What is non-Hodgkin lymphoma (NHL) in children?

NHL is a type of cancer in the lymphatic system. The lymphatic system is part of the immune system. It helps to fight diseases and infections. The lymphatic system also helps with balancing fluids in different parts of the body. The lymphatic system includes:

• Lymph. This is a fluid that contains lymphocyte cells.
• Lymph vessels. These are tiny tubes that carry lymph fluid throughout the body.
• Lymphocytes. These are a type of white blood cells that fight infections and disease. NHL starts when these cells grow out of control.
• Lymph nodes. These are small bean-shaped organs that contain lymphocytes. They are in the underarm, groin, neck, chest, belly (abdomen), and other parts of the body. They filter the lymph fluid as it moves around the body.
• Other organs and body tissues. The lymphatic system includes the bone marrow where blood is made. And it includes the spleen, thymus, tonsils, and parts of the digestive tract.

NHL causes abnormal growth of the cells in the lymphatic system. Over time this causes tumors to grow. The cells can also spread to other organs and tissues in the body (metastasis).  NHL is a rare disease in children.  It can occur at any age, and affects boys more often than girls. 

There are different types of NHL in children. But most tend to grow quickly. Your care team may order different tests based on what type of lymphoma is found. Treatment options are based on the specific type of lymphoma as well.

What causes non-Hodgkin lymphoma in a child?

Researchers don't know the exact cause of NHL. Genes and some viral infections may increase a child’s risk of having NHL. Conditions that are linked to NHL include:                                                     

• Epstein-Barr virus, the virus that causes mono (mononucleosis)
• HIV, the virus that causes AIDS
• Having a second cancer because of chemotherapy and radiation therapy
• Certain hereditary immune system conditions
• Taking anti-rejection medicines after organ transplant

What are the symptoms of non-Hodgkin lymphoma in a child?

In many cases, NHL in children may not cause symptoms until it has grown or spread. Many children have advanced disease at the time of diagnosis. This is because the symptoms start suddenly, and the tumors tend to grow fast. A child can become very sick in a few days to a few weeks.

Signs and symptoms vary depending on the type of NHL.

Symptoms of a belly (abdominal) tumor can include:

• Abdominal pain
• Nausea and vomiting
• Fever
• Trouble with bowel movements (constipation)
• Poor appetite

Symptoms of a chest tumor include:

• Trouble breathing
• Pain with deep breaths
• Cough or wheezing
• Swelling and a blue color of the skin on the head and arms 

Other symptoms may include:

• Painless swelling of the lymph nodes in neck, chest, abdomen, underarm, or groin
• Fever
• Sore throat
• Bone and joint pain
• Night sweats
• Tiring easily (fatigue)
• Weight loss
• Poor appetite
• Itching of the skin
• Recurring infections

The symptoms of NHL can be like other health conditions. Make sure your child sees a healthcare provider for a diagnosis.

How is non-Hodgkin lymphoma diagnosed in a child?

Your child's healthcare provider will ask about your child's health history and symptoms. He or she will examine your child.  Your child may have tests such as:

• Blood and urine tests. Blood and urine are tested in a lab.
• Lymph node biopsy. A sample of tissue is taken from the lymph nodes (or other abnormal areas). This is often done during surgery. The sample is checked with a microscope for cancer cells. Other tests may done on it as well. This type of biopsy is needed to diagnose NHL.
• Chest X-ray. The chest X-ray shows the heart, lungs, and other parts of the chest. This test may be done to see if NHL has spread to lymph nodes in the chest. 
• CT scan. This may be done to look at the abdomen, chest, and pelvis. A CT scan uses a series of X-rays and a computer to make detailed pictures of the body.
• MRI scan. An MRI uses large magnets, radio waves, and a computer to make detailed pictures of the body. This test can be used to check the brain and spinal cord. Or it may be used if the results of an X-ray or CT scan are unclear. 
• Ultrasound. This is also called sonography. Sound waves and a computer are used to make pictures of blood vessels, tissues, and organs.
• PET scan. For this test, a radioactive sugar is injected into the bloodstream. Cancer cells use more sugar than normal cells, so the sugar will collect in cancer cells. A special camera is used to see where the radioactive sugar is in the body. A PET scan can sometimes spot cancer cells in different parts of the body, even when they can’t be seen by other tests. This test is often used together with a CT scan. This is called a PET/CT scan.
• Bone marrow aspiration or biopsy. Bone marrow is found in the center of some bones. It’s where blood cells are made. A small amount of bone marrow fluid may be taken. This is called aspiration. Or solid bone marrow tissue may be taken. This is called a core biopsy. Bone marrow is usually taken from the hip bones. This test may be done to see if cancer cells have reached the bone marrow.
• Lumbar puncture. A special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. This is done to check the brain and spinal cord for cancer cells. A small amount of cerebral spinal fluid (CSF) is removed and sent for testing. CSF is the fluid around the brain and spinal cord.
• Pleural or peritoneal fluid sampling. Fluid is removed from around the lungs (pleura) or abdomen (peritoneum). The fluid is checked for cancer cells.                                                   

