OVERVIEW
Malignant tumors originating in the lymph nodes and extra-nodal lymphoid tissues commonly present with progressive, painless lymph node enlargement, which may be accompanied by fever, weight loss, etc. The etiology of these tumors is uncertain, and may be related to infection, immune deficiencies, physical, chemical, genetic, etc. Chemotherapy and monoclonal antibody therapy are the mainstay of treatment, and hematopoietic stem cell transplantation is feasible in some patients.
Definition
Lymphomas are a heterogeneous group of malignant neoplasms of the hematologic immune system that originate in the lymph nodes and extra-nodal lymphoid tissues.
Most of them are associated with the malignant transformation of certain immune cells resulting from the proliferation and differentiation of lymphocytes in the course of the immune response.
Lymphoma can occur in any part of the body, with lymph nodes, tonsils, spleen and bone marrow being the most likely to be involved.
Types of disease
According to histopathological changes, lymphomas can be divided into two main groups: Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL).
Hodgkin’s Lymphoma
Also known as Hodgkin’s disease, it originates mainly in the lymph nodes and is characterized by progressive enlargement of the lymph nodes.
Currently, the 2016 WHO classification of tumors of the lymphohematopoietic system is used, which is divided into two categories: nodular lymphocyte-predominant Hodgkin’s lymphoma and classic Hodgkin’s lymphoma.
Nodular lymphocyte-dominant type accounts for 5% of Hodgkin’s lymphomas and classic type accounts for 95% of Hodgkin’s lymphomas.
Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL)
More than 95% are nodular, with microscopic hyperplasia of a single small lymphocyte with scattered large tumor cells (popcorn-like).
Classical Hodgkin’s lymphoma (CHL)
In China, mixed cell type (MCHL) is the most common type of classical HL, followed by nodular sclerosing type (NSHL), lymphocyte-rich type (LRHL), and lymphocyte-depleted type (LDHL).
Non-Hodgkin’s lymphoma
It is a group of lymphomas with different histologic features and sites of onset that are prone to early distant spread.
Depending on the cellular origin, they can be classified as B-lymphocyte, T-lymphocyte, or natural killer (NK) cell lymphomas.
Based on biological characteristics, they can be further classified as inert lymphomas, aggressive lymphomas, and highly aggressive lymphomas.
The main common non-Hodgkin’s lymphoma subtypes are:
Diffuse large B-cell lymphoma (DLBCL)
It is the most common type of NHL, accounting for 35% to 40% of cases. Most are primary DLBCL, but can also progress or transform from inert lymphoma.
Typing: the 2016 edition of WHO typing further divides DLBCL into germinal center origin and non-germinal center origin based on cellular origin.
Marginal zone lymphoma (MZL)
Marginal zone refers to the structure between the lymphoid follicle and the follicular coat, and lymphomas occurring in this area are of B-cell origin and belong to the category of inert lymphomas. They can be divided into 3 subtypes according to the site of involvement:
Extraconjunctival mucosa-associated lymphoid tissue marginal zone lymphoma (MALT)
Splenic B-cell marginal zone lymphoma
Lymphoma of the marginal zone of lymph nodes
Follicular lymphoma (FL)
It is a germinal center lymphoma, of B-cell origin, often with CD10+, Bcl6+, Bcl2+ with t(14;18).
It is mostly seen in elderly onset, often with splenic and bone marrow involvement, belongs to inert lymphoma, responds well to chemotherapy, but cannot be cured, has a long course, recurrent relapse or turns aggressive.
Metachronous cell lymphoma (MCL)
It is clinically common in elderly men and accounts for 6%～8% of non-Hodgkin’s lymphoma.
This type develops rapidly, with a median survival of 2 to 3 years, and is an aggressive lymphoma with a low rate of complete remission with chemotherapy.
Burkitt’s lymphoma/leukemia (BL)
t(8;14) with MYC gene rearrangement is diagnostic, extremely fast proliferating, and a severe aggressive non-Hodgkin’s lymphoma.
Angioimmunoblastic T-cell lymphoma (AITL)
It is an aggressive T-cell lymphoma that accounts for 2% of non-Hodgkin’s lymphomas.
It is prevalent in the elderly and presents clinically with fever, enlarged lymph nodes, and a positive Coombs test with multiple strains of hyperimmunoglobulinemia.
Anaplastic large cell lymphoma (ALCL)
It is aggressive and accounts for 2% to 7% of non-Hodgkin’s lymphomas.
It is prevalent in children. The tumor cells vary in morphology and size and may resemble R-S cells, sometimes confused with Hodgkin’s lymphoma.
Peripheral T-cell lymphoma (non-specific) (PTCL)
It is a heterogeneous group of malignant tumors originating from mature (post-thymic) T cells and NK cells.
In China, PTCL accounts for 25%-30% of non-Hodgkin’s lymphoma cases, which is significantly higher than the 10%-15% in Europe and the United States.
It is aggressive and has a poor prognosis.
Myxoid granuloma/Sezary syndrome (MF/SS)
Mycosis fungoides is common, and if it invades the peripheral bloodstream, it is called Sezary syndrome.
It is a clinically inert type of lymphoma.
Incidence
Global data
GLOBOCAN 2020 data shows the following global incidence of lymphoma [1]:
In 2020, there were 83,087 new cases of Hodgkin’s lymphoma (HL) globally, including 48,981 males and 34,106 females, and 23,376 deaths, including 14,288 males and 9,088 females.
In 2020, there were 544,352 new cases of non-Hodgkin’s lymphoma (NHL) globally, ranking 13th among all new cases of malignant tumors; of which 30,451 cases were in males, ranking 10th; and 240,201 cases were in females, ranking 12th.
Data of our country
According to the national cancer report released by the National Cancer Center 2022, the incidence of lymphoma in China in 2016 was as follows [2]:
The number of new cases of lymphoma reached 89,000 in 2016, and about 51,000 people lost their lives due to lymphoma.
The overall incidence of lymphoma in 2016 was estimated to be 6.5/100,000, which is equivalent to approximately 6 per 100,000 people suffering from lymphoma.
[SPECIAL REMINDER] Due to the general lag in data from the National Tumor Registry, the data published in the 2022 report is the National Tumor Registry’s collection of 2016 registrations from the National Tumor Registry.
Causes
Causes
The causes of lymphoma are not fully understood, and the more recognized causes include infection, defective or suppressed immune function, and physical and chemical factors.
Infection
Human immunodeficiency virus (HIV) infection: Lymphoma is the most common form of lymphoma in patients, and the incidence is 60 to 100 times higher than that in the general population.
