Treatment of Non-Hodgkin Lymphoma in Children, by Type and Stage

In general, all children with non-Hodgkin lymphoma (NHL) are treated with chemotherapy (chemo), but the exact treatment differs depending on the type and stage of the lymphoma. The treatment for NHL is intense and might cause serious side effects, so it's very important that it is given in a children’s cancer center, especially when it is first started.

Lymphomas in children (especially Burkitt lymphomas) tend to grow very quickly and may already be quite large by the time they’re diagnosed, so it's important to start treatment as soon as possible. These lymphomas usually respond well to chemo, which can kill large numbers of lymphoma cells in a short period of time. A concern is that this can cause tumor lysis syndrome, a side effect in which the contents of the dead cells enter the blood and can cause problems with the kidneys and other organs. Doctors try to prevent this by making sure the child gets lots of fluids before and during treatment, and by giving certain drugs to help the body get rid of these substances.

Even children with early-stage (stage I or II) lymphomas are assumed to have more widespread disease than can be detected with exams or imaging tests. Because of this, local treatments such as surgery or radiation therapy alone are very unlikely to cure them. Therefore, chemotherapy is an important part of treatment for all children with NHL.

Treatment of lymphoblastic lymphoma (LBL)

Stages I and II: In general, treatment for early-stage LBL is similar to the treatment of acute lymphoblastic leukemia (ALL). Chemotherapy is given in 3 phases (induction, consolidation, and maintenance) using many chemo drugs. For example, the BFM regimen uses combinations of many different drugs for the first several months, followed by less intense treatment with methotrexate and 6-mercaptopurine in pill form for a total of about 2 years. Shorter and less intensive treatments, such as the chemotherapy combinations called CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) and COMP (cyclophosphamide, vincristine, methotrexate, and prednisone) have also been used.

Chemotherapy, usually with methotrexate, is also given into the spinal fluid (known as intrathecal chemo) for at least 4 doses, each separated by a week. This helps kill any lymphoma cells in the brain or spinal cord.

The total length of treatment may be as long as 2 years.

Stages III and IV: The treatment for children with advanced LBL is similar to that for earlier stage LBL, although it might be more intensive. It is given as 3 phases of chemotherapy (induction, consolidation, and maintenance) using many drugs, and it lasts for about 2 years. This is very similar to the treatment of high-risk acute lymphoblastic leukemia (ALL). For more information, see Treating Childhood Leukemia.

Intrathecal chemo is also given into the spinal fluid to kill any lymphoma cells that may have reached the brain or spinal cord. In some cases, radiation therapy may be given to the brain and spinal cord as well.

Treatment of Burkitt lymphoma/Burkitt-like lymphoma and diffuse large B-cell lymphoma (DLBCL)

Chemotherapy (chemo) is the main form of treatment for these lymphomas. Studies are now being done to determine whether adding a monoclonal antibody such as rituximab to chemotherapy will make treatment more effective.

Stages I and II: While chemo is the main treatment of these lymphomas, surgery may be done before chemo if the tumor is in only one area, such as a large abdominal (belly) tumor.

Several different chemo drugs are used. The length of treatment ranges from about 9 weeks to 6 months. Most pediatric oncologists feel that the 9-week treatment is adequate if all of the tumor is removed with surgery first.

Chemotherapy into the spinal fluid is needed only if the lymphoma is growing around the head or neck.

Stages III and IV: Children with more advanced lymphomas need more intensive chemotherapy. Because these lymphomas tend to grow quickly, the chemo cycles are short, with little rest between courses of treatment.

For example, a treatment plan known as the French LMB protocol regimen alternates between different combinations of drugs every 3 to 4 weeks for a total of about 6 to 8 months. Other similar treatment regimens are the German BFM protocol and the St. Jude Total B regimen.

Chemotherapy must also be given into the spinal fluid.

Treatment of anaplastic large cell lymphoma (ALCL)

Chemotherapy is the main form of treatment for these lymphomas. Studies are being done to determine whether adding other drugs to chemotherapy might make treatment more effective.

Stages I and II: Treatment for these lymphomas usually consists of chemotherapy with 4 or more drugs given for about 3 to 6 months. The usual chemotherapy regimen contains a 4-drug combination of cyclophosphamide, vincristine, prednisone, and either doxorubicin or methotrexate. (These are known as the CHOP or COMP regimens.)

Chemotherapy is given into the spinal fluid only if the lymphoma is near the head or neck.

Stages III and IV: ALCL doesn’t often reach the bone marrow or spinal fluid, but if it does, it requires more intensive treatment. Chemotherapy includes several drugs given over 9 to 12 months.

Intrathecal chemotherapy is given into the spinal fluid as well.

Current clinical trials are focusing on the length of chemotherapy and which drugs are important in treating ALCL. Newer drugs, such as brentuximab vedotin (Adcetris) and crizotinib (Xalkori), are now being studied.

Treatment of recurrent lymphoma

Generally, if the lymphoma comes back (recurs) after the first therapy, it is much harder to treat. When possible, more intensive chemotherapy, usually including a stem cell transplant, is recommended. This is often done as part of a clinical trial. Clinical trials of newer forms of treatment may also be an option.

More treatment information about non-hodgkin lymphoma in children

For more details on treatment options – including some that may not be addressed here – the National Cancer Institute (NCI) and the Children’s Oncology Group (COG) are good sources of information.

The NCI provides information by phone (1-800-4-CANCER) and on its website (www.cancer.gov). Detailed information intended for use by cancer care professionals is also available at www.cancer.gov.

The COG is the world’s largest organization devoted to childhood cancer research. The COG website, www.childrensoncologygroup.org, provides information to help support children and their families from diagnosis, through treatment, and beyond.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master’s-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Allen CE, Kamdar KY, Bollard CM, Gross TG. Malignant non-Hodgkin lymphomas in children. In: Pizzo PA, Poplack DG, eds. Principles and Practice of Pediatric Oncology. 7th ed. Philadelphia Pa: Lippincott Williams & Wilkins; 2016:587–603.

Kamdar KY, Sandlund JT, Bollard CM. Malignant lymphomas in childhood. In: Hoffman R, Benz EJ, Silberstein LE, Heslop HE, Weitz JI, Anastasi J, eds. Hematology: Basic Principles and Practice. 6th ed. Philadelphia, Pa: Elsevier; 2013:1255−1266.

National Cancer Institute Physician Data Query (PDQ). Childhood Non-Hodgkin Lymphoma Treatment. 2016. Accessed at www.cancer.gov/types/lymphoma/hp/child-nhl-treatment-pdq on June 8, 2017.

Rabin KR, Margolin JF, Kamdar KY, Poplack DG. Leukemias and lymphomas of childhood. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015:1500–1510.

Sandlund JT, Onciu M. Childhood lymphoma. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 5th ed. Philadelphia, Pa: Elsevier; 2014:1873–1889.

Last Medical Review: June 20, 2017 Last Revised: August 4, 2017

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