🩸 Non-Hodgkin Lymphoma (NHL) is a heterogeneous group of lymphoid malignancies arising from B cells, T cells, or NK cells. Most cases are of B-cell origin. Clinical behaviour ranges from indolent disease to highly aggressive lymphoma.

✅ UK/NICE framing: think about early recognition, urgent referral if suspected, accurate tissue diagnosis, and then subtype-specific specialist management.

📖 About

NHL is a group of lymphoid cancers with many biologically distinct subtypes.
It may arise in lymph nodes, spleen, bone marrow, blood, or extranodal tissues such as the GI tract, skin, or CNS.
Presentation and prognosis depend heavily on subtype and stage.
Malignant lymphoma is an HIV indicator condition.

⚠️ When to suspect NHL

Unexplained lymphadenopathy.
Unexplained splenomegaly.
Associated symptoms increasing suspicion: fever, drenching night sweats, weight loss, pruritus, shortness of breath.
Extranodal symptoms may occur depending on site involved.

🧾 Types of NHL

B-cell lymphomas:
- Diffuse large B-cell lymphoma (DLBCL)
- Follicular lymphoma
- MALT lymphoma / marginal zone lymphoma
- Mantle cell lymphoma
- Burkitt lymphoma
- CLL/SLL is usually classified separately in many teaching schemes but overlaps biologically with indolent lymphoid neoplasia.
T-cell / NK-cell lymphomas:
- Peripheral T-cell lymphoma
- Cutaneous T-cell lymphoma
- Anaplastic large cell lymphoma

⚠️ Risk Factors

Increasing age.
Immunodeficiency, including HIV and post-transplant states.
Autoimmune disease.
Some chronic infections are linked to specific subtypes, for example H. pylori with gastric MALT lymphoma.
Previous chemotherapy/radiotherapy may increase later haematological malignancy risk.

🧑‍⚕️ Clinical Features

Painless persistent lymphadenopathy.
B symptoms: fever, night sweats, weight loss.
Splenomegaly or hepatosplenomegaly.
Extranodal disease: GI, skin, CNS, marrow, testis, breast, kidney, adrenal, etc.
Cytopenias may occur if marrow is involved.
Raised LDH can suggest more proliferative disease.

📊 Staging

Stage	Definition
I	Single lymph node region or single extranodal site
II	2 or more nodal regions on the same side of the diaphragm
III	Nodal disease on both sides of the diaphragm
IV	Disseminated extranodal involvement, such as marrow or other organs
A	No B symptoms
B	B symptoms present

🧪 Investigations

Bloods: FBC, renal function, liver bloods, LDH, urate, and other baseline tests as guided by the clinical picture.
Excision biopsy is generally preferred as the first diagnostic procedure.
If excision biopsy is unsuitable because procedural risk outweighs benefit, needle core biopsy may be considered.
If core biopsy is non-diagnostic, pursue excision biopsy if feasible.
Histology, immunophenotyping, and molecular/cytogenetic testing help define subtype.
CT or FDG-PET-CT may be used for staging depending on subtype and whether results will alter management.
Bone marrow biopsy and lumbar puncture are used in selected cases, not universally.
Offer/consider HIV testing because lymphoma is an HIV indicator condition.

🏃 Performance Status

ECOG performance status helps assess fitness for treatment and prognosis.

💊 Management

Management is subtype-specific and specialist-led.
Treatment options may include watch and wait, radiotherapy, immunochemotherapy, targeted therapy, and stem cell transplantation.
Localised stage IIA follicular lymphoma: local radiotherapy is first-line; selected asymptomatic patients may be observed if radiotherapy is unsuitable.
Symptomatic stage III/IV follicular lymphoma: rituximab-based chemotherapy options are recommended by NICE.
Gastric MALT lymphoma: treat H. pylori if present; eradication therapy is central to management.
Mantle cell lymphoma and DLBCL: treatment depends on fitness, stage, and specialist protocol; transplant may be used in selected patients.
Supportive care includes tumour lysis prevention where relevant, fertility discussion, infection prophylaxis/support, and clear follow-up planning.

🧠 CNS Risk in DLBCL

NICE highlights increased CNS risk with involvement of the testis, breast, adrenal gland, or kidney.
Risk may also be higher with raised LDH, age >60, ECOG ≥2, >1 extranodal site, or stage III/IV disease.

📚 References

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Non Hodgkin Lymphoma ✅