Treatment may involve any of the following modalities: chemotherapy, radiation therapy, immunotherapy, targeted therapy, CAR-T cell therapy, and stem cell transplant. Very often, it is likely a combination of two or more of the above modalities. This is dependent on the subtype of the lymphoma and various prognostic features.
Chemotherapy is the primary treatment for lymphoma. It acts as a cancer treatment that uses one or more drugs to halt the growth of cancer cells. It is usually used to treat cancer when it is systemic, meaning that the cancer has spread throughout the body. Lymphoma is caused by uncontrolled growth of a type of white blood cell known as lymphocyte. It may arise from either a B or T lymphocyte. As they are important elements of the immune system that can travel through the bloodstream, the advantage of chemotherapy can help kill cancer cells wherever they may be located.
Many patients who are treated for lymphoma are given combination chemotherapy, which means two or more drugs. These drugs are given in a specific order or schedule during certain days of each treatment cycle or treatment regimen. The reason for using a combination of drugs is to increase the effectiveness of eradicating the cancer cells.
Most of the chemotherapy drugs have been used for decades. Some common chemotherapy regimens include the monoclonal antibody rituximab, or Rituxan, which is usually abbreviated with the letter R and placed at the beginning or end of the regimen abbreviation – for example:
During chemotherapy, patients receive the drug or drugs orally (pills taken by mouth) or intravenously (IV injection directly into the vein) in their course of treatment regimen, followed by a rest period. The length of the rest period and number of cycles vary depending on the lymphoma and the type of drugs used.
Radiation therapy is extremely effective in treating lymphoma. This is because most lymphomas are quite radiosensitive as they respond well to moderate doses of radiation. For early stage, intermediate, and high-grade lymphoma, patients receive chemotherapy and then radiation to the initial area or areas of concern. In advanced disease, a radiation oncologist may add radiation to previously bulky sites or sites that are not responding well to treatment. They may also use radiation in very low doses to control local symptoms in any stage.
An increasing number of cancer patients are treated successfully with radiation therapy during their course of treatment. The radiation oncologist may use radiation to cure cancer or to relieve a cancer patient’s pain or alleviate other symptoms due to the cancer.
Radiation therapy uses high-energy radiation to shrink tumours and kill cancer cells. This works because the radiation destroys the cancer cells’ ability to reproduce, and the body naturally gets rid of these cells. Radiation affects cancer cells by damaging their DNA, so that the cancer cells can no longer divide and grow. Radiation is most effective at killing cells that are actively dividing. Cancer cells are more vulnerable to radiation for two reasons:
Preparation for radiation therapy is focused on targeting the radiation dose to the cancer as precisely as possible to minimize side effects and avoid damaging normal cells. Imaging tests may be used to help determine the exact shape and location of your tumour and define its boundaries. Some common forms of radiation therapy may include:
Some lymphoma patients may be treated with radiation as their primary treatment. In some cases, radiation therapy is given at the same time as chemotherapy. Chemotherapy used with radiation therapy can improve the local response and reduce metastatic disease.
Although surgery can be used to help diagnose lymphoma through biopsies, it is rarely used as a form of treatment because of the efficacy of chemotherapy, radiation therapy, and bone marrow/stem cell transplantation. However, there are certain situations in which surgery may be a beneficial addition to a patient’s treatment plan, along with more traditional options, such as chemotherapy and radiation therapy.
One of the possibilities for surgery in a lymphoma treatment is in the case of primary pulmonary lymphomas, developed in the bronchus-associated lymphoid tissue. These tumours can sometimes be removed through surgical procedures.
Other diagnoses for which lymphoma surgery may be applicable includes:
Surgery can also be used to help drain pleural effusions, which are buildups of fluid in the chest that often develop as a complication of non-Hodgkin lymphoma. However, these surgeries are not intended to treat the cancer itself, but rather to alleviate a specific symptom and improve a patient’s quality of life.
Immunotherapy is a type of treatment that uses the patient’s own immune system, or medications that helps to stimulate or suppress the body to fight the cancer. There are many forms of immunotherapy. The different types of immunotherapies include cytokines, vaccines, bacillus Calmette-Guerin (BCG), and some monoclonal antibodies.
