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Non Hodgkin lymphoma

Non Hodgkin lymphoma
Non Hodgkin lymphoma is one of the two types of lymphoma that affect the lymphatic system.The lymphatic system is a key part of the immune system, which helps protect the body against disease and infection.
Lymphoma is a cancer that begin in white blood cells called lymphocytes. It develop when lymphocytes start to grow out of control. It is divided into two main types Hodgkin and Non-Hodgkin lymphoma. Both types develop from lymphatic system but they differ on how they behave, spread and respond to treatment. Hodgkin lymphoma has been described in another section, in this section the discussion will be of Non-Hodgkin lymphoma. To understand more on Non-Hodgkin lymphoma, it is important to know lymphatic system first.

Lymphatic system
Lymphatic system is a part of immune system of the body that protect the body against diseases and infections. It is made up of the following;
• Lymph vessels. These thin tubes that carry lymph fluid around the body. These vessels form a network throughout the body including in organs such as the spleen, thymus gland, bone marrow and liver.
• Lymph fluid. This clear fluid travels to and from the tissues in the body. The fluid contains lymphocytes.
• Lymph nodes. Lymph nodes are small, bean-shaped structures that are found along the lymph vessels. Lymph nodes filters the fluid as it passes throughout the body removing and destroying bacteria, viruses and other pathogens. Lymph nodes are located in groups throughout the body, including the neck, chest, abdomen and groin.
• Lymphoid tissue. These tissues include the lymph nodes, thymus, spleen, bone marrow, tonsils, and some tissues in the digestive tract.
• Spleen. This makes lymphocytes and other immune system cells. It also filters out damaged blood cells, bacteria, and cell waste.
• Bone marrow. This produce some lymphocytes.
• Thymus. This is an organ located behind the upper part of the breastbone. It is also responsible for T- lymphocyte development.
• Tonsils: These produce antibodies that fight against germs breathed in or swallowed.
The lymph nodes, lymph tissue and lymph fluid all contain white blood cells called lymphocytes, which help to fight infections. Upon trapping the germs, the lymph nodes become swollen as a sign that your body is fighting an infection.

Non Hodgkin lymphoma
Non Hodgkin lymphoma is a type of lymphoma that develop when heathy lymphocytes change (damaged) and start to grow out of control. As these damaged lymphocytes grow out of control, they replace normal lymphocytes which decreases the ability of the body to fight infections. There are mainly two types of lymphocytes;
• B- Cell lymphocytes. These cells make antibodies that fight germs and other infections. These are also called B-Cells.
• T-Cell lymphocytes. These are responsible for destroying germs and also they trigger B-cell lymphocytes to produce antibodies.

Types of Non-Hodgkin lymphoma
There are many types of Non-Hodgkin lymphoma classified basing on whether cancer started in B-cell or T-cell lymphocytes. Non-Hodgkin lymphoma can also be classified as either
Low grade (slow-growing) or high grade (fast-growing). In this section, the discussion will be of those more common types of Non- Hodgkin lymphoma.

T- Cell Non-Hodgkin lymphomas
These originate from T-cell lymphocytes.
• Precursor T-Cell lymphoblastic lymphoma. This is a fast growing type of T-Cell lymphoma that develop from immature (precursor) T-cells.
• Peripheral T-Cell lymphoma. This develop from more mature form of T-cells. It often occurs as widespreadenlarged, painless lymph nodesin the neck, armpit or groin.
• Cutaneous T-Cell lymphoma. These are lymphomas that develop in the skin.

B-Cell Non-Hodgkin lymphomas
These originate from B-Cell lymphocytes. • Diffuse large B-cell lymphomas. These are fast growing lymphomas. Cancer cells appear fairly large when seen under microscope. Normally start in lymph nodes in the neck, armpit and groin.
• Burkitt lymphoma. It is one of the fast growing lymphomas which is more common in children. There are different varieties of this type of lymphoma in different places of the world.
• Follicular lymphoma. Cancer cells grow slowlyin lymph nodes in circulargroups called follicles. Theselymphomas may not need to be treated when they are first diagnosed because normally at an early stage they don`t cause any health problems. Over time some follicular lymphomas turn into fast growing diffuse B-cell lymphomas.
• Small lymphocytic lymphomas. These are slow growing type of lymphomas. Small lymphocytic lymphomas (SLL) are similar to chronic lymphocytic leukemia (CLL) that makes many doctors to think that these two are the same diseases of different versions. The difference is where the cancer cells are found as SLL cells are found in lymph nodes and spleen while those of CLL are found in the blood and bone marrow.

Risk factors of Non-Hodgkin lymphomas
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factor only influence development of cancer but it does not directly cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. The risk factors for Non-Hodgkin lymphoma include the following;
• Age. Generally Non Hodgkin lymphoma can start at any age, but there are some types that are more common to children than adults like Burkitt lymphoma and those that are more common to adults. • Gender. Statistically, number of men diagnosed with Non Hodgkin lymphoma is slightly high compared to that of women.
• Immune system deficiency.The immune systemis weakened in people with HIV and those taking medicinescalled immunosuppressant after an organtransplant. People with autoimmune diseases, such asrheumatoid arthritis and coeliac disease, also have aweakened immune system.
• Infections.Some infections can slightly increase the riskof non-Hodgkin lymphoma. These include HTLV-1 (humanT-lymphotropic virus 1) which increase chance of developing some T-cell lymphomas, Helicobacter pylori which increase chances of developing lymphoma in the abdomen (stomach), Epstein-Barr virus infection which increase chance of developing Burkitt lymphoma and human herpesvirus 8.
• Exposure to some chemicals. Exposure to chemicals such as pesticides, herbicides and petrochemicals increase chance of developing Non Hodgkin lymphoma.
• Exposure to ionizing radiation. Exposure to radiations like those near nuclear reactors, radiations from atomic bombs and other radiation accidents, increase person`s chance of developing Non Hodgkin lymphoma.
• Life style. Some studies suggest that, being overweight and obese increases your chances of developing some types of Non-Hodgkin lymphomas.

Prevention of Non-Hodgkin lymphoma
To prevent something, you need to know what causes it first. Since the specific cause of Non-Hodgkin lymphoma is still unknown, there is no way of completely preventing the development of Non-Hodgkin lymphoma.
Although there are no known ways to completely prevent development of Non-Hodgkin lymphoma, someone may reduce the risk by avoiding HIV infection, doing physical exercise to avoid being overweight and for those working with pesticides and herbicides should use protective gear whenever working with those chemicals.

Early detection and screening
When it comes to cancer, early detection normally provide better treatment outcome. When Non-Hodgkin lymphoma is found early, chances for better treatment outcome are very high. For most cancers, early detection has been greatly contributed by the presence of screening processes.
Screening is the process of running some tests to someone with no symptoms of the disease with the intention of determining presence or absence of the disease. Unfortunately, there is no widely recommended screening tests for Non-Hodgkin lymphoma. Despite absence of screening tests for this cancer, some cases are nowadays found much earlier than in the past, hence they can be treated successfully.
Early detection of those few cases has been contributed by people visiting hospitals whenever they start experiencing some symptoms such as lump or bump under the skin which is caused by enlarged nodes. The lump is normally not painful.
For those at high risk of developing this disease, such as those with HIV and with autoimmune diseases, are advised to have regular medical checkup.

Signs and symptoms of Non- Hodgkin lymphoma
People with Non-Hodgkin lymphoma may experience the following signs and symptoms. But sometimes those changes are caused by medical condition that is not cancer, hence seeing your doctor upon experiencing any of those symptoms is strongly advised. Signs and symptoms of Non-Hodgkin lymphoma include the following;
• Painless swelling in the neck, under the arms or in the groin region which is normally caused by enlargement of nodes.
• Fatigue
• Unexplained weigh loss
• Excessive sweating especially at night
• Unexplained fever
• Unexplained cough
• Shortness of breath
• Loss of appetite
• Bloating, if the location is abdomen
• Itching skin

Diagnosis of Non- Hodgkin lymphoma
cancer diagnosis
Medical diagnosis simply means identification of nature of an illness by elimination of the symptoms. Normally people don`t go to hospital knowing they have cancer but during diagnostic procedures is when doctors detect the disease.
Following suspicion of the disease, doctors normally run combination of tests to determine whether there are cancerous cells in the body or not and if there are cancer cells, how far have they spread. Along with thorough medical history and physical examination, doctors normally use combination of the following tests to diagnose cancer.

