Non-Hodgkin’s Lymphoma
Non-Hodgkin’s lymphomas (NHL) are
cancers of mature B, T, and NK cells, these are
tumors that develop from lymphocytes — a
type of white blood cell.
Lymphoma occurs when the lymph-node
cells or the lymphocytes begin to multiply
uncontrollably, producing cancerous cells that
have the abnormal capacity to invade other
tissues throughout the body.
Non-Hodgkin's lymphoma can begin in the:
 B cells. B cells fight infection by producing
antibodies that neutralize foreign
invaders. Most non-Hodgkin's lymphoma
arises from B cells. Subtypes of non-
Hodgkin's lymphoma that involve B cells
include diffuse large B-cell lymphoma,
follicular lymphoma, mantle cell
lymphoma and Burkitt lymphoma.
 T cells. T cells are involved in killing
foreign invaders directly. Non-Hodgkin's
lymphoma occurs less often in T cells.
Subtypes of non-Hodgkin's lymphoma
that involve T cells include adult T-cell
lymphoma and Mycosis Fungoides.
Signs and symptoms
May include:
 Painless, swollen lymph nodes in your
neck, armpits or groin
 Abdominal pain or swelling
 Chest pain, coughing or trouble breathing
 Persistent fatigue
 Fever
 Night sweats
 Unexplained weight loss
 Swollen lymph nodes
Causes
The exact cause of non-Hodgkin lymphoma is
unknown. However, there are multiple medical
conditions that are associated with an increased
risk of developing the disease:
 Inherited immune deficiencies
 Genetic syndromes: Down syndrome,
Klinefelter's syndrome (a genetic
condition in men caused by an extra X
chromosome)
 Immune disorders, and their
treatments: Sjögren's syndrome (an
immune disorder characterized by
unusual dryness of mucus
membranes), rheumatoid arthritis,
systemic lupus erythematosus
 Celiac disease, a disease involving the
processing of certain components of
gluten, a protein in grains
 Inflammatory bowel disease, particularly
Crohn’s disease, and its treatment
 Psoriasis
 Family history of lymphoma
 Bacteria: Helicobacter pylori, associated
with gastritis and gastric ulcers; Borrelia
burgdorferi, associated with Lyme
disease; Campylobacter jejuni; Chalmydia
psittaci
 Viruses: HIV, HTLV-1, SV-40, HHV-
8, Epstein Barr virus, hepatitis virus
 Non-random chromosomal translocations
and molecular rearrangements

Risk factors
Some factors that may increase the risk of non-
Hodgkin's lymphoma include:
 Medications that suppress your immune
system. If you've had an organ transplant,
you're more susceptible because
immunosuppressive therapy has reduced
your body's ability to fight new illnesses.
 Infection with certain viruses and
bacteria. Certain viral and bacterial
infections appear to increase the risk of
non-Hodgkin's lymphoma. Viruses linked
to increased non-Hodgkin's lymphoma
risk include HIV and Epstein-Barr
infection. Bacteria linked to an increased
risk of non-Hodgkin's lymphoma include
the ulcer-causing Helicobacter pylori.
 Chemicals. Certain chemicals, such as
those used to kill insects and weeds, may
increase your risk of developing non-
Hodgkin's lymphoma. More research is
needed to understand the possible link
between pesticides and the development
of non-Hodgkin's lymphoma.
 Older age. Non-Hodgkin's lymphoma can
occur at any age, but the risk increases
with age. It's most common in people 60
or over.
Other Factors Include:
 Regular exposure to certain chemicals,
including insect and weed killers, and a
number of chemicals used in industries
such as farming, welding, and lumber
 Exposure to nuclear accidents, nuclear
testing, or underground radiation leaks
 Treatment with immunosuppressant
drugs, for prevention of organ
transplantation rejection, or for
treatment of inflammatory and
autoimmune disorders
 Tumor necrosis factor agents used to
treat psoriatic and rheumatoid
arthritis and inflammatory bowel disease
 Prior exposure to chemotherapy and/or
radiation used to treat a prior diagnosis
of cancer
 Treatment with
a medication called Dilantin (phenytoin),
commonly used to treat seizure disorders
 Use of hair dyes, especially dark and
permanent colors, used before 1980
(research is inconclusive)
 High levels of nitrates found in drinking
water
 Diets high in fat and meat products
 Ultraviolet light exposure
 Alcohol intake
Types of NHL can also be grouped based on
how fast they grow and spread:
 Indolent lymphomas grow and spread
slowly Some indolent lymphomas might
not need to be treated right away, but
can be watched closely instead. The
most common type of indolent
lymphoma in the United States is
follicular lymphoma.
 Aggressive lymphomas grow and
spread quickly, and usually need to be
treated right away. The most common
type of aggressive lymphoma in the
United States is diffuse large B cell
lymphoma (DLBCL).
  Some types of lymphoma, like mantle
cell lymphoma, don’t fit neatly into
either of these categories.
Classifying types of NHL
There are many different types of non-Hodgkin
lymphoma (NHL), so classifying it can be quite
confusing, that’s why several different systems
have been used, but the most recent system is
the World Health Organization (WHO)
classification. The WHO system groups
lymphomas based on:
 The type of lymphocyte the lymphoma
starts in
 How the lymphoma looks under a
microscope
 The chromosome features of the
lymphoma cells
 The presence of certain proteins on the
surface of the cancer cells
Types of Non-Hodgkin’s Lymphoma
Non-Hodgkin’s B-Cell Lymphoma
These are the most common form of
lymphoma.
Diffuse Large B Cell Lymphoma
Diffuse large B-cell lymphoma (DLBCL) is
the most common histologic subtype of NHL
diagnosed, representing about one-third of all
cases. Previously felt to be “one disease” it is
now recognized as a heterogeneous collection
of multiple entities. It is slightly more common
in Caucasians and men, and the median age at
diagnosis is 64. The relative risk of DLBCL is
higher amongst people with affected first-
degree relatives (RR 3.5-fold), and patients with
congenital or acquired immunodeficiency,
patients on immunosuppression, and patients
with autoimmune disorders also have a higher
risk of developing DLBCL, often EBV-related.
Follicular Lymphoma
FLs are the second leading NHL
diagnosis in the United States and Europe and
makes up 22% of NHL worldwide and at least
30% of NHL diagnosed in the United States.
This type of lymphoma can be diagnosed
accurately on morphologic findings alone and
has been the diagnosis in the majority of
patients in therapeutic trials for “low-grade”
lymphoma in the past.
Burkitt Lymphoma
Burkitt lymphoma is considered a highly
aggressive lymphoma. First discovered in
African children in the 1950s, the disease is
associated with the Epstein-Barr virus. Patients
with limited disease have an excellent
prognosis. The overall survival rate ranges from
50%–70%, although when central nervous
system or bone marrow involvement is present,
long-term survival is reduced to less than 30%.
The immunophenotypes of Burkitt lymphoma
are the expression of CD19, CD20, CD22, and
CD10 and typically are CD5 and CD23 negative.
Mantle Cell Lymphoma
Mantle cell lymphoma comprises a
distinct subset of aggressive lymphomas.
Accounting for approximately 5%–8% of all
NHLs, patients with mantle cell lymphoma
typically have a poor prognosis with standard
therapy. Mantle cells may appear as atypical
small lymphoid cells with irregular, indented
nuclei. The immunophenotype expresses CD19,
CD20, CD22, and CD5 but is negative for CD23.
Most patients with mantle cell lymphoma
present with advanced-stage disease, including
bone marrow involvement, and require therapy
immediately to control their symptoms.
Marginal Zone Lymphoma
Marginal zone lymphomas, which are
indolent, can be divided into three types:
splenic marginal zone B-cell lymphoma,
extranodal marginal zone B-cell lymphoma
(mucosa-associated lymphoid tissue [MALT]),
and nodal marginal zone B-cell lymphoma.
Marginal zone cells appear as small B
lymphocytes with varied features that are
dependent on the type of marginal zone. The
immunophenotype of marginal zone
lymphomas express CD19, CD20, and CD22 and
are negative for CD5, CD10, and CD23.