EBV infection: may be associated with the development of Hodgkin’s lymphoma, Burkitt’s lymphoma, and extranodal NK/T-cell lymphoma.
Human T-lymphoblastic leukemia virus-1 (HTLV-1) is strongly associated with adult T-cell lymphoma/leukemia.
Helicobacter pylori (Hp) infection: is a possible cause of gastric mucosa-associated lymphoma (MALT), and treatment to remove Hp results in remission in more than 2/3 of stage I gastric MALT cases.
Hepatitis C virus: possible association with splenic lymphoma.
Chlamydia psittaci infection: associated with the development of lymphoma of the ocular appendages.
Immunodeficiency or suppression
Patients with hereditary or acquired immunodeficiency have associated lymphomas more often than normal individuals.
1/3 of those who develop malignant tumors from long-term application of immunosuppressants after organ transplantation have lymphomas.
The incidence of lymphoma in patients with rheumatoid arthritis and dry syndrome is higher than that in normal people.
Physical and chemical factors
Physical factors and chemicals such as radiation, insecticides, herbicides, hair dyes, heavy metals, benzene, etc. may also be associated with the development of lymphoma.
Genetic factors
Lymphoma may have a genetic predisposition and family aggregation.
If one of the twins has lymphoma, monozygotic twins are more than 100 times more likely to develop Hodgkin’s lymphoma compared to dizygotic twins.
First-degree relatives of people with Hodgkin’s lymphoma have a five-fold increased risk of developing Hodgkin’s lymphoma.
First-degree relatives of people with chronic lymphocytic leukemia/small lymphocytic lymphoma have a 2- to 7-fold increased risk of developing lymphoma.
First-degree relatives of patients with plasma cell myeloma are more than 3.7 times more likely to develop the disease.
Pathogenesis
The exact pathogenesis of lymphomas is not well understood, such as double-hit lymphomas caused by the formation of a fusion gene between the Myc gene and the Bcl2 gene.
Symptoms
Lymphocytes can undergo malignant transformation in their “birthplace” (thymus, bone marrow) as well as in lymph nodes, spleen, tonsils and lymphoid tissues of other tissues and organs throughout the body.
In advanced stage, malignant lymphoma can also invade parts other than lymphatic tissues.
The clinical manifestations of lymphoma are complex and diverse.
Lymphatic system symptoms
Painless progressive lymph node enlargement or localized lumps are common clinical manifestations of lymphoma.
Lymph node enlargement
Painless enlargement of superficial lymph nodes is the first symptom in more than 60% of cases.
Common locations of enlarged lymph nodes include neck (60%～80%), axilla (6%～20%), groin (6%～12%).
Submaxillary and anterior and posterior to the ear are less common.
Lymph node enlargement is often asymmetric, tough and elastic, painless, and not adherent to each other in the early stage.
Deep lymph node enlargement can cause local infiltration and compression symptoms.
Symptoms of compression caused by enlarged lymph nodes
Progressive enlargement of lymph nodes may affect or compress the surrounding tissues and organs and cause corresponding symptoms.
Enlarged mediastinal lymph nodes: often manifested as swelling of the face and neck, chest tightness, chest pain and dyspnea.
Enlarged abdominal lymph nodes: may present with abdominal pain, lumbago, abdominal mass, difficulty in urination and defecation or hematuria.
Enlarged digestive tract (submucosal) lymphoid tissue: abdominal pain, diarrhea, abdominal mass, intestinal obstruction, blood in stool, intestinal perforation or malabsorption syndrome may occur.
Enlarged tonsils and pharyngeal ring lymphoid tissue: enlarged tonsils, nasopharyngeal masses, or dyspnea may occur.
Symptoms outside the lymphatic system
Lymphoma can invade organs outside the lymphatic system (i.e. extra-nodal invasion), which manifests as invasion, destruction, compression or obstruction of the corresponding organs.
Gastrointestinal symptoms
Primary gastric lymphoma
Usually epigastric pain, nausea, vomiting, fullness, and dyspepsia.
Primary intestinal lymphoma
Common symptoms may include fever, abdominal pain, diarrhea, nausea and vomiting, bleeding, weight loss, anorexia, etc. Symptoms of intestinal obstruction and intestinal perforation may also occur.
In children, acute abdomen is the most common symptom.
A polypoid mass such as lymphoma can lead to intussusception or signs similar to appendicitis.
In some cases, abdominal masses may be palpable with abdominal tenderness.
Liver and spleen related manifestations
Individual splenic lesions are often seen in advanced Hodgkin’s lymphoma, splenic marginal zone lymphoma, and chronic lymphocytic leukemia, which is often associated with splenomegaly and hypersplenism.
Hepatosplenic T-cell lymphomas often have an acute onset of hepatosplenomegaly.
In advanced stages of non-Hodgkin’s lymphoma disease, hepatomegaly and liver function abnormalities occur, and some patients may have obstructive jaundice due to enlarged hilar lymph nodes or intrahepatic cholestasis.
Symptoms of bone and soft tissue invasion
Bone invasion
Lymphoma can affect bones all over the body
The long bones of the limbs are most commonly affected, especially the femur, and the invasion range of the bones is longer.
The second most susceptible sites are the central axis bones, such as pelvis, skull, spine, jawbone, etc..
Most patients only have localized dull bone pain or soreness, which can last for several months, and the bone pain cannot be relieved after rest.
About 50% of patients develop a palpable mass due to localized bone lesions invading the surrounding soft tissues.
A few patients may develop localized swelling and pathologic fractures.
Soft tissue invasion
Soft tissue lymphomas infiltrate soft tissues in all parts of the body. It can develop from the skin and subcutaneous tissues to deep muscular intervals.
It occurs mainly in the extremities, more in the lower extremities than in the upper extremities, e.g., in the thighs, ankles, gastrocnemius (back of the calf), buttocks, iliopsoas, and upper arms.
Skin damage
Skin lesions can be categorized as specific and non-specific.
Atopic
Specific lesions, i.e., cutaneous infiltration of lymphoma, are diverse and may present as masses, nodules, infiltrative plaques, ulcers, papules, and macules.
Irregular infiltrative plaques are dark red, with smooth or uneven surfaces, often with hair loss at the infiltrates, and may also involve the oral mucosa.
The lesions are often accompanied by marked itching, thickening of the skin at the infiltrates, and a typical “lion’s face” may appear; malignant erythroderma is occasionally seen.
Non-specific
Non-specific lesions are only common inflammatory changes, manifested by pruritus, itchy rash, herpes zoster and acquired ichthyosis.