Staging

Part of diagnosing cancer is called staging. Staging is the process of seeing if the cancer has spread, and where it has spread. Staging also helps to decide the treatment. There are different ways of staging used for NHL. Talk with your child's healthcare provider about the stage of your child's cancer. One method of staging NHL in children is the following:

• Stage I. The lymphoma is in only 1 place. It’s either in a lymph node or one other part of the body. It did not start in the chest or abdomen. 
• Stage II. The lymphoma is in 2 or more places. It’s all in either the upper or lower part of the body. Or it started in the digestive tract and can be removed by surgery. It’s not in the chest. 
• Stage III. The lymphoma is in the chest or next to the spine, or it has spread throughout the abdomen. Or it is both in the upper and lower parts of the body (above and below the diaphragm), but is not in bone marrow or the brain or spinal cord (central nervous system).
• Stage IV. The lymphoma is in the bone marrow, the brain and spinal cord, or all three when it is first found.

How is non-Hodgkin lymphoma treated in a child?

Treatment will depend on the type and stage. NHL can be treated with any of the below:

• Chemotherapy. These are medicines that kill cancer cells or stop them from growing. They may be given by IV (intravenous) into the vein, injected into tissue, or taken by mouth. 
• Radiation therapy. These are high-energy X-rays or other types of radiation. They are used to kill cancer cells or stop them from growing.
• Surgery. Surgery may be done to remove tumors.
• Monoclonal antibodies. This is a type of targeted therapy that kills cancer cells without harming healthy cells.
• High-dose chemotherapy with a stem cell transplant. Young blood cells (stem cells) are taken from the child or from someone else. The child is then given a large amount of chemotherapy medicine. This causes damage to the bone marrow. After the chemotherapy, the stem cells are replaced.
• Antibiotic medicines. These help to prevent or treat infections.
• Supportive care. Treatment can cause side effects. Medicines and other treatments can be used for pain, fever, infection, and nausea and vomiting
• Clinical trials. Ask your child's healthcare provider if there are any treatments being tested that may work well for your child. 

Your child will need follow-up care during and after treatment to:

• Check on your child's response to the treatment
• Manage the side effects of treatment
• Look for returning or spreading cancer

With treatment, most children with NHL go on to live long lives. With any cancer, how well a child is expected to recover (prognosis) varies. Keep in mind:           

• Getting medical treatment right away is important for the best prognosis. 
• Ongoing follow-up care during and after treatment is needed.
• New treatments are being tested to improve outcome and to lessen side effects.

What are the possible complications of non-Hodgkin lymphoma in a child?

Possible complications depend on the type and stage of the lymphoma, and can include:

• Increased risk of infection
• Heart disease
• Lung problems
• Increased chance of other cancers
• Trouble having children (infertility)
• Death

Treatment may also cause complications. They can include:

• Increased risk of bleeding
• Increased risk for infection
• Nausea and vomiting
• Diarrhea
• Poor appetite
• Sores in the mouth
• Hair loss

How can I help my child live with non-Hodgkin lymphoma?

You can help your child manage his or her treatment in many ways. For example:

• Get emotional support for your child. Find a counselor or child support group that can help.
• Make sure your child goes to all follow-up appointments.
• Your child may have trouble eating. A dietitian may be able to help.
• Your child may be very tired. He or she will need to balance rest and activity. Encourage your child to get some exercise. This is good for overall health. And it may help to lessen tiredness.
• If your child smokes, help him or her quit. If your child doesn’t smoke, make sure he or she knows the danger of smoking. 

When should I call my child’s healthcare provider?

Call the healthcare provider if your child has:

• Symptoms that get worse
• New symptoms
• Side effects from treatment

Key points about non-Hodgkin lymphoma in children

• NHL is a type of cancer in the lymphatic system. 
• Symptoms depend on what part of the body is affected. There may be symptoms from tumors in the belly (abdomen) or chest. Other symptoms include painless swelling of lymph nodes, trouble breathing, night sweats, fever, and feeling tired.
• A lymph node biopsy is needed to diagnose NHL. Many other tests are also done.
• Treatment may include medicines, radiation, stem cell transplants, and surgery.

Next steps

• Know the reason for the visit and what you want to happen.
• Before your visit, write down questions you want answered.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.
• Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.
• Ask if your child’s condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if your child does not take the medicine or have the test or procedure.
• If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.