If you see your GP with symptoms of NHL, they will ask about your health and carry out a simple physical examination.
If necessary, your GP will refer you to hospital for further tests. In hospital, it is likely that a biopsy will be carried out, as this is the only way to confirm a diagnosis of NHL.
A biopsy involves removing some or all of an affected lymph node, which is then studied in a laboratory.
Biopsies are small operations that can often be carried out under a local anaesthetic, although there may be some cases where the affected lymph node is not easily accessible and a general anaesthetic may be required.
A pathologist (expert in the study of diseased tissue) will then check the tissue sample for the presence of lymphoma cells. If they find lymphoma cells, they will go onto identify exactly which type of NHL you have, which is a very important factor in planning your treatment.
If they find lymphoma cells, they will go on to identify exactly which type of NHL you have, which is an important factor in planning your treatment.
There are more than 40 types of NHL and these are grouped into categories depending on their rate of growth, and from which type of lymphocyte they originated from; either ‘B’ or ‘T’ lymphocytes.
The majority of NHLs are from abnormal B lymphocytes.
High grade NHL grows fairly quickly and treatment generally starts within 3-6 weeks. Occasionally some rare forms of NHL need to be treated much more quickly. They tend to respond well to chemotherapy treatment and in most cases can be cured. The most common type of high grade NHL is a subtype called diffuse large B cell lymphoma.
Low grade NHLs are slower growing and are considered indolent and it may be that you have had the cancer for many years without symptoms. In some cases, there is no immediate need to treat and you can be safely monitored with regular check-ups, but it is their slow growing nature that means that in the majority of cases they cannot be cured. However, they should be considered a treatable cancer, which can be ‘dampened down’ if it is causing problems or symptoms. This process can be repeated with different drugs in the future if the need arises again. The most common type of low grade NHL is a subtype called Follicular lymphoma.
In some cases, low-grade lymphomas can develop into high-grade lymphomas.
If the biopsy confirms a diagnosis of NHL, the next step is to check how far the lymphoma has spread. This is important as it allows a doctor to determine the stage of your lymphoma.
This is done by a process called imaging. These techniques show us where the lymphoma may be in the body. These tests are normally done as an outpatient and may include some of the tests outlined below:
- X-ray – produce pictures of the structures in the body.
- Computerised tomography (CT) scan – this scan takes a series of X-rays that build up a 3D picture of the inside of the body and provide a more detailed picture than an x-ray.
- magnetic resonance imaging (MRI) scan – this scan uses strong magnetic fields to build up a detailed picture of particular areas of your body.
- positron emission tomography (PET/CT) scan – Used in combination with CT scans and involves an injection of sugar (glucose) labelled with a small amount of radioactivity which goes to parts of the body that use glucose for energy. Areas of uptake on PET/CT scan can be used to assess the presence, location and severity of cancers.
The team will also require some further blood tests, it is common to have blood tests whilst on treatment. These tests can give information regarding your general health, the levels of red and white cells and platelets in your blood, and how well organs such as your liver and kidneys are working.
Other tests may also include:
- Blood tests – samples of blood will be taken throughout your diagnosis and treatment to check your general health, the levels of red and white cells and platelets in your blood, and how well organs, such as your liver and kidney, are working
- Bone marrow biopsy – this procedure is done to assess whether the lymphoma has spread to your bone marrow. It involves using a long needle to remove a sample of bone marrow from your pelvis and is done using a local anaesthetic. The procedure usually takes approximately 20 minutes in the outpatient department. You may be in the hospital for up to an hour.
- Lumbar puncture – using a thin needle, a sample of spinal fluid is taken and examined to see if it contains any lymphoma cells. Again it is done under local anaesthetic and takes approximately 20 minutes generally in the outpatient department, however for this procedure you will need to stay for a couple of hours after it is completed.
Once all the test results are complete, it is possible to determine the stage of your lymphoma. Staging tells us which parts of the body are affected by the lymphoma and this is important when planning your treatment.
The stages of Hodgkin lymphoma are:
stage 1 – the cancer is limited to one group of lymph nodes, such as your neck or groin nodes either above or below your diaphragm (the sheet of muscle underneath the lungs)
stage 2 – two or more lymph node groups are affected, either above or below the diaphragm
stage 3 – the cancer has spread to lymph node groups above and below the diaphragm
stage 4 – the cancer has spread through the lymphatic system and is now present in organs or bone marrow
Health professionals also add the letters "A" or "B" after your stage to indicate whether or not you have certain symptoms.
"A" is put after your stage if you have no additional symptoms other than swollen lymph nodes. "B" is put after your stage if you have any one of the following; unexplained weight loss greater than 10% of your body weight in the preceding 6 months, unexplained fevers over 38 C or drenching night sweats.