Neurologic lesions
Lymphoma can invade the central nervous system through metastasis, or it can be a primary central nervous system lymphoma, with different presentations at different sites of disease.
There may be cerebral nerve paralysis, headache, seizures, increased intracranial pressure, spinal cord compression and paraplegia.
Symptoms related to Weil’s ring
Ring of Weil refers to a ring of lymphoid tissue that includes the nasopharynx, soft palate, tonsils, oropharynx, and root of the tongue.
Tonsillar lymphoma infiltration
Often presents as a reddish or exophytic mass, which may be smooth and non-ulcerated, or ulcerated and necrotic.
There may be localized swelling, foreign body sensation and pain in the throat, and dyspnea and dysphagia may be present if the mass is large.
Nasopharyngeal lymphoma infiltration
Common symptoms include sore throat, nasal congestion and hearing loss.
The lesion may invade the nasal sinuses and cause nasal congestion, with unilateral progressive nasal congestion as the main cause.
Rhinorrhea and decreased sense of smell may also occur.
Oropharyngeal lymphoma: It may manifest as refractory ulcers.
Other symptoms
When advanced patients present with tumor invasion of sites other than lymphatic tissues, a variety of the following clinical manifestations may occur:
Liver enlargement, jaundice (yellowing of the skin and whites of the eyes, deepening of the color of the urine).
Bone pain, pathologic fractures.
Breast enlargement.
Protruding eyeballs.
Skin lumps.
Pleural effusion.
Pericardial effusion, masses in the lungs.
Paralysis of limbs and cerebral nerves, paraplegia, etc.
Systemic symptoms
Lymphoma is a systemic disease, in addition to the localized symptoms mentioned above, about half of the patients may also experience the following symptoms:
Fever
30% to 40% of patients with Hodgkin’s lymphoma have persistent fever of unknown cause as the starting symptom.
They are usually slightly older, more often male, and often have retroperitoneal lymph node involvement.
About 1/6 have periodic fever.
Itching
Localized and generalized itching of the skin may be present.
Itching can be the only systemic symptom of Hodgkin’s lymphoma.
Consultation
Department of Medicine
Hematology
If you develop unexplained fever, night sweats, weight loss, or fatigue, or if you develop painless, progressively enlarging lymph nodes or masses, you should seek medical attention.
Lymphoma Diagnosis and Treatment Center
If you are diagnosed with lymphoma, you can also seek treatment at the Lymphoma Treatment Center of a specialized oncology hospital.
Preparation
Consultation Information: Registration, Preparation of Documents, Frequently Asked Questions
Tips for Medical Treatment
Lymphoma has no specific symptoms in the early stage and is easy to be neglected. Therefore, people with family history of lymphoma should have regular medical checkups for cancer prevention.
Those who apply immunosuppressant for a long period of time after organ transplantation have a higher probability of developing lymphoma, so it is recommended to follow the doctor’s instructions for regular follow-up.
Preparation List for Medical Consultation
Symptom checklist
Particular attention should be paid to the time of onset of symptoms, special manifestations, etc.
Are there painless lymph node enlargement or localized lumps?
Is there any unexplained persistent fever?
Any recent localized or generalized itching of the skin?
Medical History Checklist
Is there a family history of lymphoma or other malignant tumors in the family?
Any history of radiation therapy?
Any drug or food allergies?
Any history of EBV, Helicobacter pylori (Hp), etc.?
Any immune system diseases such as rheumatoid arthritis, dry syndrome, etc.?
Any history of organ transplantation?
Checklist
Test results in the past six months, which can be brought to the doctor’s office
Specialized tests: blood smear, bone marrow image test, lymph node biopsy.
Laboratory tests: blood test, urine test, stool test, biochemical test.
Imaging tests: ultrasonography, CT scan, magnetic resonance imaging (MRI), PET-CT.
Diagnosis
Diagnosis is based on
Medical history
Any history of viral infection.
Whether there is autoimmune disease such as lupus erythematosus, rheumatoid arthritis.
Whether there is a family history of lymphoma or other malignant tumors.
Clinical manifestations
Common signs and symptoms
Systemic symptoms such as fever, night sweats, malaise, lethargy, lack of appetite, rash and itching.
Painless progressive enlargement of cervical or supraclavicular lymph nodes, or axillary lymph nodes.
The enlarged lymph nodes may move or adhere to each other and fuse into lumps, with cartilage-like sensation on palpation.
Other manifestations
Masses on the skin, chest and abdomen.
Enlarged liver and spleen.
Bone tenderness.
Imaging
Computed tomography (CT)
CT is currently the most commonly used imaging tool in patients with lymphoma.
CT can clearly show the size and density of lymph nodes in each area, their relationship with surrounding blood vessels and organs, and also extra-nodal lesions.
It can be used as an imaging method for lymphoma staging, restaging, efficacy evaluation and follow-up, and enhanced CT scanning will be used for patients without contraindications to iodine contrast.
Generally all patients with non-Hodgkin’s lymphoma require CT of the neck, chest, abdomen, pelvis and other relevant areas before, during and after treatment.
Magnetic Resonance Imaging (MRI)
MRI is preferred for lesions in the central nervous system, bone marrow and muscle areas.
For parenchymal organ lesions such as the liver, spleen, kidneys, and uterus, MRI may be selected or preferred, especially for those for whom enhanced CT scanning is contraindicated, or as a further examination after a suspicious lesion is detected by CT.
Positron emission computed tomography (PET-CT)
Currently, it is the best test for staging and restaging of lymphoma, evaluation of treatment efficacy and prognosis prediction, except for inert lymphoma.
PET-CT is recommended in the following cases and when available:
As a routine test for pre-treatment staging as well as re-staging of Hodgkin’s lymphoma and non-Hodgkin’s lymphoma subtypes with high affinity for fluorodeoxyglucose.
Hodgkin’s lymphoma and most diffuse large B-cell lymphomas require clarification of the presence or absence of bone marrow involvement.
Biopsy sites need to be identified in the conversion of inert lymphomas to more aggressive types of pathology.
Efficacy needs to be assessed and prognostic predictions made.
Ultrasound
Can be used for diagnosis and review of superficial lymph node and superficial organ (e.g., testes, thyroid, breast, etc.) lesions, but is generally not used for staging lymphoma.
For abdominal and pelvic lymph node examination, it is usually used selectively.
For the evaluation of abdominal and pelvic substantial organs such as liver, spleen, kidney, uterus, etc., it can be used as a supplement to CT and MRI, especially when enhanced CT scanning cannot be performed.
