Diagnosing Non-Hodgkin Lymphoma

Non-Hodgkin lymphoma is a form of cancer that affects the lymphocytes, a type of white blood cell found in the lymphatic system. The lymphatic system consists of a series of vessels that drain excess fluid from tissues. The system also contains lymph nodes—the small glands that filter this fluid and trap foreign substances such as viruses and bacteria for the lymphocytes to destroy—and other small organs such as the spleen that filter the blood and fight infection.

People with non-Hodgkin lymphoma have abnormal lymphocytes that multiply and accumulate to form tumors in the lymph nodes, spleen, and other organs.

Doctors do not fully understand what causes non-Hodgkin lymphoma. Likely, when a lymphocyte divides to produce another lymphocyte, a mistake in the copying of the genes leads to a cancerous transformation. Because a healthy immune system may detect and destroy these abnormal cells, you may have an increased risk of developing this cancer if you have an immune system that does not function properly. For example, people with HIV, those with inherited immune disorders, or those who are taking immune suppressive therapy for long periods may be slightly more likely to develop non-Hodgkin lymphoma than the general population.

People with non-Hodgkin lymphoma may experience weight loss, unexplained fevers of more than 101 degrees, and drenching night sweats. They may also have noticeably swollen lymph nodes on either side of the neck above the collarbone, under the arms, or around the groin, and swelling in their abdomen due to an enlarged spleen.

More than 67 types of non-Hodgkin lymphoma exist. Examples include large B cell lymphoma, follicular lymphoma, chronic lymphocytic leukemia, hairy cell leukemia, primary central nervous system lymphoma, cutaneous T-cell lymphoma, and AIDS-related lymphoma.

These various types of non-Hodgkin lymphoma are formed in either B cells or T cells. B cells are lymphocytes that produce proteins called antibodies that can attack viruses, bacteria, and other foreign matter. About 85 percent of people with non-Hodgkin lymphoma have a type that forms in B cells. The other 15 percent have non-Hodgkin lymphoma that forms in T cells. T cells, or T lymphocytes, are white blood cells that help to organize an immune response and attack foreign matter in the body.

Non-Hodgkin lymphoma can occur in adults and children. Our experienced team of pediatric oncologists and hematologists at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders care for children with non-Hodgkin lymphoma.

Many of the forms of non-Hodgkin lymphoma can be categorized into one of the three following groups, depending on how fast the cancer grows.

• indolent, or slow-growing
• intermediate
• highly aggressive, or fast-growing

After conducting a physical exam, which includes feeling your lymph nodes and asking about your symptoms and medical history, your doctor may perform several tests to determine whether non-Hodgkin lymphoma is present and, if so, how fast it is growing. As part of the diagnosis, your doctor can also determine how far the disease has spread, how well the disease may respond to therapy, and how likely it is to come back after treatment.

Making an accurate diagnosis is a critical part of determining the best treatment for you.

Blood Tests

Blood tests can help your doctors detect the presence of some of the telltale signs of non-Hodgkin lymphoma. These may include anemia, or low levels of red blood cells, which are needed to carry oxygen to the body’s organs and tissues. A common symptom of anemia is fatigue. People with this form of cancer may also have low levels of healthy white blood cells, which fight infection, and low platelet counts, which help the blood to clot.

Our doctors may also test the blood for high levels of lactate dehydrogenase, also known as LDH. People with non-Hodgkin lymphoma sometimes produce this enzyme in increased amounts, though an elevated level of LDH may also signal other medical problems.

After a diagnosis of non-Hodgkin lymphoma is confirmed with other tests, doctors may measure your LDH levels to help determine how aggressive the disease is.

Lymph Node Biopsy

To diagnose non-Hodgkin lymphoma, NYU Langone doctors perform a biopsy, in which they take a tissue sample from a swollen lymph node found during the physical exam or with imaging tests, such as CT, PET, or MRI, which doctors often use when diagnosing cancer, and evaluate it under a microscope.

The tissue sample taken during a biopsy helps your doctor determine the presence of proteins or other substances on individual cancer cells. The appearance of these “surface markers” allows your doctor to identify your type of non-Hodgkin lymphoma. Also, studies of the cells may reveal genetic mutations associated with specific types of non-Hodgkin lymphoma. All of these tests help our doctors decide which medications might best manage the cancer.

