Neeva's lovely NHL

[Neeva Tessler]

NHL
Non-Hodgkin’s Lymphoma

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At a Glance:

• A lymphoma is a cancer that develops in the lymphatic system.
  
• The most common symptom of non-Hodgkin's lymphomas is a painless swelling in the lymph nodes in the neck, underarm, or groin.
  
• Non-Hodgkin's lymphomas are diagnosed with a biopsy of an enlarged lymph node.
  
• Treatment of non-Hodgkin's lymphomas depends on the type and location of the lymphoma, as well as the age and health of the patient.
  
• Follow-up examinations are important after lymphoma treatment. Most relapses occur in the first 2 years after therapy.

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Signs/Symptoms:

• Swollen, painless lymph nodes in the neck, armpits, or groin. (Check) (Unnoticed by Neeva)
  
• Unexplained weight loss (Check) (Neeva generally weighs near 100 lbs, but this trip she will be less than 82, having dropped seventeen lbs within a two weeks, for no reason)
  
• Fever (Check) (She will have chills and head aches, which will eventually be seen as a moderate fever of between 100-102 degrees)
  
• Soaking night sweats (Check) (She has been, but thinks nothing of it. She will divulge this with questioning)
  
• Coughing, trouble breathing, or chest pain (not noticed on Neeva)
  
• Weakness and tiredness that don't go away (Check) (She supposes it is stress and lack of sleep)
  
• Pain, swelling, or a feeling of fullness in the abdomen (not noticed on Neeva)

Brief outline of the illness:

• Non-Hodgkin lymphoma is cancer that begins in cells of the immune system. The immune system fights infections and other diseases.
  
• The lymphatic system is part of the immune system. The lymphatic system includes the following:
  
• Lymph vessels: The lymphatic system has a network of lymph vessels. Lymph vessels branch into all the tissues of the body.
  
• Lymph: The lymph vessels carry clear fluid called lymph. Lymph contains white blood cells, especially lymphocytes such as B cells and T cells.
  
• Lymph nodes: Lymph vessels are connected to small, round masses of tissue called lymph nodes. Groups of lymph nodes are found in the neck, underarms, chest, abdomen, and groin. Lymph nodes store white blood cells. They trap and remove bacteria or other harmful substances that may be in the lymph.
  
• Other parts of the lymphatic system: Other parts of the lymphatic system include the tonsils, thymus, and spleen. Lymphatic tissue is also found in other parts of the body including the stomach, skin, and small intestine.
  
• Because lymphatic tissue is in many parts of the body, Hodgkin lymphoma can start almost anywhere. Usually, it's first found in a lymph node.
  
• Non-Hodgkin lymphoma begins when a lymphocyte (usually a B cell) becomes abnormal. The abnormal cell divides to make copies of itself. The new cells divide again and again, making more and more abnormal cells. The abnormal cells don't die when they should. They don't protect the body from infections or other diseases. The buildup of extra cells often forms a mass of tissue called a growth or tumor.

Tests:

• If you have swollen lymph nodes or another symptom that suggests non-Hodgkin lymphoma, your doctor will try to find out what's causing the problem. Your doctor may ask about your personal and family medical history.
  
• Physical exam: Your doctor checks for swollen lymph nodes in your neck, underarms, and groin. Your doctor also checks for a swollen spleen or liver.
  
• Blood tests: The lab does a complete blood count to check the number of white blood cells. The lab also checks for other cells and substances, such as lactate dehydrogenase (LDH). Lymphoma may cause a high level of LDH.
  
• Chest x-rays: You may have x-rays to check for swollen lymph nodes or other signs of disease in your chest.
  
• Biopsy: A biopsy is the only sure way to diagnose lymphoma. Your doctor may remove an entire lymph node (excisional biopsy) or only part of a lymph node (incisional biopsy). A thin needle (fine needle aspiration) usually cannot remove a large enough sample for the pathologist to diagnose lymphoma. Removing an entire lymph node is best. The pathologist uses a microscope to check the tissue for lymphoma cells.

Staging:

• Your doctor needs to know the extent (stage) of non-Hodgkin lymphoma to plan the best treatment. Staging is a careful attempt to find out what parts of the body are affected by the disease.
  
• Lymphoma usually starts in a lymph node. It can spread to nearly any other part of the body. For example, it can spread to the liver, lungs, bone, and bone marrow.
  
• Bone marrow biopsy: The doctor uses a thick needle to remove a small sample of bone and bone marrow from your hipbone or another large bone. Local anesthesia can help control pain. A pathologist looks for lymphoma cells in the sample.
  
• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your head, neck, chest, abdomen, or pelvis. You may receive an injection of contrast material. Also, you may be asked to drink another type of contrast material. The contrast material makes it easier for the doctor to see swollen lymph nodes and other abnormal areas on the x-ray.
  
• MRI: Your doctor may order MRI pictures of your spinal cord, bone marrow, or brain. MRI uses a powerful magnet linked to a computer. It makes detailed pictures of tissue on a computer screen or film.
  
• Ultrasound: An ultrasound device sends out sound waves that you cannot hear. A small hand-held device is held against your body. The waves bounce off nearby tissues, and a computer uses the echoes to create a picture. Tumors may produce echoes that are different from the echoes made by healthy tissues. The picture can show possible tumors.
  
