Lymphoma: When Lymphocytes Become Malignant
Most people first hear about lymphoma after a lymph node has stayed enlarged longer than expected. The lump is what can be seen or felt, but the disease itself is a problem of lymphocytes. These are white blood cells that normally move through the blood, lymphatic vessels, lymph nodes, spleen and other lymphoid tissues as part of the immune response. B lymphocytes can mature into antibody-producing cells, while T lymphocytes help coordinate immune responses and destroy infected or abnormal cells.
In lymphoma, one of these lymphocytes acquires changes that allow it to survive and multiply beyond the normal limits of the immune system. The abnormal cells form a clone and begin to accumulate. Because lymphocytes naturally circulate through lymphoid tissue, lymphoma can involve more than one lymph-node region and may also affect the spleen, bone marrow or tissues outside the lymphatic system. If the marrow becomes involved, normal blood-cell production can be disturbed, which may contribute to anaemia, thrombocytopenia or altered white-cell counts. Bleepbook's Bone Marrow: Where Blood Cells Are Made article explains the normal marrow physiology behind this.
Hodgkin and non-Hodgkin lymphoma
Lymphoma is divided broadly into Hodgkin lymphoma and non-Hodgkin lymphoma, but both groups contain different diseases with different patterns of growth. Most Hodgkin lymphoma is classical Hodgkin lymphoma. On biopsy, the pathologist looks for characteristic Reed-Sternberg cells, large malignant cells derived from B lymphocytes and usually surrounded by a mixture of non-malignant immune and inflammatory cells. Nodular lymphocyte-predominant Hodgkin lymphoma has different pathology and behaviour and is increasingly classified separately from classical Hodgkin lymphoma.
Non-Hodgkin lymphoma is much more varied. Most forms arise from B cells, although T-cell and natural killer-cell lymphomas also occur. Some grow slowly and may remain stable for long periods, while others progress quickly. Follicular lymphoma is a common indolent B-cell lymphoma and may sometimes be monitored before treatment is needed if the patient is well and the disease is not causing problems. Diffuse large B-cell lymphoma is an aggressive lymphoma that usually requires treatment soon after diagnosis. The label “lymphoma” therefore tells you far less than the final subtype does.
Presentation, diagnosis and staging
Painless lymphadenopathy is a common presentation, particularly in the neck, axilla or groin. Deeper lymph nodes can enlarge without being palpable. A mediastinal mass may cause cough, chest pressure or breathlessness, while abdominal lymphadenopathy can cause discomfort or early satiety. Splenomegaly can occur, and lymphoma outside the lymphatic system may present with symptoms from the organ involved.
The formal B symptoms used in lymphoma staging are otherwise unexplained fever, drenching night sweats and unexplained loss of more than 10% of body weight over six months. Fatigue and pruritus are also seen, but they are not part of the formal B-symptom definition. A small number of patients with Hodgkin lymphoma report pain in affected lymph nodes after alcohol. None of these features is specific to lymphoma, so persistent unexplained lymphadenopathy still needs proper investigation rather than diagnosis from symptoms alone.
Blood tests are useful for showing the effects of disease and for preparing for treatment, but they do not usually confirm lymphoma. A full blood count may show cytopenias if the marrow is involved, although it can also be normal. Renal and liver function, calcium, electrolytes, urate and lactate dehydrogenase may be checked depending on the clinical situation. The diagnosis itself comes from tissue. A lymph-node biopsy allows the pathologist to assess both the cells and the architecture of the node, with immunohistochemistry, cytogenetic testing and molecular studies used to define the subtype more precisely. NICE recommends considering excision biopsy first for suspected non-Hodgkin lymphoma when appropriate, with core biopsy used where surgery is not suitable. Bleepbook's Full Blood Count (FBC): How to Read Hb, White Cells and Platelets article can help with the blood results that often form part of the assessment.
Once the subtype is known, imaging is used to establish the extent of disease. Depending on the lymphoma, this may include computed tomography (CT), fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT), blood tests and sometimes bone-marrow assessment. Many lymphomas are staged using a system derived from Ann Arbor and Lugano criteria. Stage I involves one lymph-node region or one localised site; stage II involves two or more lymph-node regions on the same side of the diaphragm; stage III involves lymph-node regions on both sides of the diaphragm; and stage IV describes more diffuse extranodal involvement such as bone marrow or liver. In Hodgkin lymphoma, A and B are used to indicate whether formal B symptoms are absent or present.
Treatment and nursing care
Treatment depends on the exact lymphoma, its stage, the symptoms it is causing and the patient's general condition. Classical Hodgkin lymphoma is commonly treated with combination systemic anticancer therapy, sometimes with radiotherapy. Many B-cell non-Hodgkin lymphomas are treated with chemotherapy combined with a monoclonal antibody such as rituximab, which targets CD20 on many B-cell lymphomas. Some localised lymphomas can be treated with radiotherapy. Some indolent lymphomas can be monitored without immediate treatment. Relapsed or refractory disease may need different drug combinations, targeted therapies, stem-cell transplantation or, in selected B-cell lymphomas, CAR-T therapy.
Stage IV lymphoma does not carry exactly the same meaning as stage IV solid cancer. Some lymphomas remain highly treatable even when several sites are involved, while some indolent lymphomas can be managed over many years. Prognosis depends on the subtype, stage, biological features, tumour burden, response to treatment, age and general health.
On the ward or in day treatment, nursing assessment often centres on the effects of both the lymphoma and its treatment. Systemic anticancer therapy can suppress bone marrow, so fever or acute illness during treatment must be taken seriously because neutropenic sepsis is a medical emergency. Local oncology pathways should be followed. Bleepbook's Neutropenic Sepsis: Building Marianne’s Nursing Care Plan looks at that complication in more detail.
Fast-growing lymphomas with a high tumour burden can also put the patient at risk of tumour lysis syndrome. Rapid breakdown of malignant cells releases intracellular contents into the bloodstream. Potassium and phosphate may rise, calcium may fall and uric acid can increase, with a risk of acute kidney injury, cardiac arrhythmias and neurological complications. Patients at risk are identified and managed by the specialist team, but nursing care contributes through observations, fluid balance, blood sampling, medicines and early recognition of deterioration.
Other problems vary with the treatment being given. Cytopenias can contribute to infection, bleeding and fatigue. Monoclonal antibodies can cause infusion reactions. Chemotherapy can cause nausea, mucositis and poor oral intake. Central venous access devices bring infection and thrombosis risks. Lymphoma itself can also cause urgent problems if a mass compresses nearby structures. New facial or neck swelling with breathlessness, stridor or prominent chest veins needs urgent assessment, and new weakness or sensory change should also be escalated promptly.
References
National Institute for Health and Care Excellence (NICE) (2016) Non-Hodgkin lymphoma: diagnosis and management (NG52). Available at: NICE.
National Institute for Health and Care Excellence (NICE) (2015, updated 2026) Suspected cancer: recognition and referral (NG12). Available at: NICE.
NHS. Hodgkin lymphoma. Available at: NHS.
NHS. Non-Hodgkin lymphoma. Available at: NHS.
Lymphoma Action. Classical Hodgkin lymphoma. Available at: Lymphoma Action.
Cancer Research UK. Lymphoma. Available at: Cancer Research UK.