Lymphoplasmacytic Lymphoma
About 1% of all NHLs will be
lymphoplasmacytic lymphomas, which are
indolent B-cell NHLs with lymphoplasmacytic
differentiation, most commonly associated with
a monoclonal IgM paraprotein. Nearly all
patients will have stage IV disease at diagnosis
with bone marrow involvement. Patients with
high levels of circulating IgM paraproteins
constitute a specific entity known as
Waldenstrom macroglobulinemia and can have
symptoms due to hyperviscosity as a result of
the circulating IgM.
Non-Hodgkin’s T-Cell Lymphoma
Adult T-Cell Lymphoma
Adult T-cell leukemia/ lymphoma (ATLL)
is a disease that is most prevalent in Japan and
the Caribbean basin. It is a neoplasm that is
driven by HTLV-1, often contracted through the
breast milk of infected mothers. The average
age at diagnosis is 60, so there is a long latency
between viral infection and viral
transformation, and only 4% of infected
patients will develop the disease.
Mycosis fungoides
Mycosis fungoides is also known as
cutaneous T-cell lymphoma. This lymphoma is
more often seen by dermatologists than
internists. The median age of onset is in the
mid-fifties, and the disease is more common in
males and in blacks. Mycosis fungoides is an
indolent lymphoma with patients often having
several years of eczematous or dermatitic skin
lesions before the diagnosis is finally
established. The skin lesions progress from
patch stage to plaque stage to cutaneous
tumors.
Staging
NHL is staged based on the Ann Arbor staging
system, which is used to summarize the extent
of the disease8:
• Stage I: The cancer is located in a single
region, usually 1 lymph node and the
surrounding area. Stage I will often not have
obvious, outward symptoms.
• Stage II: The cancer is located in 2 separate
lymph node regions, and both regions are on
the same side of the diaphragm (either above
or below the diaphragm).
• Stage III: The cancer involves lymph nodes
or organs on both sides of the diaphragm (both
above and below the diaphragm).
• Stage IV:
 o The cancer has spread to multiple spots of
an organ (or multiple organs) outside the
lymph system. Cancer cells may or may not be
found in the lymph nodes near these organs.
o The cancer has spread to only 1 organ
outside the lymph system, but lymph nodes far
away from that organ are involved.
o There is bone marrow involvement.
The staging of HL is based on the Cotswold
system, a modification of the Ann Arbor
system9:
• Stage I: The cancer is found in only 1 lymph
node area or lymphoid organ such as the
thymus (stage I), or the cancer is found in only
1 area of a single organ outside the lymph
system (stage IE).
• Stage II: The cancer is found in 2 or more
lymph node areas on the same side of the
diaphragm (stage II), or the cancer extends
locally from one lymph node area into a
nearby organ (stage IIE).
• Stage III:
o The cancer is found in lymph node areas
on both sides of the diaphragm (stage III).
o The cancer is in lymph nodes both above
and below the diaphragm, and it has also
spread to a nearby organ (stage IIIE), to the
spleen (stage IIIS), or to both (stage IIIES).
• Stage IV:
o The cancer has spread widely through 1 or
more organs outside the lymph system. Cancer
cells may or may not be found in nearby
lymph nodes.
o The cancer is found in organs in 2 distant
parts of the body (and not in nearby lymph
nodes).
o The cancer is in the liver, bone marrow,
lungs (other than by growing there directly
from another site), or cerebrospinal fluid.
In both NHL and HL, one of the following
letters can be added to the stage to provide
further detail (stage IIA, stage IIIB)8:
A: The patient has no symptoms.
B: The patient has one or more “B
symptoms”: loss of more than 10% of body
weight over the previous 6 months (without
dieting), unexplained fever of at least 100.4°F
(38°C), or drenching night sweats.
E: The disease is “extranodal” (not in the
lymph nodes) or has spread from lymph nodes
to adjacent tissue.
X: The largest tumor is larger than 10 cm
(also called “bulky disease”), or the lymph
node mass in the center of the chest
(mediastinum) is wider than one-third of the
chest on a chest X-ray.
Diagnostic Tests:
Medical history and physical exam
The doctor will get a complete medical history,
including information about the symptoms,
possible risk factors, and other medical
conditions.
Also, the doctor will do a physical examination,
paying special attention to the lymph nodes and
other areas of the body that might be affected,
including the spleen and liver. Because
infections are the most common cause of
enlarged lymph nodes, the doctor will look for  For a core needle biopsy, the doctor
an infection near the swollen lymph nodes. uses a larger needle to remove a slightly
larger piece of tissue.