• Spinal tap: The doctor uses a long, thin needle to remove fluid from the spinal column. Local anesthesia can help control pain. You must lie flat for a few hours afterward so that you don't get a headache. The lab checks the fluid for lymphoma cells or other problems.
  
• PET scan: You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Lymphoma cells use sugar faster than normal cells, and areas with lymphoma look brighter on the pictures.
  
• The stage is based on where lymphoma cells are found (in the lymph nodes or in other organs or tissues). The stage also depends on how many areas are affected. The stages of non-Hodgkin lymphoma are as follows:
  
• Stage I: The lymphoma cells are in one lymph node group (such as in the neck or underarm). Or, if the abnormal cells are not in the lymph nodes, they are in only one part of a tissue or organ (such as the lung, but not the liver or bone marrow).
  
• Stage II: The lymphoma cells are in at least two lymph node groups on the same side of (either above or below) the diaphragm. Or, the lymphoma cells are in one part of an organ and the lymph nodes near that organ (on the same side of the diaphragm). There may be lymphoma cells in other lymph node groups on the same side of the diaphragm.
  
• Stage III: The lymphoma is in lymph nodes above and below the diaphragm. It also may be found in one part of a tissue or an organ near these lymph node groups.
  
• Stage IV: Lymphoma cells are found in several parts of one or more organs or tissues (in addition to the lymph nodes). Or, it is in the liver, blood, or bone marrow.
  
• Recurrent: The disease returns after treatment.
  
• In addition to these stage numbers, your doctor may also describe the stage as A or B:
  
• A: You have not had weight loss, drenching night sweats, or fevers.
  
• B: You have had weight loss, drenching night sweats, or fevers.
  

Survival:

• The five-year relative survival rate for NHL patients has risen from 31 percent in whites in 1960-1963 to 64.9 percent for all races in 1996-2004.
  In 2008 there are approximately 574,525 people in the U.S. living with lymphoma (with active disease or in remission): 143,814 with Hodgkin lymphoma and 430,711 with NHL.
  
• Survival for Children
  In children 0-19 years of age, five-year relative survival for NHL is now 83.3 percent. This represents a significant improvement in the rate of recovery; even in the mid-1970s, the majority of children with NHL did not live five years after diagnosis. source

Treatment:

• Early stage, localized NHL is sometimes treated with radiation; widespread disease requires chemotherapy, and/or chemotherapy monoclonal antibody therapy with radiation, depending on the tumor size, cell type and location of the lymphoma. Treatment for NHL sometimes includes vaccines and other forms of immunotherapy.
  
• Chemotherapy. Doctors use a combination of drugs — given orally or by injection — against fast-growing cancer cells. This combined treatment approach is used for intermediate- and high-grade lymphomas and advanced stages of low-grade lymphomas. A single drug may be used if you have a low-grade type of the disease.
  
• Radiation. High doses of radiation kill cancerous cells and shrink tumors. This treatment is for early stages of low-grade lymphomas. Sometimes, it's used along with chemotherapy on intermediate-grade tumors or to treat specific sites, such as the brain.
  
• Stem cell transplantation. Lymphomas tend to be sensitive to chemotherapy. However, if lymphoma recurs, higher doses of chemotherapy may be necessary to treat the disease. The amount of chemotherapy that can be given is limited because of the damage chemotherapy does to your bone marrow. In order to avoid this serious side effect, healthy stem cells — those capable of producing new cells — are taken from your blood or bone marrowand frozen. After you undergo very high doses of chemotherapy to kill the lymphoma, the healthy stem cells are thawed and injected back into your body. This treatment is used primarily to treat intermediate- or high-grade lymphomas that relapse after initial, successful treatment.
  
• Observation. If your lymphoma appears to be slow growing, a wait and see approach may be an option. Slowly growing lymphomas with few symptoms may not require treatment for a year or more.
  
• Biotherapy. Rituximab (Rituxan) is approved by the Food and Drug Administration (FDA) for the treatment of B cell non-Hodgkin's lymphoma. Rituximab is a type of monoclonal antibody that helps the immune system specifically target and destroy cancer cells. Rituximab is frequently used in combination with chemotherapy. It's also sometimes given in tandem with radioimmunotherapy.
  
• Radioimmunotherapy. Two radioimmunotherapy drugs — ibritumomab (Zevalin) and tositumomab (Bexxar) — are currently FDA-approved. Radioimmunotherapy uses monoclonal antibodies combined with radioactive isotopes. The antibodies attach themselves to the cancer cells, while the added radiation helps destroy the cancer cells. Radioimmunotherapy is generally well tolerated; however, serious side effects, including reduced blood cell counts, hemorrhage and life-threatening infections, are possible with these medications. That's why the FDA has approved their use only after other treatments have failed.
  
• Interferon therapy. Interferons are proteins that occur naturally in your body to help fight viral infection and regulate your immune system. Some research suggests that genetically engineered interferon can slow or stop the progression of some types of non-Hodgkin's lymphomas. More studies are needed to determine whether interferon medications are an effective treatment for this disease.

Follow Up Care:

• You'll need regular checkups after treatment for non-Hodgkin lymphoma. Your doctor will watch your recovery closely and check for recurrence of the lymphoma. Checkups help make sure that any changes in your health are noted and treated as needed. Checkups may include a physical exam, lab tests, chest x-rays, and other procedures. Between scheduled visits, you should contact the doctor right away if you have any health problems.

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Final Diagnosis:
Non-Hodgkin’s Lymphoma

Mistaken Diagnosis: