When this happens, the head and arms can swell and the brain can be affected. This is a very serious condition (called SVC syndrome) that can be life-threatening and needs to be treated right away.

Lymphoma of the brain: Lymphomas of the brain cause headache, trouble thinking, weakness in certain parts of the body, personality changes, and sometimes seizures. Other types of lymphoma can spread to the area around the brain and spinal cord. This can cause double vision, facial numbness, and trouble speaking.

Lymphomas of the skin: Lymphomas of the skin may be seen or felt. They often start as very itchy, red to purple lumps under the skin. (For more details, see the document Lymphoma of the Skin.)

General symptoms: Some symptoms of NHL are known as B symptoms. These include:

  • Weight loss without a known reason
  • Fever
  • Heavy night sweating (enough to soak clothes and sheets)

B symptoms sometimes mean the cancer is faster growing.

Other symptoms can be caused by low blood counts. Blood counts can become low when lymphoma spreads to the bone marrow and crowds out the normal, healthy cells that make new blood cells. Lymphoma can also cause the body to destroy blood cells. Low blood counts can lead to problems like:

  • Severe or frequent infections (from low white blood cell counts)
  • Easy bruising or bleeding (from low blood platelet counts)
  • Fatigue (from low red blood cell counts or anemia)

Tests used to find NHL

If there is a reason to think that you may have non-Hodgkin lymphoma, your doctor will want to get a complete medical history, with information about your symptoms, risk factors, family history, and other medical conditions. Next, the doctor will do an exam, paying special attention to the lymph nodes and other places of the body that might be involved, including the spleen and liver. If you have swollen lymph nodes, the doctor will look for an infection in that area. Enlarged lymph nodes are more likely to be caused by an infection than by lymphoma.

If the doctor suspects that NHL might be causing the symptoms, he or she will recommend a biopsy and some other tests.

Lymph node biopsy

Because swollen lymph nodes are more often caused by infection, not cancer, doctors often give antibiotics and wait a few weeks to see if the nodes stay large. If the nodes stay the same or keep on getting bigger, either a small piece of the node or the whole node is often removed for testing. This is called a biopsy. A biopsy might be needed right away if there is a strong reason to suspect cancer. But unless it is a very fast growing lymphoma, waiting a few weeks is not harmful.

A doctor with special training (called a pathologist) looks at the biopsy samples under a microscope to look for lymphoma and see what type it is. Sometimes the first biopsy does not give a final answer. If more tests are needed, be sure to ask your doctor or nurse to explain what the tests involve and what they will learn from them.

The doctor might use other lab tests to diagnose and classify NHL such as immunohistochemistry, cytogenetics, flow cytometry, FISH, and PCR. These tests are explained in our detailed guide, Non-Hodgkin Lymphoma.

There are a few kinds of biopsies, and the doctor will choose which one is needed.

Excisional or incisional biopsy: For these, a surgeon cuts through the skin to remove either the whole node (excisional biopsy) or a small part of a large tumor (incisional biopsy). If the node is near the skin surface, this can often be done with numbing medicine. But if the node is inside the chest or belly (abdomen), general anesthesia is used to make the patient sleep.

Needle biopsy: There are two types of needle biopsies. A fine needle aspiration (FNA) uses a thin, hollow needle to remove a small amount of fluid and tiny bits of tissue from the tumor. A core needle biopsy uses a larger needle to remove a slightly larger piece of tissue. The sample collected with a needle biopsy is usually too small to be used to diagnose lymphoma. But for someone known to have lymphoma, a FNA might be done to see if a swollen lymph node or organ in a different place also contains lymphoma.

Other types of biopsies

Other types of biopsies are mostly used to stage (find out the extent of) the disease once it has been diagnosed.

Bone marrow aspiration and biopsy: These 2 tests are often done at the same time. Samples are usually taken from the back of the hip bone to see if the lymphoma has reached the bone marrow.

For a bone marrow aspiration, you lie on a table (either on your side or on your belly). After cleaning the area, the skin over the hip and the surface of the bone are numbed. A thin, hollow needle and syringe are then used to suck out a small amount of liquid bone marrow (about 1 teaspoon). Even with the numbing drugs, most patients still have some brief pain when the marrow is removed.

A bone marrow biopsy is usually done just after the aspiration. A small piece of bone and marrow is removed with a slightly larger needle that is twisted as it is pushed down into the bone. The biopsy may also cause some brief pain. Once the biopsy is done, pressure will be put on the site to help stop any bleeding.

Lumbar puncture (spinal tap): This test looks for lymphoma cells in the cerebrospinal fluid (CSF), which is the liquid around the brain and spinal cord. For this test, patients may lie on their side or sit up and lean forward. The doctor first numbs an area in the lower part of the back near the spine. A small needle is placed between the bones of the spine into the area around the spinal cord to withdraw some of the fluid. Most people with lymphoma will not need this test.