Other types of biopsies
Biopsy

These procedures are not normally done to

For a biopsy, a small piece of a lymph node or,
diagnose lymphoma, but they might be used to
more often, an entire lymph node is removed
help determine the stage or extent of a
for testing in a lab.
lymphoma that has already been diagnosed.
Excisional or incisional biopsy: This is the
preferred and most common type of biopsy if
Bone marrow aspiration and biopsy: These
lymphoma is suspected, because it almost
procedures are often done after lymphoma has
always provides enough of a sample to
been diagnosed to help determine if it has
diagnose the exact type of NHL.
reached the bone marrow. The samples are
In this procedure, a surgeon cuts through the
usually taken from the back of the pelvic (hip)
skin to remove the lymph node.
bone, although in some cases they may be
 If the doctor removes the entire lymph taken from other bones.
node, it is called an excisional biopsy.
 If a small part of a larger tumor or node
Lumbar puncture (spinal tap): This test looks
is removed, it is called an incisional
biopsy. for lymphoma cells in the cerebrospinal fluid
(CSF). Doctors may order it for certain types of
lymphoma or if a person has symptoms that
Needle biopsy: Needle biopsies are less invasive suggest the lymphoma may have reached the
than excisional or incisional biopsies, but the brain.
drawback is that they might not remove enough
of a sample to diagnose lymphoma or to Pleural or peritoneal fluid
determine which type it is. sampling: Lymphoma that has spread to the
There are 2 main types of needle biopsies: chest or abdomen can cause fluid to build up.
Pleural fluid (inside the chest) or peritoneal
 In a fine needle aspiration (FNA)
biopsy, the doctor uses a very thin, fluid (inside the abdomen) can be removed by
hollow needle attached to a syringe to placing a hollow needle through the skin into
withdraw (aspirate) a small amount of the chest or abdomen.
tissue from an enlarged lymph node or
a tumor mass.
  When this procedure is used to remove
fluid from the area around the lung, it’s
called a thoracentesis.
 When it is used to collect fluid from
inside the abdomen, it’s known as
a paracentesis.
Imaging tests
Imaging tests use x-rays, sound waves,
magnetic fields, or radioactive particles to
produce pictures of the inside of the body.
These tests might be done for a number of
reasons, including:
 To look for possible causes of certain
symptoms (such as enlarged lymph
nodes in the chest in someone having
chest pain or trouble breathing)
 To help determine the stage (extent) of
the lymphoma
 To help show if treatment is working
 To look for possible signs of lymphoma
coming back after treatment
Chest x-ray
The chest might be x-rayed to look for enlarged
lymph nodes.
Computed tomography (CT) scan
A CT scan combines many x-rays to make
detailed, cross-sectional images of the body.
This scan can help tell if any lymph nodes or
organs in the body are enlarged. CT scans are
useful for looking for lymphoma in the
abdomen, pelvis, chest, head, and neck.
Magnetic resonance imaging (MRI) scan
Like CT scans, MRI scans show detailed images
of soft tissues in the body. But MRI scans use
radio waves and strong magnets instead of x-
rays. This test is not used as often as CT scans
for lymphoma, but if the doctor is concerned
about spread to the spinal cord or brain, MRI is
very useful for looking at these areas.
Ultrasound
Ultrasound can be used to look at lymph nodes
near the surface of the body or to look inside
the abdomen for enlarged lymph nodes or
organs such as the liver and spleen. It can also
detect kidneys that have become swollen
because the outflow of urine has been blocked
by enlarged lymph nodes.
Positron emission tomography (PET) scan
For a PET scan, you are injected with a slightly
radioactive form of sugar, which collects mainly
in cancer cells. A special camera is then used to
create a picture of areas of radioactivity in the
body. The picture is not detailed like a CT or
MRI scan, but it can provide helpful information
about your whole body.
PET scan might be done to:
  See if an enlarged lymph node contains
lymphoma.
 Find small areas that might be
lymphoma, even if the area looks
normal on a CT scan.
 Check if a lymphoma is responding to
treatment. Some doctors will repeat the
PET scan after 1 or 2 courses of
chemotherapy. If the chemotherapy is
working, the lymph nodes will no longer
absorb the radioactive sugar.