In the case of Hodgkin Lymphoma, the main form ones are the monoclonal antibodies that target a specific protein on the Hodgkin Lymphoma cancer cells with injections known as checkpoint inhibitors. These treatments are highly effective in killing cancerous cells in Hodgkin Lymphoma.
Brentuximab vedotin is usually used as the first treatment for stage lll or lV classic Hodgkin lymphoma, along with chemotherapy. It is also given to patients at high risk of the cancer coming back after treatment. This drug is infused into a vein (IV), usually for every three weeks.
Rituximab is given as an IV infusion When used by itself, it is usually given once a week for four weeks, which may then be repeated several months later. When given along with chemotherapy, it is most often given on the first day of each chemo cycle.
In non-Hodgkin lymphoma (NHL), there are several monoclonal antibodies that are used for immunotherapy treatment (infused into a vein; IV) such as:
Lastly, immunomodulating drugs such as thalidomide (Thalomid) and lenalidomide (Revlimid) are thought to work against certain cancers by affecting parts of the immune system. Sometimes used to help treat certain types of lymphoma, after other treatments have been tried, these drugs are taken daily as pills.
A bone marrow transplant is a medical procedure by which healthy stem cells are transplanted into your bone marrow or your blood. This restores your body’s ability to create the red blood cells, white blood cells, and platelets it needs.
A bone marrow transplant is also called a stem cell transplant or, more specifically, a hematopoietic stem cell transplant. Transplantation can be used to treat certain types of lymphoma, and other blood and immune system diseases that affects the bone marrow.
Stem cells are special cells that can make copies of themselves and change into the many kinds of cells that your body needs. There are several kinds of stem cells, and they are found in different parts of the body at different times. Cancer and cancer treatment can damage your hematopoietic stem cells. Hematopoietic stem cells are stem cells that turn into blood cells.
Bone marrow is soft, spongy tissue in the body that contains hematopoietic stem cells. It is found in the center of most bones. Hematopoietic stem cells are also found in the blood that is moving throughout your body.
When hematopoietic stem cells are damaged, they may not develop into red blood cells, white blood cells, and platelets. These blood cells are very important and each one has a different function:
There are different types of bone marrow/stem cell transplants. The two main types are:
After chemotherapy, the stem cells are returned to your body, restoring your immune system and your body’s ability to produce blood cells and fight infection. This process is also called an AUTO transplant or stem cell rescue.
If cases where a donor match cannot be found, there are other options such as:
Parent-child transplant and haplotype mismatched transplant. Cells from a parent are at best a 50% match for a patient’s HLA type. Doctors are using these types of transplants more often, to expand the use of transplantation as an effective cancer treatment.
CAR-T cell therapy is used to treat some types of lymphoma that have relapsed or not responded to at least two previous courses of treatment. It is a very intensive type of treatment that uses a patient’s own immune system to fight lymphoma. These cells are called T cells, or T lymphocytes.
T cells are a type of white blood cell. Besides killing germs, T cells usually recognise and kill any of your own cells that have become abnormal (such as cancer cells). However, cancer cells are good at tricking the T cells, either by looking very similar to healthy cells or by sending signals to T cells to not attack them.
In CAR T-cell therapy, your own T cells are collected and sent off to a lab. In the lab, they are genetically modified so they can recognise and stick to a particular protein on the surface of your lymphoma cells. These genetically modified T cells are known as CAR-T cells. CAR stands for ‘chimeric antigen receptor’.
After they become modified, the CAR-T cells are grown in the lab until there are enough of them to treat your lymphoma. They are then given back to you, though a blood transfusion. When they stick to the lymphoma cells in your body, the CAR-T cells are activated and will kill the lymphoma cells.
CAR-T cell therapy involves a few different steps:
Making and growing the CAR-T cells can take several weeks. During this time, you might need chemotherapy or radiation therapy to keep your lymphoma under control, also often called as bridging therapy.