For superficial lymph node dissection biopsy, the selection of lymph nodes with abnormal sonograms detected by ultrasound can help improve the accuracy of the biopsy.
Ultrasound-guided puncture biopsy is also used in the diagnosis of lesions in the deep lymph nodes, liver, and mediastinum.
Isotope bone scan
Conventional bone scan has limited clinical assessment value for patients with primary Hodgkin’s lymphoma, but bone scan is better than CT for follow-up observation and prognostic assessment after treatment of primary bone lymphoma.
Barium gastrointestinal imaging
Gastrointestinal barium contrast is commonly used to diagnose gastrointestinal non-Hodgkin’s lymphoma.
Gastric non-Hodgkin’s lymphoma: the gastric mucosa shows “cobblestone-like” changes, the lesions are mainly located in the submucosa, and gastric peristalsis still exists when the lesions are extensive, which is the main basis for differentiating from gastric cancer.
Non-Hodgkin’s lymphoma of the small intestine: there are multiple scattered and well-margined filling defects in the small intestine, or coexistence of narrowing and dilatation of the intestinal lumen.
Non-Hodgkin’s lymphoma of the large intestine: it is common in the rectum and cecum, and is characterized by nodular or mass filling defects and narrowing and thickening of the intestinal wall.
Laboratory tests
Blood tests
Routine blood tests, liver and kidney function, blood glucose, calcium, serum proteins, lactate dehydrogenase, beta 2 microglobulin, etc. The above tests can help to understand the prognosis and determine whether treatment is contraindicated.
Patients with Hodgkin’s lymphoma often have mild or moderate anemia, and some patients have elevated eosinophils.
Patients with non-Hodgkin’s lymphoma tend to have normal white blood cell counts with an absolute or relative increase in lymphocytes. When lymphoma cell leukemia occurs in advanced stages, leukemia-like blood picture may be presented.
Bone marrow examination
Bone marrow tests such as bone marrow smear, flow cytology, or bone marrow biopsy are helpful in pre-treatment evaluation.
Immunization program
In the early stage, 40% of patients have slightly increased IgG and lgA and decreased IgM, and in the late stage, 50% develop alpha-globulin hypoglobulinosis and decreased antibody production.
The presence of cellular immunocompromise is indicated by immunologic markers such as tuberculin, bacitracin, and dinitrochlorobenzene (DNCB).
Pathologic examination
Pathologic examination is the main means of lymphoma diagnosis.
Principles of examination
Lymph node lesions: complete lymph nodes need to be removed. If lymph node lesions are located in superficial areas, try to choose cervical, supraclavicular and axillary lymph nodes.
Hollow-core needle puncture: only used in patients where resection or excision of diseased tissue cannot be obtained effectively and safely.
Initial diagnosis and recurrence: For initial diagnosis, resection or excision of the lesion tissue should be preferred; for patients with recurrence, if resection or excision of the lesion tissue specimen cannot be obtained, pathological diagnosis can be made from the lesion tissue obtained by hollow-core needle aspiration.
Diagnostic method
The pathologic diagnosis of lymphoma requires a combination of morphology, immunohistochemistry, genetics and molecular biology techniques as well as flow cytometry, etc. No single method can be defined as the “gold standard”.
Morphology
Morphology is very important in the pathologic diagnosis of lymphomas, and different types of lymphomas have characteristic and diagnostic morphologic features.
The definitive diagnosis of Hodgkin’s lymphoma is based on pathologic examination, and R-S cells may be found in lymph nodes or extra-nodal tissues such as bone marrow, lungs, or skeletal tissues.
Immunohistochemistry
can be used to identify the immunophenotype of lymphoma cells, such as B or T/NK cells, differentiation and maturation of tumor cells.
Differential diagnosis of different pathologic subtypes is performed by combining relevant IHC markers.
Fluorescence in situ hybridization (FISH) detection technology
It can detect specific chromosome breaks, translocations or amplifications, etc., which is instructive for the auxiliary diagnosis of specific chromosomal abnormality-associated lymphomas.
For example, t(8;14) translocation associated with Burkitt’s lymphoma and t(14;18) translocation associated with follicular lymphoma.
Lymphocyte antigen receptor gene rearrangement detection technology
Monoclonal rearrangements of lymphocyte receptor genes are a major feature of lymphoma cells.
It can be used to assist in identifying the monoclonal versus polyclonal nature of lymphocyte proliferation, as well as lymphomas that cannot be diagnosed by IHC, and is an important complement to morphology and IHC tests.
Others: These include in situ hybridization, second-generation sequencing (NGS), and flow cytometry, which are useful complements to conventional pathology diagnostic methods.
Other targeted tests
Gastroscopy and enteroscopy: patients with suspected gastrointestinal tract invasion should undergo gastroscopy and enteroscopy.
Cardiac examination: routine electrocardiography; selective echocardiography for those with basic cardiovascular diseases, advanced age, or those proposed to apply anthracycline drugs.
Pulmonary function tests: those who are proposed to use bleomycin and have underlying lung disease should have pulmonary function tests.
Staging
Correct staging is important for judging prognosis and selecting treatment.
Ann-Arbor staging is the current universal staging system for describing Hodgkin’s lymphoma and non-Hodgkin’s lymphoma.
The Ann-Arbor (revised by Cotswolds) staging system is as follows.
Staging
Stage I: invasion of a single lymph node area (I), or invasion of a single extra-lymph node organ or site (IE).
Stage II: invasion of two or more lymph node areas on one side of the diaphragm (II) or plus limited invasion of a single extra-nodal organ or site (IIE).
Stage III: invaded lymph node areas on both sides of the diaphragm (III) or plus limited invasion of one extranodal organ or site (IIIE) or the spleen (IIIS) or both (IIIES).
Stage IV: diffuse or disseminated invasion of one or more extranodal organs with or without lymph node invasion.
Recording symbols
The following recording symbols may be used for the site of involvement:
E: Extranodal, lymphoma involving organs outside the lymph nodes.
When a single extranodal site is invaded and the lesion invades an organ/tissue that is directly connected to a lymph node/lymphoid tissue, it is not recorded as stage IV.
The letter “E” should be entered after each stage (e.g., if the lesion infiltrates into the skin connected to the left cervical lymph node, it is recorded as “IE”).
X: Large mass, tumor diameter > 1/3 of chest width or fusion mass > 7.5 cm in diameter.
Others: M (bone marrow), S (spleen), H (liver), O (bone), D (skin), P (pleura), L (lung).
Grouping
Each stage can be subdivided into Group A and Group B according to the presence or absence of systemic symptoms.
Group A: no systemic symptoms.