 Help decide whether an enlarged lymph
node still contains lymphoma or is just
scar tissue after treatment.
Bone scan
This test is usually done if a person is having
bone pain or has lab results that suggest the
lymphoma may have reached the bones.
For bone scans, a radioactive substance
called technetium is injected into a vein. It
travels to damaged areas of bone, and a special
camera can then detect the radioactivity.
Lymphoma often causes bone damage, which
may be seen on a bone scan. But bone scans
can’t show the difference between cancers and
non-cancerous problems, such as arthritis and
fractures, so further tests might be needed.
Other tests
Blood tests
Blood tests are not used to diagnose lymphoma,
but they can sometimes help determine how
advanced the lymphoma is.
 A complete blood count (CBC) measures
the levels of different cells in the blood.
For a person already known to have
lymphoma, low blood cell counts might
mean that the lymphoma is growing in
the bone marrow and affecting new
blood cell formation.
 Blood chemistry tests are often done to
look at how well the kidney and liver
function are working.
 If lymphoma has been diagnosed,
the lactate dehydrogenase (LDH) level
may be checked. LDH levels are often
increased in patients with lymphomas.
 For some types of lymphoma or if
certain treatments might be used, your
doctor may also advise you to have
tests to see if you’ve been infected with
certain viruses, such as hepatitis B virus
(HBV), hepatitis C virus (HCV), or human
immunodeficiency virus
(HIV). Infections with these viruses may
affect your treatment.
Tests of heart and lung function
These tests are not used to diagnose
lymphoma, but they might be done if you are
going to get certain chemotherapy drugs
commonly used to treat lymphoma that could  Chlorambucil
affect the heart or the lungs.  Bendamustine

 Ifosfamide
 Your heart function may be checked
with an echocardiogram (an ultrasound Corticosteroids
of the heart).
 Prednisone
 Your lung function may be checked
with pulmonary function tests, in which  Dexamethasone
you breathe into a tube connected to a Platinum drugs
machine.

 Cisplatin
Chemotherapy  Carboplatin

 Oxaliplatin
Chemotherapy (chemo) is the use of anti-
Purine analogs
cancer drugs that are usually injected into a
vein (IV) or taken by mouth. These drugs
 Fludarabine
enter the bloodstream and reach almost all
 Pentostatin
areas of the body, making this treatment very
useful for lymphoma.  Cladribine (2-CdA)

Anti-metabolites
Chemo is the main treatment for most people
with non-Hodgkin lymphoma (NHL). Depending  Cytarabine (ara-C)
on the type and the stage of the lymphoma,  Gemcitabine
chemo may be used alone or combined with
 Methotrexate
other treatments, such as immunotherapy
drugs or radiation therapy.  Pralatrexate

Anthracyclines
Here are some of the drugs more commonly
used to treat lymphoma (divided into groups  Doxorubicin (Adriamycin)
based on how they work):  Liposomal doxorubicin (Caelyx)

Others
Alkylating agents
 Vincristine
 Cyclophosphamide
 Mitoxantrone
  Etoposide (VP-16) Certain chemo drugs can have other possible side
 Bleomycin effects. For example:

 Platinum drugs such as cisplatin can cause

Intrathecal chemo
Most chemo drugs given systemically (IV or
by mouth) can’t reach the cerebrospinal fluid
(CSF) and tissues around the brain and spinal
cord. To treat lymphoma that might have
reached these areas, chemo may also be
given into the CSF. This is called intrathecal
chemo. The chemo drugs most often used for
intrathecal chemo are methotrexate and
cytarabine.
Possible side effects
nerve damage (neuropathy), leading to
numbness, tingling, or even pain in the
hands and feet.
 Ifosfamide can damage the bladder. The
risk of this can be lowered by giving it along
with a drug called mesna.
 Doxorubicin can damage the heart. Your
doctor may order a test of your heart
function (like a MUGA scan or
echocardiogram) before starting you on
this drug.
 Bleomycin can damage lungs. Doctors
often test lung function before starting
someone on this drug.

 Hair loss  Many chemo drugs can affect fertility (the

ability to have children).