Laboratory tests
Laboratory tests are important in ruling out other conditions and confirming diagnosis. For cancer diagnosis laboratory tests normally include blood tests, urine tests, tumor markers and other body fluids tests.
• Blood tests. Blood tests help to reveal level of different substances in the blood which will help doctors to know if there is anything wrong in the body. From blood tests doctors can see complete blood count which indicates number, size and maturity of blood cells. Also from the blood tests doctors can analyze if kidney and liver are working properly.
• Urine tests. Urine tests (urinalysis) involve laboratory examination of urine to check presence of blood, proteins, and other substances such as drugs. For instance blood in the urine may be an indication of benign condition, infection or other health problem.
• Tumor markers. These are biomarkers (proteins) that can be produced by both cancer cells and normal body cells in response to cancer. Tumor markers are released into the blood or urine. Although studies are still conducted to determine role of these markers in diagnosing cancer because sometimes people with benign condition will have elevated level of these proteins. Also not all tumors have their markers and some markers are not specific to one type of tumor.
• Other body fluids. Despite being rarely used, sometimes body fluids can be tested in the lab during diagnosis of cancer. For instance the use of cerebral spinal fluid (CSF) and pleural fluid. CSF is used in diagnosis of brain tumors while pleural fluid for lung cancer.

Diagnostic imaging
Diagnostic imagings involve tests that create pictures of inside the body that help the doctor to see if there is tumor or not. There are several imaging tests used in cancer diagnosis depending on the type and location of cancer suspected. These imaging tests include;
• Computed tomography (CT) scan. CT scan machine is a donut-shaped scanner that uses x-rays to create series of pictures of body organs from different angles. This machine is linked to a computer where those series of pictures taken will be combined to create a 3D- image of inside the body. During the scanning process patient will lie still on the table which will slide into the scanner. In order to get a clear image, sometimes the doctor will inject the patient with a contrast material before scanning. From the images the doctor will be able to differentiate between healthy and unhealthy tissues.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses powerful magnet and radio waves to take series of pictures of body organs and create a 3D image in a computer linked to a machine. Just like in CT, during MRI procedure the patient will lie on a table that will slide into a long round chamber. Also during this procedure the doctor may inject the patient with a contrast material for clear image view.
• X-ray. This is an imaging technique that is uses low dose of radiation to create pictures of inside your body. Technician will position the patient and direct the x-ray beam to the intended part of the body.
• Ultrasound. Ultrasound is a diagnostic imaging procedure that uses high energy sound waves to produce images of organs inside the body. During the examination, a patient will lie on the table while the technician will slowly move a device called transducer on the skin over the part of the body that is being examined.
• PET scan. Positron emission tomography (PET) scan is an imaging test that uses radioactive glucose to create 3-D images of areas inside the body. Radioactive glucose is used for this test because cancer cells tend to absorb more glucose than normal body cells, so the scan will show which areas of the body has more glucose than others. Before the scan, doctor will inject the patient with tracer called radioactive glucose then during imaging the patient will be asked to lie on the table that will be moving back and forth through the scanner.
• Bone scan. Bone scan is used to examine bones. When it comes to cancer, bone scan is used for diagnosis of bone cancer or cancer that has metastasized into the bones. Before the test, patient will be injected with small amount of radioactive material that tends to collect more on abnormal parts of the bones. Then pictures that will be taken by a scan will indicate the distribution of those radioactive materials in the bones throughout the body.