Group B: Systemic symptoms, including unexplained fever (>38°C for 3 consecutive days or more), night sweats (e.g., profuse sweating during sleep requiring change of bed sheets or covers for 7 consecutive days or more), or weight loss (loss of 10% or more within 6 months with no other explainable cause).
Special Reminder.
Certain non-Hodgkin’s lymphomas with a primary extranodal lymph node, such as chronic lymphocytic leukemia, cutaneous T-cell lymphoma, primary extranodal nasal-type NK/T-cell lymphoma, and primary gastric, intestinal, and central nervous system lymphomas, make it difficult to apply Ann-Arbor staging.
These non-Hodgkin’s lymphomas that originate in specific extranodal organs and sites usually have their own exclusive staging system.
Differential Diagnosis
Lymphoma is a systemic disease and therefore actually needs to be differentiated from many diseases, especially those that occur outside of the lymph nodes, and from diseases at the corresponding sites.
The final diagnosis of most lymphomas is determined by pathology, and some may require molecular testing for final characterization.
Enlargement of superficial lymph nodes
Acute lymphadenitis
Similarities: Both have enlarged superficial lymph nodes.
Differences: Acute lymphadenitis tends to have limited lymph node enlargement, the skin may be flushed, and the texture is soft to moderately hard. There is spontaneous pain and tenderness. The surface of the lymph nodes is smooth to the touch, without adhesions, and the enlargement stops when it reaches a certain level. In patients with lymphoma, the symptoms of superficial lymph node enlargement will progressively worsen and are usually painless.
Chronic lymphadenitis
Similarities: Both may have long-term enlarged lymph nodes.
Differences
Chronic lymphadenitis is characterized by enlarged lymph nodes in the lateral neck or submandibular region, about the size of a green bean to a fava bean, flat, medium-soft in texture, smooth surface, and movable.
There may be mild or no tenderness. If necessary, needle aspiration cytology can be done, chronic inflammatory cells can be seen, and lymph node biopsy can confirm the diagnosis.
Metastatic cancer of lymph nodes
Similarity: superficial lymph nodes may be present.
Difference: when lymph node metastasis occurs in cancer, patients usually have the clinical manifestations of primary tumor lesions, and lymph node biopsy can help to differentiate.
Diseases causing long-term fever
Lymphoma with fever as the main manifestation needs to be differentiated from tuberculosis, sepsis, connective tissue disease, necrotizing lymphadenitis and hemophagocytic lymphohistiocytosis.
Generally, it needs to be judged together with medical history and relevant examination results, and pathological diagnosis is needed to confirm the diagnosis if necessary.
Extranodal lymphoma
Lymphoma of non-lymph nodes needs to be differentiated from other malignant tumors of corresponding organs or sites. Pathologic diagnosis is usually required to confirm the diagnosis.
For example, MALT lymphoma and diffuse large B-cell lymphoma need to be differentiated from gastric cancer and gastrointestinal mesenchymal tumor.
Treatment
Aims and principles of treatment
Treatment aim: to maximize clinical cure or long-term progression-free survival of the disease through treatment, and to maximize the improvement of patients’ quality of life.
Treatment principle: choose reasonable treatment means and carry out comprehensive treatment according to the typing, staging and prognosis of lymphoma.
Treatment means
According to the patient’s age, physical condition, lymphoma subtype, lesion site, staging and other factors, and under the premise of following the guidelines and treatment principles, standardized, comprehensive and individualized treatment is the key to obtaining good therapeutic effect.
Chemotherapy
Chemotherapy, or chemotherapy for short, is a treatment method that uses chemically synthesized drugs to kill tumor cells and inhibit their growth.
Chemotherapy is the main treatment for lymphoma. Chemotherapy for lymphoma mostly adopts multi-drug combination chemotherapy program. According to the characteristics of lymphoma cell growth cycle, cell cycle specific and cell cycle non-specific drugs are combined.
Commonly used chemotherapy drugs for lymphoma
Anthracyclines: doxorubicin, epirubicin, etc.
Alkylating agents: cyclophosphamide, isocyclophosphamide, etc.
Dihydrofolate reductase inhibitors: methotrexate, etc.
Antibiotics: bleomycin, etc.
Plant-based drugs: etoposide, vincristine, etc.
Note: Adequate drug dosage intensity and duration of therapy are essential to achieve satisfactory efficacy.
Characteristics of chemotherapy for lymphoma
Compared with solid tumors, the chemotherapy dose for lymphoma is larger, the treatment time is longer, and the general condition of patients is relatively poorer, therefore, the toxicity of bone marrow suppression, cardiac injury, liver and kidney damage caused by chemotherapy needs to be closely monitored and promptly treated.
Lymphoma patients are more common among adolescents and have a higher cure rate, so the long-term toxicity caused by chemotherapy (e.g., infertility, second tumors) is also getting more attention.
Doctors usually combine chemotherapeutic agents to minimize toxic side effects while ensuring efficacy.
Commonly used chemotherapy regimens
CVP regimen: cyclophosphamide + vincristine + prednisone. Mainly used in the treatment of Hodgkin’s lymphoma.
ABVD regimen: doxorubicin + bleomycin + vincristine + dacarbazine. Mainly used in the treatment of Hodgkin’s lymphoma.
CHOP regimen: cyclophosphamide + doxorubicin + vincristine + prednisone. It is the standard treatment regimen for aggressive non-Hodgkin’s lymphoma.
R-CHOP regimen: i.e. CHOP regimen with rituximab before chemotherapy.
DHAP regimen: dexamethasone + high-dose cytarabine + cisplatin. Commonly used in second-line treatment.
Special reminder
Drug therapy, especially chemotherapy is cytotoxic drug therapy, the specific use must be under the guidance of the doctor to choose the appropriate program and individualized treatment.
Radiotherapy
Radiation therapy for tumors, referred to as radiotherapy, is a local treatment that can be used to eradicate and destroy local primary tumors or metastatic lesions, and can be used to treat tumors alone.
Lymphoma is one of the most common radiosensitive tumors, and radiotherapy plays an important role in local control, consolidation and palliative reduction of lymphoma.
Role of radiotherapy in lymphoma treatment
Radical effect: for certain early lymphomas, such as early Hodgkin’s lymphoma without poor prognostic factors, early mucosa-associated tissue lymphoma, follicular lymphoma, etc., radiotherapy alone can achieve radical effect.
Consolidation of therapeutic effect
For some aggressive lymphomas, such as diffuse large B-cell lymphoma with primary mediastinal and central origin, advanced follicular lymphoma, and condyloma, the addition of radiotherapy on the basis of chemotherapy can further consolidate the therapeutic effect.