 Mouth sores
 Some chemo drugs can raise your risk of
 Loss of appetite developing leukemia several years later.
 Nausea and vomiting

 Diarrhea or constipation
Immunotherapy
 Increased chance of infection (from a shortage
of white blood cells)
Immunotherapy is treatment that either boosts
 Bleeding or bruising after minor cuts or injuries
the patient’s own immune system or uses man-
(from a shortage of platelets)
made versions of the normal parts of the
 Fatigue and shortness of breath (from too few
immune system to kill lymphoma cells or slow
red blood cells)
their growth.
These side effects usually go away after treatment is
finished. If serious side effects occur, the dose of
chemo may be reduced or treatment may be
delayed.
Monoclonal antibodies
Antibodies are proteins made by your immune
system to help fight infections. Man-made
versions, called monoclonal antibodies, can be
designed to attack a specific target, such as a
substance on the surface of lymphocytes (the
cells in which lymphomas start).
Antibodies that target CD20
A number of monoclonal antibodies target the
CD20 antigen, a protein on the surface of B
lymphocytes. These include:
 Rituximab (Rituxan): This drug is often
used along with chemotherapy (chemo)
for some types of NHL, but it may also be
used by itself.
 Obinutuzumab (Gazyva): This drug is
often used along with chemo as a part of
the treatment for small lymphocytic
lymphoma/chronic lymphocytic
leukemia (SLL/CLL). It can also be used
along with chemo in treating follicular
lymphoma.
 Ofatumumab (Arzerra): This drug is used
mainly in patients with SLL/CLL that is no
longer responding to other treatments.
 Ibritumomab tiuxetan (Zevalin): This
drug is made up of a monoclonal
antibody that is attached to a
radioactive molecule. The antibody
brings radiation directly to the
lymphoma cells.
Antibodies targeting CD52
Alemtuzumab (Campath) is an antibody
directed at the CD52 antigen. It is useful in some
cases of SLL/CLL and some types of peripheral T-
cell lymphomas. This drug is infused into a vein
(IV), usually 3 times a week for up to 12 weeks.
The most common side effects are fever, chills,
nausea, and rashes. It can also cause very low
white blood cell counts, which increases the risk
for serious infections. Antibiotic and antiviral
medicines are given to help protect against
them, but severe and even life-threatening
infections can still occur. Rare but serious side
effects can include strokes, as well as tears in the
blood vessels in the head and neck.
Antibodies that target CD30
Brentuximab vedotin (Adcetris) is an anti-CD30
antibody attached to a chemotherapy drug. The
antibody acts like a homing signal, bringing the
chemo drug to lymphoma cells, where it enters
the cells and kills them.
Brentuximab can be used to treat some types of
T-cell lymphoma, either as the first treatment
(typically along with chemo) or if the lymphoma
if it has come back after other treatments. This
drug is infused into a vein (IV), typically every 3
weeks. Common side effects can include nerve
damage (neuropathy), low blood counts, fatigue,
fever, nausea and vomiting, infections, diarrhea,
and cough.
Antibodies that target CD79b
Polatuzumab vedotin-piiq (Polivy) is an anti-
CD79b antibody (polatuzumab) attached to a
chemotherapy drug (MMAE). The antibody finds
the lymphoma cell and attaches to the surface
protein CD79b. Once connected, polatuzumab is
drawn into the lymphoma cell where the chemo
is released and destroys it.
Polatuzumab can be used with bendamustine
and rituximab to treat DLBCL, if the lymphoma
has come back after receiving two other
treatments. This drug is infused into a vein (IV),
typically every 3 weeks. Common side effects
can include numbness or tingling of hands/feet
(peripheral neuropathy), low blood counts,
fatigue, fever, decreased appetite, diarrhea, and
pneumonia.
Immune checkpoint inhibitors
Immune system cells normally have substances
that act as checkpoints to keep them from
attacking other healthy cells in the body. Cancer
cells sometimes take advantage of these
checkpoints to avoid being attacked by the
immune system.
Drugs such as pembrolizumab (Keytruda) work
by blocking these checkpoints, which can boost
the immune response against cancer cells.
Pembrolizumab can be used to treat primary
mediastinal large B-cell lymphoma (PMBCL) that
has not responded to or has come back after
other therapies.