The side effects of chemotherapy commonly include the following:
The possible side effects of radiation therapy depend on where the radiation is targeted. The common side effects include:
Surgery, like all cancer treatments, has benefits, risks, and side effects. After surgery, it is common to have some pain from the surgery’s effect on the body. The amount and location of the pain varies depending on your surgery. Factors that can affect the pain you experience include:
Fatigue is also common after surgery. Many people are very tired after major surgery, especially when it involves the abdomen or chest. Fatigue usually goes away gradually two to four weeks after surgery.
The side effects of targeted therapy may include:
The side effects of bone marrow transplant may differ for everyone, depending on the type of transplant, your general health, and other factors. Some of the common side effects include:
As CAR-T cells multiply, they can release large amounts of chemicals called cytokines into the blood, which can ramp up the immune system. The possible side effects from this release can include:
If you suspect that you or your loved one have lymphoma, it is advisable to get the support you need. Early detection and diagnosis of lymphoma is key to treating the disease.
Regardless of what stage your lymphoma may be, you should schedule an appointment to see an oncologist specialising in lymphoma as soon as possible. With the speed of developments in lymphoma diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist.
Which lymphoma treatments are right for you depends on the type and stage of your disease, your overall health, and your preferences. The goal of treatment is to destroy as many cancer cells as possible and bring the disease into remission.
Our cancer specialists at OncoCare specialise in treating late stage and advanced stages of lymphoma, as well as earlier stages of the disease. Make an appointment with us if you have any persistent signs or symptoms that worry you.
Senior Consultant, Medical Oncologist
MBBS (Delhi) – American Board Certified (Int Med) – American Board Certified (Hematology) –
American Board Certified (Med Oncology)
Before joining OncoCare Cancer Centre at Mount Elizabeth Hospital, Singapore, Dr Akhil Chopra was a Senior Consultant in Medical Oncology at Johns Hopkins Singapore, Tan Tock Seng Hospital and Adjunct Associate Professor at Lee Kong Chian School of Medicine.
Dr Chopra has experience treating multiple cancer types including breast cancer, lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers; as well as lymphomas and chronic leukaemia’s/multiple myeloma. Besides his clinical and research work, he has been involved in teaching medical students from the Lee Kong Chian School of Medicine as well as medical residents and students from Johns Hopkins University, Baltimore in USA.
Senior Consultant, Medical Oncologist
MBBS (Singapore) – ABIM Int. Med (USA) – ABIM Med Onc(USA) – FAMS (Medical Oncology)
Dr. Kevin Tay is a Senior Consultant Medical Oncologist with the OncoCare Cancer Center and also a Visiting Consultant at the National Cancer Center Singapore. Dr. Tay received his medical degree from the National University of Singapore, School of Medicine and did his post-graduate training in Internal Medicine at the University of Hawaii and his Medical Oncology fellowship at the National Cancer Institute (NCI), National Institute of Health (NIH) in USA. Dr. Tay was also appointed Chief Resident and Chief Fellow during both his residency and fellowship program respectively. He currently holds American Board certifications for the practice of Internal Medicine and Medical Oncology.
During his time at the National Cancer Institute (NCI) and the National Institute of Health (NIH) in USA, Dr Tay trained under several renowned oncologists, including Dr Sandy Swain, a world expert on breast cancer and the previous President of the American Society of Clinical Oncology, and Dr Giuseppe Giaccone, the previous Chair of the EORTC’s Lung Cancer Cooperative Group and also the Associate Director for Clinical Research at the Lombardi Comprehensive Cancer Center, Georgetown University. Dr Tay also spent two years doing research at the NIH with an internationally renowned translational research group, under the mentorship of Dr Wyndham Wilson, Dr Louis Staudt and Dr Elaine Jaffe.
Lymphoma is a type of blood cancer that begins in cells of the lymph system. It involves the lymphatic tissues where the normal lymphocytes become cancerous. Lymphocytes are part of the body’s immune system. These cells are in the lymph nodes, spleen, thymus, bone marrow, and other parts of the body. When you have lymphoma, lymphocytes change and grow out of control.