Biopsy
Biopsy is a diagnostic procedure that involves removing a tissue sample from the body and examines it under microscope in the laboratory. Examination in the laboratory is normally done by a pathologist who will check if the cells in the tissue are cancerous or not. In most cancer cases, biopsy is considered to be the confirmatory test. Depending on the location and type of cancer, biopsy can be obtained in different ways. Some of them include;
• Using needle. By using a thin needle, doctors can draw same tissue or fluid for examination under microscope. This method can be used to draw some fluid (spinal tap), bone marrow (bone marrow aspiration), blood or small amount of tumor from the suspected organ such as liver and breast (fine needle aspiration).
• Surgery. Abnormal tissue samples are obtained while the doctor is performing the surgery. Tissues are then sent to the lab for examination during the surgery. If the surgeon removes just a portion of abnormal area it is called incisional biopsy while when the entire tumor (abnormal site) is removed it is called excisional biopsy.
• Using endoscope. Endoscope is a thin, lighted tube with a camera (focusing telescope) at the end. It is used for viewing inside the body through natural openings like mouth and anus. During an examination if the doctor sees any abnormal tissue, then endoscope can also be used to take sample for that tissue. There are different kinds of endoscopy exams depending on the site of the body being examined. Some of the exams include colonoscopy (for rectum and colon), bronchoscopy (for trachea, bronchi and lungs) and esophagogastroduodenoscopy EGD (for esophagus, stomach and duodenum)
In addition to medical history and physical examination, diagnosis of Non- Hodgkin lymphoma normally involves the use of biopsy, CT-Scan, MRI Scan, PET scan, Ultrasound and blood tests.

Stages of Non- Hodgkin lymphoma
Staging is a standard way used by cancer care team to explain how far the cancer has grown or spread. Staging also enables the oncology team to decide on the suitable treatment option. In this process of staging doctors normally use systems in order to describe the stage of cancer.
When dealing with Non- Hodgkin lymphoma doctors normally describe staging by using a system known as Lugano classification system which describe the stage basing on the following;
• Number of affected lymph nodes. • Whether the affected lymph nodes are in one area or not. • Whether the affected lymph nodes are on only one or both sides of the diaphragm.
• Whether the disease has spread to other organs outside the lymphatic system.
In addition to that, group stages of Hodgkin lymphoma can further be subdivided into A and B depending on whether you are experiencing any specific symptoms.
1. This means you have none of the usual symptoms such as weight loss, fever and
Night sweats. • This means that you are experiencing some of the usual symptoms such as fever and night sweats.
Stages Stage I. Only one lymph node is affected and it is on either side of the diaphragm.
Stage II. More than one lymph node is affected and they may be above or below the
Diaphragm. Stage III. More than one lymph nodes is affected and they are on both sides of the
Diaphragm. Stage IV. Cancer is in multiple lymph nodes and has spread to other organs beyond the
Lymph nodes. Such as liver, bone marrow and lungs.

Treatment of Non- Hodgkin lymphoma
Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps.
After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.
Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.
In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These types of treatments are called clinical trials.
If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time

Treatment options
Treatment of Non- Hodgkin lymphoma requires a team of doctors and other health care professionals. This team work together and it is called multidisciplinary team. Team may vary depending on the treatment option for a particular case. But generally multidisciplinary team for treatment of Non- Hodgkin lymphoma includes hematologist, medical oncologist, radiation oncologist, oncology nurses and other health care professionals like pharmacist and palliative care team. Treatment options include the following;
Watchful waiting Watchful waiting is an option that is used for those slow growing (low grade) Non- Hodgkin lymphoma such as follicular type. Once diagnosed with low grade Non- Hodgkin lymphoma, you may not have treatment straightaway, but instead have regular check-ups to monitor the progress. Having treatment earlier than necessary can cause unpleasant side effects. It can also make your body resistant to treatment, so if you need it later it may not work as well.
Experience suggests that, many people in this watchful waiting period, continue their usual daily activities for a long period. But if you feel uncomfortable with watchful waiting, you may contact your medical team that they may put you in contact with someone who had similar experience.