Fluid sampling: If lymphoma spreads to the chest or belly (abdomen), it can cause fluid to build up. This fluid can be removed by putting a hollow needle through the skin into the area. The doctor uses medicine to numb the skin before putting the needle in. The fluid is then taken out and looked at under the microscope to check for lymphoma cells.

Blood tests

Blood tests may be used to measure the amounts of certain types of cells and chemicals in the blood. They are not used to find out if a person has lymphoma, but they can be helpful in deciding how advanced the lymphoma is and how fast it is growing. Blood tests can also help find liver or kidney problems caused by either the spread of lymphoma side effects of certain chemotherapy drugs. Tests may also be done to make sure blood is clotting like it should.

For some types of lymphoma, your doctor may also want other blood tests to check for viral infections that may affect your treatment.

Imaging tests to find and stage NHL

Imaging tests are ways to take pictures of the inside of the body. These tests are used to help find a place that might be cancer, to learn how far a cancer may have spread, and to find out whether treatment is working.

Chest x-ray

An x-ray of the chest may be done to look for swollen lymph nodes in this area.

CT scan (computed tomography)

The CT scan is a special type of x-ray test that takes many pictures as it moves around the body. A computer then combines these to make a detailed picture. A CT scan is useful in looking for lymphoma in the belly (abdomen), pelvis, chest, head, and neck. CT scans can also be used to help guide a biopsy needle into a swollen lymph node.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. Before any pictures are taken, you may be asked to drink a liquid that helps outline the intestine for the scan. After the first set of pictures is taken, you may also get an intravenous (IV) injection of a "dye" to help outline the structures in your body. A second set of CT scan pictures is then taken. Sometimes the dye causes flushing (a feeling of warmth, especially in the face), hives, or, rarely, a serious allergic reaction like trouble breathing or low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays.

MRI scan (magnetic resonance imaging)

MRI scans use radio waves and strong magnets instead of x-rays to take pictures. This test is not used as often as CT scans for lymphoma, but if your doctor is concerned about spread to the spinal cord or brain, MRI is very useful for looking at these areas. A contrast substance (called gadolinium) may be put into a vein before the scan to better show details. It is different than the dye used for CT scans, so being allergic to one doesn’t mean you are allergic to the other. Still, be sure to let the doctor know if you have had a problem with it in the past.

MRIs take longer than CT scans and you may have to lie in a narrow tube, which upsets some people. Special, open MRI machines may sometimes be an option. The drawback of the more open machines is that the pictures aren’t as clear.

The machine makes loud buzzing and clicking noises, but some places will give you earplugs or headphones to help block this out.

Ultrasound

This test uses sound waves to make a picture of the inside of the body. It is a very easy test to have done. For most scans, a kind of wand is moved along your skin over the part of your body being looked at. No radiation is used. An ultrasound can find tumors under the skin or in the belly and can show if the kidneys have become swollen because the flow of urine has been blocked by swollen lymph nodes.

PET scan (positron emission tomography)

PET scans use a form of sugar that has a radioactive atom attached to it. The sugar mixture is put into a vein and travels throughout the body. Cancer cells take up the radioactive sugar more than other cells, and then a special camera is used spot the areas of radioactivity.

PET is useful to look for lymphoma all over the body. It can help tell whether a swollen lymph node has cancer in it. It is also used during and after treatment to find out whether an enlarged lymph node still contains cancer or just has scar tissue. For patients with lymphoma, a machine that combines the PET scan with a CT scan (PET/CT scan) is often used.

Gallium scan

In this test a radioactive substance is put into a vein. It goes to lymph tissues in the body. A special camera is used to show these areas. This test can find tumors that might be NHL in bones and other organs. This test is not used as much now as in the past because most doctors do a PET scan instead. But it can still sometimes be useful in finding areas of lymphoma that the PET scan may miss.

Bone scan

For bone scans, a different radioactive substance is used. After it is put into the blood, it travels to areas of the bone that are damaged. This test is not usually done unless a person is having bone pain or has lab test results that suggest the lymphoma may have reached the bones. The scan will show bone damage caused by lymphoma, but will also pick up other problems, such as arthritis and fractures. Lymphoma in the bone can also be seen on a PET scan, so this test isn’t used if a PET has been done.

Tests of heart and lung function

These tests are not used to help find non-Hodgkin lymphoma, but they might be done if you are going to get certain chemotherapy drugs that could affect the heart or the lungs.

  • Your heart function may be checked with an echocardiogram (an ultrasound of the heart) or a MUGA scan.
  • Your lung function may be checked with pulmonary function tests, in which you breathe into a tube hooked up to a machine.

Last Medical Review: 04/18/2013
Last Revised: 04/18/2013