Especially for patients with isolated residual lesions after chemotherapy or large masses before chemotherapy, consolidation radiotherapy can reduce local recurrence of the tumor and thus improve long-term survival rate.
Symptom reduction: For patients with poor tolerance to chemotherapy, especially those who have received too many courses of chemotherapy in the past or elderly patients, radiotherapy can reduce local symptoms, slow down disease progression, prolong the survival time and improve the quality of life.
Rescue treatment: for spinal cord compression and gastrointestinal obstruction caused by certain lymphoma, local radiotherapy can rapidly relieve or reduce the compression, relieve the symptoms and finally achieve the effect of rescue treatment.
Side effects of radiotherapy
Acute toxic reactions caused by radiotherapy: mucosal reactions (ulceration, leukoplakia, pain, etc.), gastrointestinal reactions (nausea, lack of appetite, vomiting) and bone marrow suppression.
Post-radiotherapy complications: radiation pneumonitis, pericarditis, myelitis, hypothyroidism, etc.
In children and adolescents, special attention also needs to be paid to the fact that radiotherapy may affect bone development.
Patients who have undergone expanded field high-dose irradiation have an increased likelihood of developing a second tumor in the radiotherapy field and need to be followed up closely at regular intervals.
Hematopoietic stem cell transplantation (HSCT)
Hematopoietic stem cell transplantation refers to the intravenous infusion of normal human hematopoietic stem cells into patients who have undergone pretreatment (chemotherapy/radiotherapy) to rebuild the hematopoietic and immune functions of the patients in order to treat certain diseases.
Classification
Hematopoietic stem cell transplantation is classified according to the source of the hematopoietic stem cells: bone marrow transplantation (BMT), peripheral blood stem cell transplantation (PBSCT), and cord blood transplantation (CBT).
According to donor genetics, it can be classified into autologous hematopoietic stem cell transplantation (AHSCT), homozygous hematopoietic stem cell transplantation between identical twins, and allogeneic hematopoietic stem cell transplantation.
Allogeneic HSCT
In the following cases, doctors may try to perform autologous or allogeneic HSCT after high-dose combination chemotherapy with the aim of maximizing tumor cell killing and achieving longer-term remission and disease-free survival.
Age under 55 years.
Normal function of vital organs.
Short remission period.
Aggressive lymphoma that is refractory and prone to relapse.
Those who can achieve more than 3/4 lymph node shrinkage with 4 CHOP regimens.
Autologous peripheral blood hematopoietic stem cell transplantation
When autologous peripheral blood hematopoietic stem cell transplantation is used for lymphoma treatment, there is less chance for the graft to be contaminated by lymphoma cells, the hematopoietic function recovers quickly, and it is suitable for patients with bone marrow involvement or those who have been irradiated through the pelvis.
Surgical treatment
As a systemic malignant tumor of the blood system, surgical resection of lymphoma is mostly not used as a conventional treatment. Surgical intervention is still required in some special cases, mainly including:
For enlarged lymph nodes or suspected invading organs, surgical excision (or resection) biopsy is performed to clarify the pathological diagnosis.
For early primary gastrointestinal lymphoma, surgical resection can be given followed by chemoradiotherapy for consolidation.
For the complications such as spinal cord compression syndrome and cavity organ obstruction caused by lymphoma compression, decompensated surgery is feasible.
For those with hypersplenism, splenectomy can be performed if there is an indication for splenectomy, so as to improve the blood image and create favorable conditions for future chemotherapy.
Biological therapy
Monoclonal antibody
The majority of non-Hodgkin’s lymphomas are B-cell, 90% of which express CD20. the lymphocyte-dominant form of Hodgkin’s lymphoma also expresses CD20 at high density.
Application: All CD20-positive B-cell lymphomas can be treated with CD20 monoclonal antibodies (e.g., rituximab).
Improvement of chemotherapeutic efficacy: Applied before each cycle of chemotherapy, it can significantly improve the complete remission rate and disease-free survival time of inert or aggressive B-cell lymphoma.
Improvement of transplantation outcome: In vivo purification of B-cell lymphoma with rituximab prior to hematopoietic stem cell transplantation may improve the efficacy of transplantation therapy.
Interferon
Interferon has antiviral and antitumor activity and immunomodulatory effects.
It has a partial palliative effect on mycosis fungoides and others.
Anti-Helicobacter pylori (Hp) drugs
Gastric MALT lymphoma is treated with anti-Hp therapy in some patients with improvement of symptoms and disappearance of lymphoma.
CAR-T therapy
CAR-T (chimeric antigen receptor T-Cell) cellular immunotherapy, i.e. chimeric antigen receptor T-cell immunotherapy, is effective in treating relapsed refractory B-cell lymphoma.
Treatment of common lymphomas
Nodular lymphocyte predominant Hodgkin’s lymphoma
Staging
Stage IA/IIA (no large mass): observation or local radiotherapy.
Stage IB/IIB and Stage IA/IIA (with large masses): local radiotherapy ± chemotherapy ± rituximab treatment.
Stage III/IV: chemotherapy ± rituximab ± local radiotherapy.
Commonly used chemotherapy regimens
The main first-line chemotherapy regimens are as follows:
ABVD regimen: doxorubicin + bleomycin + vincristine + dacarbazine, which is the treatment of choice.
CHOP regimen: cyclophosphamide + doxorubicin + vincristine + prednisone.
CVP regimen: cyclophosphamide + vincristine + prednisone.
Note: The above regimen may be ± rituximab treatment.
Classic Hodgkin’s lymphoma
Staged treatment
Stages I and II: generally require 2 to 6 cycles of chemotherapy, plus radiation therapy with irradiation of the involved field (IFRT) or irradiation of the site (ISRT).
Stages III and IV: generally require 8 cycles of chemotherapy followed by irradiation of the involved field of radiotherapy (IFRT), or a change in chemotherapy regimen.
First-line chemotherapy regimen for first-treatment patients
First-line chemotherapy regimens for first-treatment patients include:
ABVD regimen: doxorubicin + bleomycin + vincristine + dacarbazine.
Stanford V regimen: doxorubicin + vincristine + nitrogen mustard + vincristine + bleomycin + etoposide + prednisone given weekly.
BEACOPP regimen: etoposide + doxorubicin + cyclophosphamide + vincristine + bleomycin + prednisone + methylbenzylhydrazine.
Chemotherapy regimen for relapsed/refractory patients
Relapsed/refractory patients receive second-line regimens including:
DHAP regimen: dexamethasone + high-dose cytarabine + cisplatin.