Surgical Biopsy

Doctors at NYU Langone prefer to remove one entire lymph node during a biopsy. This provides the greatest amount of tissue for molecular and genetic testing. Your doctor removes the lymph node in the hospital by making a surgical incision. Depending on how deep the suspicious lymph node is within the body, the surgery may require general anesthesia, but it is generally done using local anesthesia. Most people can go home the same day as the surgery.

Needle Biopsy

If surgical biopsy is not possible because the swollen lymph node is too close to vital blood vessels or nerves that make it difficult to reach, your doctor may obtain a smaller tissue sample using a needle biopsy.

One type of needle biopsy is fine needle aspiration, in which a small needle is used to withdraw fluid and cells from an enlarged lymph node. Another option is a core needle biopsy, which uses a larger needle to remove a larger portion of tissue.

If the tumor is deep within the body, your doctor may conduct the biopsy using image guidance provided by, for instance, a CT scan, which is a type of X-ray, or an ultrasound. A local anesthetic is used for needle biopsy, which can often be performed as an outpatient procedure.

Bone Marrow Aspiration and Biopsy

Our doctors may use bone marrow aspiration and biopsy to determine if non-Hodgkin lymphoma has spread to the bone marrow, the soft spongy tissue that makes blood cells and is found in the center of bones throughout the body. Cancerous lymphocytes from the lymph nodes may travel to the bone marrow, which is also part of the lymphatic system. Cancer in the bone marrow is a sign the disease has advanced.

During a bone marrow aspiration, your doctor uses a needle to withdraw liquid and tissue from bone marrow in the back of the pelvis. During a bone marrow biopsy, your doctor removes a piece of bone and marrow from this same area. Tissue samples are then evaluated under a microscope for signs of non-Hodgkin lymphoma. Both of these procedures require a local anesthetic and may be conducted either in the doctor’s office or in the hospital. People can go home the same day as the biopsy.

Lumbar Puncture

Doctors may perform a lumbar puncture if they suspect you have a type of non-Hodgkin lymphoma that could spread to the cerebrospinal fluid, which surrounds the spine and brain. This test involves inserting a needle into the spinal canal through the lower back and withdrawing a sample of fluid for evaluation under a microscope. Doctors use local anesthesia for this procedure.

Imaging Tests

Our doctors may use a series of imaging tests to determine how far within the body non-Hodgkin lymphoma has spread.

CT Scan

A CT scan uses X-rays and a computer to create three-dimensional, cross-sectional images of the body. The test can help your doctor to determine the size of non-Hodgkin lymphoma tumors and the organs affected.

Your doctor may give you a contrast agent before this scan, taken either as a liquid or pill by mouth or as an injection into a vein. This contrast agent travels throughout the body, allowing your doctor to see clear images of organs and blood vessels. The contrast fluid is iodine based, so this test is not recommended for anyone with an allergy to seafood or iodine.

PET Scan

Your doctor may use a PET scan to look for small non-Hodgkin lymphoma tumors and to determine how rapidly the cancer is growing. With a PET scan, your doctor may also be able to see parts of the body not seen on a CT scan.

A PET scan requires an injection of a small amount of radioactive glucose, or sugar, into a vein. This substance collects in tumor cells, which are detected by a computer during the scan. The computer then creates three-dimensional images of cancer activity in the tissues in your body.

Evidence of greater amounts of radioactive glucose in the cells indicates that the non-Hodgkin lymphoma is more active, or growing more quickly.

MRI Scan

An MRI scan uses a magnetic field and radio waves to create computerized, three-dimensional images of structures in your body. Your doctor may use MRI when other imaging methods do not provide enough detail in areas possibly affected by non-Hodgkin lymphoma, including the spine and brain.

Ultrasound

An ultrasound, which uses sound waves to create images on a computer monitor, may be useful in determining the size of your spleen. The spleen helps make lymphocytes as part of the lymphatic system; non-Hodgkin lymphoma often enlarges this organ, located above the stomach on the left side of your body.

After our doctors have completed the testing, they can determine what type of treatment is best for you. Generally, slow-growing (indolent) non-Hodgkin lymphoma requires less treatment than intermediate or aggressive cancer.