Immunomodulating drugs
Drugs such as thalidomide
(Thalomid) and lenalidomide (Revlimid) are
thought to work against certain cancers by
affecting parts of the immune system, although
exactly how they work isn’t clear. They are
sometimes used to help treat certain types of
lymphoma, usually after other treatments have
been tried. Lenalidomide can be given with or
without rituximab.
These drugs are taken daily as pills. Side effects
of can include low white blood cell counts (with
an increased risk of infection) and neuropathy
(painful nerve damage), which can sometimes be
severe and may not go away after treatment.
There is also an increased risk of serious blood
clots (that start in the leg and can travel to the
lungs), especially with thalidomide. Thalidomide
can also cause drowsiness, fatigue, and severe
constipation.
Chimeric antigen receptor (CAR) T-cell therapy
In this treatment, immune cells called T cells are
removed from the patient’s blood and altered
in the lab to have specific receptors
(called chimeric antigen receptors, or CARs) on
their surface. These receptors can attach to
proteins on the surface of lymphoma cells. The
T cells are then multiplied in the lab and given
back into the patient’s blood, where they can
seek out the lymphoma cells and launch a
precise immune attack against them.
Axicabtagene ciloleucel (Yescarta) is a type of
CAR T-cell therapy approved by the FDA to treat
people with diffuse large B-cell lymphoma,
primary mediastinal large B-cell lymphoma, high
grade B-cell lymphoma and diffuse large B-cell
lymphoma arising from follicular lymphoma
after at least two other kinds of treatment have
been tried. Because this treatment can have
serious side effects, it is only given in medical
centers that have special training with this
treatment. Potentially life-threatening side
effects can include high fever, chills, flu-like
symptoms, and serious neurological changes.
Other severe side effects include infection, low
blood cell counts, and a weakened immune
system.
Tisagenlecleucel (Kymriah) is another type of
CAR T-cell therapy approved to treat people
with diffuse large B cell lymphoma, high grade B
cell lymphoma, and diffuse large B cell
lymphoma arising from follicular lymphoma
after trying at least two other kinds of
treatment. Potentially life-threatening side
effects can include fever, headache, low blood
pressure, a fast heart rate, and trouble
breathing. Other severe side effects include
infection, diarrhea, swelling, and nausea. This
drug must also be given in centers with
specialized training.
Radiation Therapy
Radiation therapy uses high-energy rays to kill
cancer cells. Radiation might be used to treat
non-Hodgkin lymphoma (NHL) in some different
situations:
 It can be used as the main treatment
for some types of NHL if they are found
early (stage I or II), because these
tumors respond very well to radiation.
 For more advanced lymphomas and for
some lymphomas that are more
aggressive, radiation is sometimes used
along with chemotherapy.
 People who are getting a stem cell
transplant may get radiation to the
whole body along with high-dose
chemotherapy, to try to kill lymphoma
cells throughout the body.
 Radiation therapy can be used to ease
(palliate) symptoms caused by
lymphoma that has spread to internal
organs, such as the brain or spinal cord,
or when a tumor is causing pain
because it’s pressing on nerves.
Possible side effects
The side effects of radiation therapy depend on
where the radiation is aimed. Common side
effects include:
  Skin changes in areas getting radiation,
ranging from redness to blistering and
peeling
 Feeling tired
 Nausea
 Diarrhea
Nausea and diarrhea are more common if the
abdomen (belly) is treated with radiation.
Radiation given to several areas, especially after
chemotherapy, can lower blood cell counts and
increase the risk of infections.
Radiation to the head and neck area can lead
to mouth sores and trouble swallowing. Some
people later have problems with dry mouth.
Surgery
Surgery is often used to get a biopsy sample to
diagnose and classify a lymphoma, but it’s
rarely used as a form of treatment.
Rarely, surgery may be used to treat
lymphomas that start in the spleen or in certain
organs outside the lymph system, such as the
thyroid or stomach, and that have not spread
beyond these organs. But for treating
lymphoma that’s completely confined to one
area, radiation therapy is usually preferred over
surgery.