DICE regimen: dexamethasone + isocyclophosphamide + cisplatin + etoposide.
ESHAP regimen: etoposide + methylprednisolone + high-dose cytarabine + cisplatin.
GDP regimen: gemcitabine + cisplatin + dexamethasone.
GVD regimen: gemcitabine + vincristine + liposomal doxorubicin.
ICE regimen: isocyclophosphamide + carboplatin + etoposide.
IGEV: isocyclophosphamide + gemcitabine + vincristine.
miniBEAM regimen: carmustine (carzapine) + etoposide + cytarabine + mirfan.
MINE regimen: mesna + isocyclophosphamide + mitoxantrone + etoposide.
Other treatment options for relapsed/refractory patients:
For young patients with good general status, after remission with rescue therapy, high-dose chemotherapy combined with autologous hematopoietic stem cell transplantation should be chosen as consolidation therapy, as well as radiotherapy for sites that have not been treated with radiotherapy at the time of initial treatment.
For relapsed/refractory patients, programmed cell death protein 1 (PD-1) monoclonal antibody can be chosen as rescue therapy. For CD30-positive relapsed/refractory patients, CD30 monoclonal antibody (BV) is an option.
Non-Hodgkin’s Lymphoma
The most important treatment for non-Hodgkin’s lymphoma is chemotherapy, especially for those with moderate to high malignancy. Radiation therapy also has a place in the management of non-Hodgkin’s lymphoma.
Surgery, on the other hand, is a useful option in the comprehensive treatment of some extranodal lesions, for example, in the treatment of gastrointestinal lymphomas, especially when there is a risk of localized perforation of the tumor.
The treatment of non-Hodgkin’s lymphoma is closely related to the pathologic subtype, and only a brief description of treatment strategies is provided here; for specific treatment directions, please participate in the relevant entries on the pathologic subtypes of lymphoma.
Inert Lymphoma
Inert lymphomas develop slowly and are effectively treated with chemotherapy and radiation, but do not resolve easily.
B-cell inert lymphomas: These include small lymphocytic lymphomas, lymphoplasmacytic lymphomas, marginal zone lymphomas, and follicular lymphomas.
T-cell inert lymphoma: refers to mycosis fungoides/Sezary syndrome.
Stage I and II
Survival can be up to 10 years after radiotherapy or chemotherapy, and some patients have spontaneous tumor regression, so the palliative care principle of watch and wait is advocated.
If the disease progresses, oral monotherapy with nitrogen mustard phenylbutyrate or cyclophosphamide may be used.
Stage II and IV
The median survival time after chemotherapy can be up to 10 years, even though there may be many relapses. Combination chemotherapy can be used with COP regimen or CHOP regimen.
FC (fludarabine, cyclophosphamide) regimen can be tried for those whose progression cannot be controlled.
Aggressive lymphoma
B-cell aggressive lymphomas: these include primitive B-cell lymphoma, primitive immune cell lymphoma, condyloma, diffuse large B-cell lymphoma, and Burkitt’s lymphoma.
T-cell aggressive lymphoma: including primitive T-cell lymphoma, angioimmunoblastic T-cell lymphoma, mesenchymal large cell lymphoma and peripheral T-cell lymphoma.
Treatment principle: chemotherapy should be the mainstay of aggressive lymphoma regardless of the stage, and local radiotherapy can be used to expand the irradiation as a supplement to chemotherapy for residual mass of chemotherapy, local huge mass or central nervous system involvement.
CHOP regimen: cyclophosphamide + doxorubicin + vincristine + prednisone. It is the standard treatment regimen for aggressive non-Hodgkin’s lymphoma.
R-CHOP regimen: i.e. CHOP regimen with rituximab added before chemotherapy, which can obtain better efficacy and is the classic regimen for the treatment of diffuse large B-cell lymphoma.
Treatment Related Nursing
Chemotherapy care
Leukopenia: Infection will be more likely to occur when white blood cells are reduced. During chemotherapy, pay attention to warmth and rest, avoid catching cold, and reduce close contact with people to reduce the risk of infection.
Anorexia, nausea and vomiting: Eat small meals and eat easily digestible, light food. If necessary, consult your doctor if you need to take anti-emetic drugs.
Fever
For fever below 38℃, no antipyretic drugs can be used, drink plenty of warm boiled water and pay attention to rest.
If the temperature exceeds 38℃ and there is obvious headache or general discomfort, you should go to the hospital for follow-up.
Generalized weakness
This kind of weakness is often related to anemia, and requires sufficient rest and nutrition. Consuming enough calories and protein can help relieve the discomfort.
If necessary, ask your doctor if you need to take medication to correct your anemia.
Hair loss: Hair loss may occur during radiotherapy, but it will grow back after the treatment is over, and a wig may be worn if needed.
Radiotherapy care
Before radiotherapy, patients need to remove metal objects from their bodies. Wear loose, soft cotton clothing.
The skin will be dry and itchy during radiotherapy, so avoid strong heat or cold stimulation of the skin at the radiotherapy site, do not use hot water bags, and avoid direct sunlight.
When molt and scabs appear, do not peel them off with your hands.
When cleaning the skin at the radiotherapy site, use a soft towel, the action should be gentle, and avoid using irritating substances, such as soap and alcohol.
Prognosis
Generally speaking, Hodgkin’s lymphoma develops slightly slower, has a slightly longer course, responds better to treatment, and can even be partially cured.
Non-Hodgkin’s lymphoma (except for the low-grade malignant type) tends to develop more rapidly, has a shorter course, has a variable response to treatment, and is prone to relapse even if it goes into remission, resulting in a poorer prognosis.
Survival rate
Survival rates are statistics used in clinical studies, usually based on the results of previous studies of large groups of people with a particular cancer (e.g., staging), and they do not predict or represent the survival of any individual.
The 5-year survival rate refers to the percentage of patients whose tumors survive for more than 5 years after various comprehensive treatments, and does not mean that patients can only survive for 5 years.
There is no authoritative data on lymphoma survival rates in China, and according to the American Cancer Society’s Surveillance, Epidemiology, and End Results (SEER) database, the 5-year survival rates for lymphoma are as follows [9]:
The overall 5-year survival rate for Hodgkin’s lymphoma is 88%.
The overall 5-year survival rate for non-Hodgkin’s lymphoma is 73%.
[Hint] For more detailed prognosis, please refer to the section on reading the prognosis of Hodgkin lymphoma and non-Hodgkin lymphoma.
