B-cell lymphoma: symptoms, types, treatment and outlook

Lymphoma is a cancer of the lymphatic system, which is part of the immune system. Cancer Research UK explains that you develop lymphoma when white blood cells called lymphocytes divide abnormally and grow out of control. There are two types of lymphocyte, T cells and B cells. B-cell lymphoma is lymphoma in which the abnormal cells are B lymphocytes.

There are two main groups of lymphoma, Hodgkin lymphoma and non-Hodgkin lymphoma (NHL). Cancer Research UK says they are two different diseases with different treatment, and that doctors tell them apart because NHL does not contain Reed-Sternberg cells. B-cell lymphomas belong to NHL, which has more than 60 different types that can behave in very different ways, so your specialist will tell you which type you have.

Diffuse large B cell lymphoma (DLBCL) is the best-known B-cell lymphoma. Cancer Research UK says it is a common type of fast-growing (high grade) NHL, with about 5,000 people diagnosed each year in the UK and more than 40 in 100 adult cases of NHL.

The NHS says the main symptoms of non-Hodgkin lymphoma, which includes B-cell lymphoma, are listed here. Some of these symptoms are common and can be caused by many other conditions, so having them does not mean you have lymphoma, but the NHS says it is important to get them checked by a GP.

• A painless lump or swelling, usually in the neck, armpit or the top of the inner thigh (groin). The NHS says this is the most common symptom.

• A high temperature, or feeling hot, cold or shivery.

• Night sweats.

• Shortness of breath.

• Itchy skin.

• Sudden unexplained weight loss.

Cancer Research UK describes a group of general symptoms called B symptoms: heavy sweating at night, temperatures that come and go for no obvious reason, and losing a lot of weight (more than one tenth of your total weight over 6 months) without knowing why. Doctors assess these to stage the lymphoma and plan treatment, though many people with NHL do not have them.

Because lymphoma can develop outside the lymph nodes, symptoms depend on where it grows. Cancer Research UK gives examples: lymphoma in the tummy or bowel might cause pain, diarrhoea or bleeding, and lymphoma in the chest might cause breathlessness or a cough. When lymphoma cells are in the bone marrow, low blood counts can cause tiredness (anaemia), infections or bleeding problems. For DLBCL, Cancer Research UK says symptoms can start or get worse in just a few weeks.

Cancer Research UK points out that lymph nodes can get bigger with a throat infection and that most people with these symptoms will not have a lymphoma, but you should see your GP about them. It specifically advises seeing your GP about a swollen lymph node that does not go away after 3 to 4 weeks.

The NHS says the GP will ask about your symptoms, may feel for lumps in the neck, armpit and groin, and may arrange a blood test. If they think you have symptoms that could be cancer, you may get an urgent referral for more tests or to see a specialist in hospital. The NHS stresses this does not definitely mean you have cancer.

The NHS says it is not known what causes non-Hodgkin lymphoma, but anyone can get it and some things may increase the chance. These are listed below. Cancer Research UK adds that NHL is more common in older people: almost 40% of people diagnosed are aged 75 and over.

• Being over 50.

• Certain infections, including Epstein-Barr virus (which causes glandular fever) and hepatitis C.

• A weakened immune system, from a condition such as HIV or from treatment that weakens the immune system.

• An autoimmune condition, such as coeliac disease or psoriasis.

• A close relative (parent, brother or sister) who has had non-Hodgkin lymphoma.

The NHS says the main test is a biopsy, where a sample of the affected lymph node is taken and checked for signs of cancer. You may have part or all of a lymph node removed (excision biopsy) or a sample of cells taken with a thin needle (needle biopsy), usually under local or general anaesthetic. You should get the results within 2 weeks, and the NHS says you can call the hospital or GP if they are taking longer.

If lymphoma is found, you may need more tests to show how far it has spread (staging) and what type it is. The NHS lists blood tests, scans such as PET, CT, MRI or ultrasound, and a bone marrow biopsy. Cancer Research UK adds that, for DLBCL, a lumbar puncture may be used to check for lymphoma cells in the fluid around the brain and spinal cord.

The type, grade and stage help your team decide on treatment. Cancer Research UK explains there are 4 main stages (stage 1 to stage 4): early stage usually means stage 1 or 2, and advanced stage means stage 3 or 4. It also describes an International Prognostic Index, a score based on age, how lymphoma affects well-being, a blood enzyme called LDH, whether lymphoma is outside the lymph nodes and the stage.

Doctors group NHL into two grades according to how the cells look under a microscope: high grade (fast growing) and low grade (slow growing). The NHS says the difference shapes the approach to treatment.

The NHS lists the main treatments for non-Hodgkin lymphoma as chemotherapy, targeted medicines and immunotherapy, radiotherapy, stem cell transplant and, for slow-growing disease, watch and wait. Your specialist team explains the benefits and side effects and builds a plan around you. Some treatment can affect fertility, so the NHS advises speaking to your team beforehand if you want children in the future.

For DLBCL, Cancer Research UK says treatment usually starts soon after diagnosis and includes chemotherapy together with a targeted drug called rituximab (chemoimmunotherapy), with the aim of cure for most people. It is usually given in 3-week cycles, normally as an outpatient. R-CHOP is one of the main combinations, containing rituximab, cyclophosphamide, doxorubicin, vincristine and the steroid prednisolone.

Cancer Research UK says that if there is no sign of lymphoma after treatment this is called remission, and that sometimes it can come back (relapse). Your specialist may then suggest further treatment, including a stem cell transplant, CAR-T cell therapy, or targeted drugs on their own or with chemotherapy. For people at higher risk of spread to the brain and spinal cord, preventive chemotherapy such as high-dose methotrexate may be discussed.

The NHS says that if lymphoma is advanced and cannot be cured, the aim of treatment is to slow its growth, help symptoms and help you live longer, and you will be referred to a palliative care or symptom control team who can also support your loved ones.

The NHS says you will be helped through diagnosis and treatment by a team of specialists, usually including a clinical nurse specialist who is your main point of contact and can answer questions. Macmillan Cancer Support, Cancer Research UK and Blood Cancer UK are named by the NHS as sources of information and support.

On the NHS, the pathway usually starts with a GP, who may make an urgent suspected cancer referral. A haematologist (blood specialist), as Cancer Research UK explains, usually leads diagnosis and treatment, supported by a multidisciplinary team. Some people use private care for earlier scans or a second opinion. The biopsy, staging and treatment principles are the same, and treatment decisions are normally made by the specialist team looking after you.