Early Symptoms of Lymphoma

• Painless swelling of lymph nodes — most commonly in the neck, armpits or groin
• Unexplained fever, drenching night sweats and significant weight loss (the "B symptoms")
• Persistent fatigue
• Itching (pruritus) without an obvious skin cause
• Abdominal swelling or discomfort if abdominal nodes or the spleen are involved
• Shortness of breath if mediastinal (chest) nodes are enlarged

The combination of fever, night sweats and weight loss — known as B symptoms — is clinically significant and influences staging and prognosis.

Types of Lymphoma

Lymphoma is one of the most biologically diverse cancers — with over 60 recognised subtypes classified under two broad categories.

Hodgkin Lymphoma (HL):

Distinguished by the presence of Reed-Sternberg cells on biopsy. Four classic subtypes exist:

• Nodular Sclerosis HL: The most common subtype (~65–70%); predominantly affects young women and mediastinal lymph nodes.
• Mixed Cellularity HL: More common in older adults and HIV-positive patients.
• Lymphocyte-Rich HL: Rare; excellent prognosis.
• Lymphocyte-Depleted HL: Rare; most aggressive classical HL subtype.
• Nodular Lymphocyte-Predominant HL (NLPHL): A distinct entity from classical HL; characterised by "popcorn cells" (LP cells) rather than Reed-Sternberg cells. Behaves more indolently and may be treated differently.

Non-Hodgkin Lymphoma (NHL): Over 60 distinct subtypes — broadly categorised as B-cell, T-cell or NK-cell lymphomas.

Common B-cell NHL subtypes:

• Diffuse Large B-Cell Lymphoma (DLBCL): The most common aggressive lymphoma globally. Treated with R-CHOP. Cell of origin (GCB vs ABC subtype) and molecular features (MYC, BCL2, BCL6 rearrangements) guide treatment intensification decisions.
• Follicular Lymphoma: The most common indolent lymphoma. Often managed with watch and wait in early stages; treated with rituximab-based regimens when treatment is needed.
• Marginal Zone Lymphoma (MALT, Splenic, Nodal): Indolent. Gastric MALT lymphoma often responds to H. pylori eradication alone.
• Mantle Cell Lymphoma: Aggressive; characterised by CCND1 (cyclin D1) overexpression from t(11;14). Requires intensive treatment.
• Burkitt Lymphoma: Highly aggressive; characterised by MYC translocation. Requires intensive short-duration chemotherapy (CODOX-M/IVAC).
• Primary Mediastinal Large B-Cell Lymphoma: Predominantly affects young women; treated with DA-EPOCH-R.
• Chronic Lymphocytic Leukaemia / Small Lymphocytic Lymphoma (CLL/SLL): Indolent; the same disease in different anatomical compartments.

Common T-cell/NK-cell NHL subtypes:

• Peripheral T-Cell Lymphoma (PTCL-NOS): Aggressive; poor outcomes with standard R-CHOP equivalent regimens.
• Anaplastic Large Cell Lymphoma (ALCL): ALK-positive ALCL carries a better prognosis than ALK-negative ALCL. Treated with BV-CHP (brentuximab vedotin-containing regimen) or CHOP.
• Extranodal NK/T-Cell Lymphoma: Associated with EBV. Primarily treated with L-asparaginase-based regimens and radiation.

Diagnosis and Staging

Diagnosis requires lymph node biopsy ideally excisional biopsy of an affected node for histopathological classification. Flow cytometry, immunohistochemistry, and molecular studies determine the precise lymphoma subtype. PET-CT is the standard staging modality for Hodgkin lymphoma and many aggressive NHL subtypes. Bone marrow biopsy may be performed for certain subtypes. Staging follows the Lugano classification system an internationally accepted staging framework based on PET-CT findings adapted from the Ann Arbor staging system, used to guide treatment decisions.

Treatment Options

Chemotherapy: ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) is the standard regimen for Hodgkin lymphoma. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) is widely used for aggressive B-cell NHL. The lymphoma treatment cost in India varies significantly by protocol, number of cycles, and hospital

Immunotherapy / Targeted Therapy: Rituximab (anti-CD20 monoclonal antibody) is standard in CD20-positive B-cell NHL. Brentuximab vedotin is used in relapsed Hodgkin lymphoma and certain T-cell lymphomas. For relapsed or refractory diffuse large B-cell lymphoma, CAR-T cell therapy — a form of personalised immunotherapy using the patient's own modified immune cells — is an established option at specialist centres.

Radiation Therapy: May be used after chemotherapy for Hodgkin lymphoma or as consolidation in certain localised NHL cases.