Nursing Interventions:
Physiological integrity
a. Monitor complete blood cell count, white
blood cell count, platelet count, uric acid
level, and electrolytes.
b. Initiate bleeding precautions if
thrombocytopenia occurs.
c. When the platelet count is less than
50,000 mm3 (50Â109/L), minor trauma can
lead to episodes of prolonged bleeding;
when less than 20,000 mm3 (20Â109/L),
spontaneous and uncontrollable bleeding can
occur; withhold the medication if the platelet
count drops (according to agency policy) and
notify the health care provider (HCP).
Bleeding precautions are initiated.
d. Monitor for petechiae, ecchymoses,
bleeding of the gums, and nosebleeds
because the decreased platelet count can
precipitate bleeding tendencies.
e. Avoid intramuscular injections and
venipunctures as much as possible to
prevent bleeding.
f. Withhold the medication and initiate
neutropenic precautions if the segmented
neutrophil count decreases below 18%
conventional units (0.18 SI units); notify the
HCP.
g. Monitor for fever, sore throat, unusual
bleeding, and signs and symptoms of
infection.
h. Inform the client that loss of appetite
also may be the result of taste changes or a
bitter taste in the mouth from the
medications.
i. Monitor for nausa and vomiting and provide
a high-calorie diet with protein supplements.
j. Administer antiemetics several hours
before chemotherapy and for 12 to 48
hours after as prescribed, because
antineoplastic medications stimulate the
vomiting center in the brain.
k. Encourage hydration; IV fluids are
administered before and during therapy.
l. Promote a fluid intake of at least 2000
mL/ day to maintain adequate renal function.
Safe and effective care environment
a. Prepare IV chemotherapy in an air-vented
space (biological safety cabinet).
b. Wear appropriate personal protective
equipment (PPE), including gloves, gown, eye
protectors, and mask as indicated, to reduce
exposure whenever there is a risk of
hazardous medications being released into
the environment.
c. Nurses who are pregnant should avoid
chemotherapy preparation or the
administration of chemotherapy.
d. Discard IV equipment in designated
(biohazard) containers.
e. Administer antineoplastic medication
precisely as prescribed to maximize
antineoplastic effects while allowing normal
cells to recover.
f. Monitor for phlebitis with IV administration
because these medications may irritate the
veins. g. Vesicants should be administered
through a central line when possible; if a
peripheral line is used, blood return should
be checked prior to administration.
h. As prescribed, reduce IV site pain by
altering IV rates or warming the injection
site to distend the vein and increase blood
flow.
i. Monitor for extravasation (leakage of
medication into surrounding skin and
subcutaneous tissue, which causes tissue
necrosis) and notify the HCP if this occurs;
heat or ice is applied depending on the
medication, and an antidote may be injected
into the site.
Psychosocial integrity
a. Instruct the client about the possibility of
hair loss and that varying degrees of hair
loss may occur after the first or second
treatment.
b. Discuss the purchase of a wig before
treatment starts and consider cutting hair
short.
c. Inform the client that new hair growth
will occur several months after the final
treatment.
d. Instruct the client about the need for
contraception because these medications
have teratogenic effects.
e. Discuss the potential effect of infertility,
which may be irreversible.
f. Encourage pretreatment counseling and
encourage sperm banking or preservation of
eggs if the client is still of childbearing age.
Health promotion and maintenance
a. Instruct the client, if diarrhea is a problem, to
avoid spicy foods, high-fiber foods, and foods
that are hot in temperature, which increase
peristalsis.
b. Instruct the client to inspect the oral
mucosa frequently for erythema and ulcers,
rinse the mouth after meals, and carry out
good oral hygiene.
c. Instruct the client to use mouth rinses as
prescribed for mouth sores if necessary.
d. Instruct the client in the use of antifungal
agents for mouth sores, if prescribed, for
the development of a fungal infection.
e. Instruct the client to avoid crowds and
persons with infections and to report signs of
infection such as a low-grade fever, chills, or
sore throat.
f. Instruct individuals with colds or infections
to wear a mask when visiting or to avoid
visiting the client.
g. Instruct the client to use a soft tooth brush
and electric razor to minimize the risk of
bleeding.
h. Instruct the client to avoid aspirin-
containing products to minimize the risk of
bleeding.
i. Instruct the client to consult the HCP
before receiving vaccinations (live vaccines
should not be administered).