Non-Hodgkin's Lymphoma Symptoms, Diagnosis and Stages

Because many patients are asymptomatic during the first stages of the disease, early diagnosis of NHL is not always straightforward.

Symptoms may differ from one individual to the next. A lot depends on the location of the tumor in the body.

The most common symptom, however, tends to be a painless swelling of the lymph nodes, typically in the neck, above the collar bone, or in the chest area, underarms, groin, legs or ankles. Non-Hodgkin's lymphomas can start anywhere in the lymphatic system, or in organs such as the spleen or intestines.

Although some lymphomas are localized, the disease can also spread to remote parts of the body, outside the lymphatic system.

Other symptoms associated with NHL may include fever, night sweats, trouble breathing, coughing, nausea, persistent itching, a poor appetite, fatigue and unexplained weight loss.

The diagnosis may be delayed because swollen lymph nodes are more commonly associated with a wide range of other illnesses than they are with NHL. If a patient presents with swollen lymph nodes, a doctor's initial strategy is likely to be to "wait and see" whether the swellings grow over a period of several weeks.

Non-Hodgkin's Lymphoma Diagnosis

Sometimes, patients show classic lymphoma symptoms at the initial consultation: swollen lymph nodes in the neck, collarbone, underarm areas or groin, accompanied by so-called "B" type lymphoma symptoms such as unexplained weight loss, fever and night sweats. In such cases, an immediate biopsy is required.

Alternatively, a biopsy may be performed following a period of monitoring.

What is a Biopsy?

A biopsy involves removing a small sample of the affected tissue or an entire lymph node for examination under a microscope.

The choice of biopsy method is determined by each patient's individual circumstances. In general, however, excisional or incisional surgical biopsy procedures that can examine larger tissue samples and preserve the shape and size of the tumor are preferable to the fine needle aspiration method of diagnosis.

A lumbar puncture may also be required if NHL is suspected in the region of the spinal cord. This involves inserting a thin needle into the spinal cavity to withdraw a sample of cerebrospinal fluid for further analysis.

What Happens After Diagnosis?

After the initial diagnosis, a detailed medical history is taken and a second, more specific physical examination is performed.

Routine blood samples are taken to evaluate the patient's blood cells, electrolytes (chemicals required for various functions in the body) and various protein levels.

In addition, further laboratory tests are performed to determine the precise type of the disease and to tailor a treatment strategy that best suits the individual's requirements.

Other tests may be ordered, including an analysis of the cell surface or intracellular proteins of the affected cells using specific monoclonal antibodies. These tests are called immunohistochemistry and flow cytometry. Other tests include cytogenetic testing, which examines cells for chromosome abnormalities, and molecular genetic DNA analysis, which analyzes cells at the gene level.

Radiographic imaging is often performed to assess the stage of the disease.

Stages of Non-Hodgkin's Lymphoma

Staging is the term used to describe the extent of tumor spread to other parts of the body. NHL is divided into four main stages. Essentially, Stages I and II refer to localized tumors, whereas Stages III and IV describe more advanced lymphomas that have spread to other organs. Specific treatment decisions are based on these findings.

Staging involves:

standard chest x-rays: looks for enlarged lymph nodes deep inside the chest
computed tomography (CT): a cross-sectional scan uses x-rays to produce "slice" images on a computer screen
ultrasound scans: ultrasonic sound waves are used to obtain an image of internal body structures that may be affected
magnetic resonance imaging (MRI): detects the spread of the cancer to bones and/or the central nervous system
positron emission tomography (PET): uses radioactive sugar to indicate areas of high metabolic activity, such as a malignancy
gallium scan: like PET, but uses radioactive gallium injected into the vein to locate highly aggressive lymphomas
bone marrow aspiration: rarely used in the early staging process for NHL, it is useful for determining how aggressively a particular type of lymphoma is behaving.

The Ann Arbor Staging System

The most commonly used system identifies these stages:

Stage I: in one lymph node region, organ, or other site only
Stage II: in two or more lymph node regions on the same side of the diaphragm (upper or lower half), an organ and lymph nodes on the same half of the body, or another site and lymph nodes on the same half
Stage III: in lymph node regions, spleen, or both and on both sides of the diaphragm
Stage III (1): above the renal vessels, e.g. spleen: splenic, hilar, celiac and portal nodes
Stage III (2): in the lower abdomen, e.g. periaortic, pelvic or inguinal nodes
Stage IV: extranodal, diffuse involvement of non-lymphatic organs or tissues, e.g. bone, marrow, lung, liver.

Resources

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Beers, M. H., & Berkow, R. (ed). Table 139-2. Ann Arbor staging of Hodgkin's disease and non-Hodgkin's lymphoma. The Merck Manual of Diagnosis and Therapy, 17th Edition. Merck Research Laboratories, NJ, 1999.

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