The type of lymphocyte and at which stage of the lymphocyte life cycle determines the type of lymphoma. The two main types are Hodgkin lymphoma and non-Hodgkin lymphoma (NHL). Accurate diagnosis of the exact type of lymphoma is the most important first step to receive effective treatment.
Globally, non-Hodgkin lymphoma affects more than 500,000 people while Hodgkin lymphoma affects about 83,000 in both sexes and all ages.
In Singapore, one in every four people may develop cancer in their lifetime. Lymphoma incidence has been rising over the years, affecting 3.7% of our population as the fifth most common cancer in men, and sixth most common in women. Lymphoma has been consistent among the most frequent cancers in males and affecting older patients with the median age of diagnosis in their sixties.
(Source: https://www.who.int/cancer/country-profiles/SGP_2020.pdf, https://www.singaporecancersociety.org.sg/learn-about-cancer/cancer-basics/common-types-of-cancer-in-singapore.html, https://www.nrdo.gov.sg/docs/librariesprovider3/default-document-library/thespore-cancerregistry_commerativebook_-1.pdf?sfvrsn=231fce6e_0)
The most common symptoms of Lymphoma are:
Screening for Lymphoma
Even though there are no routine lymphoma screening test, early detection is possible for both Hodgkin and non-Hodgkin lymphoma. The typical diagnostic process involves a physical exam and medical history, along with a biopsy and cell/blood test.
If you suspect that you or your loved ones have lymphoma, it is advisable to not ignore the symptoms and get the support you need. Early detection and diagnosis of lymphoma is key to treating the disease.
Regardless of what stage your lymphoma may be, you should schedule an appointment to see our oncologist specialising in lymphoma as soon as possible. With the speed of developments in lymphoma diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist.
Tests to diagnose Lymphoma include:
Other tests and procedures may also be used depending on your situation.
Many types of lymphoma exist and knowing exactly which type you have is key to developing an effective treatment plan. Research shows that having a biopsy sample reviewed by an expert pathologist improves the chances for an accurate diagnosis. Consider getting a second opinion from our cancer specialist who can confirm your diagnosis.
The following factors may increase the risk of lymphoma:
Lymphomas are categorised into two groups, Hodgkin, and non-Hodgkin lymphoma (NHL). These two diseases may sound similar, but these cancers have distinct differences.
Both Hodgkin and non-Hodgkin lymphoma originate in a type of white blood cell in your immune system known as a lymphocyte. Lymphocytes help your immune system remain strong by protecting your body from germs. When you have a weakened immune system, that means there are not enough white blood cells in your bloodstream to help keep you healthy.
Lymphomas are caused by cancerous lymphocytes. Hodgkin lymphoma and NHL are two main types of lymphoma. While both cancers develop in your immune system, the primary difference in the lymphomas is the presence of a specific abnormal cell found in the biopsy.
Our Cancer Specialists will be able to tell the type of lymphoma you have by using a microscope to look for Reed-Sternberg cells. Reed-Sternberg cells appear in people with Hodgkin lymphoma, and the number of these cells increase as the disease advances. NHL does not feature Reed-Sternberg cells.
Before deciding the stage of lymphoma, the lymphoma specialists will examine you and refer you for tests. If the tests show you have cancer, the specialist will advise you about treatment options.
Stage 1 means that there is cancer found in one lymph node, a lymphoid organ such as the thymus or one area of a single organ outside of the lymphatic system.
Stage 2 means there is cancer in two or more groups of lymph nodes. These can be anywhere in the body, but to be diagnosed with stage 2 lymphoma, they must all be on the same side of the diaphragm.
Stage 3 means there is cancer is found in several lymph nodes, both above and below the diaphragm, and may also have spread to the spleen.
Stage 4 means that cancer is found outside of the lymphatic system or in two or more distant organs such as the liver or the lungs.
Sometimes, the lymphoma specialist will add the letter “A” or “B” after the numerical lymphoma stage. Stage A is assigned if a patient does not have night sweats, unexplained fevers, or unexplained weight loss, while stage B is assigned if any of these symptoms are present.