Prognostic Factors
The prognosis of lymphoma depends on the type of pathology, clinical stage, and a combination of other factors.
The International Prognostic Index (IPI) is now commonly used as a prognostic stratification, involving factors such as patient age, ECOG (Eastern Cooperative Oncology Group) score, clinical stage, number of extranodal invasion sites, and lactate dehydrogenase (LDH).
Long-term complications
The following complications may occur in long-term survivors of lymphoma: secondary tumors, cardiovascular disease, hypothyroidism, and reproductive effects are the most serious complications, with the incidence increasing with time.
Secondary tumors
Solid tumors are the most common secondary tumors, most commonly occurring 10 years after completion of treatment.
The risk of secondary tumors resulting from different first-line treatment modalities is, in descending order, radiotherapy alone, combined radiotherapy and chemotherapy alone.
Chemotherapy alone had an increased risk of developing lung or breast cancer.
Lung and breast cancers are the most common secondary tumors (20% to 25% of secondary tumors) after treatment for both Hodgkin lymphomas.
This may be related to chest radiotherapy, alkylating agent therapy, or a history of smoking.
Cardiovascular disease
Mediastinal radiotherapy and anthracycline-containing chemotherapy are high risk factors for the development of cardiovascular disease, with 66% of fatal cardiac events being coronary heart disease.
Radiotherapy-induced cardiotoxicity usually occurs 5 to 10 years or later after completion of treatment.
Cardiovascular symptoms can appear at any age. Therefore, even in the absence of clinical symptoms, follow-up electrocardiograms and annual blood pressure monitoring are recommended 10 years after completion of treatment.
Hypothyroidism
Hypothyroidism occurs in approximately 50% of long-term survivors, especially in patients who have received radiotherapy to the neck or mediastinum.
Patients should have a careful physical examination of the thyroid gland and thyroid function tests at least once a year, especially in those who have received radiotherapy to the neck.
Impact on fertility
Impaired fertility in young patients with Hodgkin’s lymphoma is one of the treatment-related long-term complications that seriously affect quality of life.
The incidence of primary ovarian insufficiency and oligozoospermia/azoospermia is higher in those treated with alkylating agents such as cyclophosphamide or methylbenzylhydrazine, or those treated with pelvic or testicular radiotherapy.
Disease in progression and age greater than 30 years are risk factors for female infertility.
Sperm freezing prior to treatment is recommended for male patients.
There is no standardized method for assessing and protecting female fertility; freezing eggs prior to chemotherapy is an optional, but still experimental, means of protecting fertility.
Daily
Life Management
Mindfulness and Emotional Adjustment
Good emotions and mindset cannot be replaced by drugs.
After diagnosis, the patient may develop a sense of fear and may be afraid of pain, abandonment and death.
Family members should pay attention to listen to the patient’s heart, improve the patient’s mental ability and relieve anxiety symptoms.
Encourage the patient’s family to give support so that the patient can face the surgery and other treatments positively with a good mindset.
During the period between treatments and after treatment, family members are advised to encourage the patient to do work and household chores that are within their ability, so as to reintegrate into their social roles.
Living
The living environment should be kept clean, with sufficient ventilation, sufficient sunlight and suitable greenhouse temperature. Disinfect the room regularly to avoid infection.
Maintain good hygiene and cleanliness to prevent accidental bodily injury. Rinse your mouth with saline solution and use a soft-bristled toothbrush after meals and before bedtime.
Maintain a positive and optimistic state of mind, reduce tension and anxiety, and avoid excessive activity and trauma for those prone to bleeding. If the lesion is in the lower limbs, try not to get out of bed to avoid fracture.
Dietary regulation
Balanced dietary structure, diversified food types and rich nutrition. Pickled, fried and deep-fried food should be avoided.
Eat more vitamin-rich vegetables and fruits, such as broccoli, tomatoes, celery, lettuce, kiwi, apples and bananas.
Eat more protein-rich foods, such as eggs, milk, lean meat and fish.
It is recommended not to eat foods that stimulate the secretion of stomach acid, such as foods that are too sweet and spicy.
Rest and Exercise
Pay attention to rest, avoid staying up late or straining, and ensure sufficient sleep and rest to reduce physical exertion and promote recovery.
When the condition improves, start with low intensity exercise such as walking and gradually resume normal activities.
Review and Follow-up
Lymphoma patients should pay attention to self-monitoring of the condition, regular follow-up, and timely consultation if there is weakness, fever, night sweats, emaciation, and enlarged lymph nodes.
Lymphoma follow-up can refer to the recommended criteria of the 2014 Lugano Conference, please follow the doctor’s instructions.
Follow-up content
Medical history, physical examination, routine laboratory tests, imaging tests.
For patients with more than 1 year of follow-up, minimize CT or MRI and replace them with chest radiographs and ultrasound.
PET-CT is usually not recommended as a follow-up examination.
Frequency of follow-up
Curable types
For example, diffuse large B-cell lymphoma and Hodgkin’s lymphoma are reviewed every 3 months for the first 2 years after completion of treatment.
Thereafter, review every 6 months for up to 5 years.
Thereafter, 1 review every year for life.
Incurable types
Such as follicular lymphoma, set cell lymphoma, etc.
It is recommended to review every 3 to 6 months for the rest of your life.
Prevention
There is no standard prevention program for lymphoma, but paying attention to the following may help reduce the incidence of lymphoma.
Health care for children
The lymphatic system is related to the whole body, so it is important to guard against viruses in daily life.
During infancy, children should be immunized with various vaccines on a date-by-date basis, and from an early age, they should develop the habit of exercising to strengthen their bodies and build a line of defense against various viruses and bacteria.
Strengthening the immune system
Strengthen the immune system in many ways, eat a balanced diet, eat regularly and prevent malnutrition.
When you are sick, use medication wisely, and do not take antibiotics or corticosteroids that are harmful to the immune system unless you have to.
Adopt good living habits, enhance physical exercise, quit smoking and drinking, and avoid staying up all night.
Avoid spicy and stimulating food, eat less fried and fatty food, and eat more taro, monkey head mushroom, barley and other food with anti-cancer effect.
Pay attention to keep warm and personal hygiene to avoid viral infection.
Improve lifestyle
Purify the living environment and stay away from radiation and pollution, which tend to denature lymphocytes, so the decoration of houses emphasizes the use of environmentally friendly materials.
Avoid exposure to radiation or reduce the time of exposure to radiation, and use protective equipment scientifically.
Early detection and treatment
People with family genetic tendency need regular medical checkups for early detection and treatment.
Timely treatment of certain chronic inflammatory diseases to improve the body’s immune function.