Chemotherapy
Chemotherapy is a treatment option that involve the use of drugs to destroy cancer cells or slow its growth. It is the most used treatment option when dealing with Non- Hodgkin lymphoma. It is given by a specialized doctor known as medical oncologist. Chemotherapy is normally given through injection into veins (intravenously) and rarely swallowed as pill or capsule.For non-Hodgkin lymphoma, chemotherapy is often combined with other treatments, such as immunotherapy.
Side effects of chemotherapy Side effects of chemotherapy depend on the dose given, type of drug used and periodic time by which the drug has been used. Some of the possible side effects include the following;
• Loss of hairs
• Nausea and/or vomiting
• Risk of infection due to decreased white blood cells
• Feeling tired due to low number of red blood cells
• Easily bruised and bleeding due to low platelets
• Loss of appetite
• Constipation.

Radiation therapy
Radiation therapy is an option that involve using high energy x-rays or other radiation particles to destroy cancer cells. It is given by a specialized doctor known as radiation oncologist. Radiation therapy is normally given after the course of chemotherapy. Non- Hodgkin lymphoma is always treated by using external beam radiation therapy which involve treatment of cancer from the source (machine) outside the body.
The treatment is usually given as multiple small doses over several days or weeks to maximize the effect of the radiotherapy and reduce side effects

Side effects of radiation therapy
Side effects of radiation therapy depends on the dose given and area of the body being treated. Most of the side effects will go away soon after completion of treatment. Some of the possible side effects of radiation therapy include the following;
• Mild skin reactions
• Fatigue
• Upset stomach
• Loose bowel movement
• Sore throat
• Sore and Dry mouth
• Lethargy

Immunotherapy
Immunotherapy is a treatment that involve taking drugs that either boosts the patient’s own immune system or use man-made versions to destroy lymphoma cells or slow their growth. For treatment of Non- Hodgkin lymphoma, immunotherapy may involve the use of;
• Monoclonal antibodies. These uses drugs that target specific substances on the surface of lymphocytes. For example there are those that target CD 20 and those that target CD 52
• Interferons. This is a chemical substance that is normally made by white blood cells. But since white blood cells are damaged and cannot produce it, then man made interferons are used. These may help shrink the lymphomas or stop its growth.

Side effects of immunotherapy
Possible side effects of immunotherapy will depend on type of drug used, dose given and periodic time by which the drug has been used. The side effects of this treatment option include the following;
• Fatigue
• Change of mood
• Fever
• Headaches
• Muscle and joint aches.

Stem cell transplantation
Stem cell transplantation is a treatment option that involve replacing a patient`s bone marrow by highly specialized cells called hematopoietic stem cells. This treatment option is sometimes known as bone marrow transplantation. These cells will mature into heathy bone marrow. Hematopoietic stem cells are blood forming cells found in the bone marrow.
Stem cell transplantation is used when Non- Hodgkin lymphoma comes back (recurs or relapses) or didn`t respond to initial treatment, that resulted to the use of high doses of chemotherapy to help destroy the cancer cells. High doses may have led to the damage of stem cells, hence you may need a stem cell transplant to help restore the bone marrow and rebuild your immune system. A transplant is normally done in several stages and the entire procedure, including recovery, can take months. There are two types of stem cell transplantation;
• Autologous stem cell transplantation. This type uses stem cells that were previously removed from your blood stream and later are transplanted (reinfused) back into your body.
• Allogeneic transplantation. This involve the use of stem cells taken from another person (donor). The donor may be a family member or from a donor registry. This type of transplant is less common, as most people with Non- Hodgkin lymphoma respond to treatment with either chemotherapy, radiotherapy or an autologous transplant.

Side effects of stem cell transplantation
. Most of the side effects of this treatment option resemble to those of chemotherapy but with this treatment options the side effects may be a little bit severe. Some of the possible side effects of stem cell transplantation include, nausea and vomiting, hair loss, risk of infection, easily bruising and bleeding and fatigue.

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