Non-Hodgkin Lymphoma in Children

What are the signs and symptoms of non-Hodgkin lymphoma?

Symptoms depend on the area of the body where cancer is found and how fast the cancer grows. Symptoms may include:

• Painless swelling of the lymph nodes in the neck, underarm, stomach or groin
• Swelling of the head, neck, arms or upper body
• Trouble swallowing
• Shortness of breath or unable to lay down flat
• Persistent cough
• Swelling in the abdomen
• Night sweats
• Unexplained weight loss
• Fatigue
• Unexplained fever

What tests are used to diagnose non-Hodgkin lymphoma?

Your child’s doctor will do a physical exam to check for swollen lymph nodes in the abdomen, neck or under the arm. The doctor will also order tests to diagnose non-Hodgkin lymphoma and to see how widespread the lymphoma is within the body if your child does have non-Hodgkin lymphoma. This process is called tumor staging. Your child may need the following tests:

• Blood tests may be done to look for signs of disease.
• Chest X-rays are used to check for any enlarged lymph nodes.
• A CT scan (or CAT scan) gives doctors even more detailed pictures of the inside of the neck, chest, abdomen and pelvis to look for any other sites of disease.
• An ultrasound uses sound waves to produce pictures of the inside of the body.
• A PET scan is used to look for any areas in the body that are using up sugar faster than usual, indicating that they have increased metabolic activity. One characteristic of lymphoma cells is that they have increased metabolic activity, so PET scans are a sensitive way to find any areas in the body where the lymphoma may be hiding.
• An MRI uses magnets to produce detailed images of the body’s organs and structures.
• A lymph node biopsy is a minor surgical procedure that we do in the operating room while your child is asleep so that they don’t experience any pain. One of our pediatric surgeons will take a sample of tissue from the lymph node during the procedure. Sometimes, your child can go home the same day that the biopsy is done and doesn’t need to stay in the hospital. A pathologist (a doctor who specializes in looking at cells) will look at the tissue under the microscope. Usually, it takes a day or two after the biopsy to gather all the information needed to make a diagnosis. In some cases, it may take longer.
• A bone marrow aspirate and biopsy is an additional test we often do as part of the staging process because the lymphoma cells can also hide in the bone marrow. A small amount (around a teaspoon) of bone marrow is drawn out of the back hipbones through a needle. This procedure is painful, so we almost always do it in the operating room while your child is asleep. We may also do it at the same time as the biopsy of the lymph node if your doctor thinks there is a strong chance that your child has lymphoma.

How do we diagnose non-Hodgkin lymphoma?

Once we make a diagnosis, the next important step is to evaluate the tumor staging. Using all the information we collect from testing, our doctors will assign a stage (I to IV), or group, that describes how far the cancer has spread. Staging is important because it helps doctors to plan the most effective treatment. Most non-Hodgkin lymphomas are higher stages when diagnosed.

• Stage I (one) means that the lymphoma only involves one lymph node area.
• Stage II (two) means that the lymphoma involves more than one lymph node area, but all of the disease is either above or below the diaphragm, which is the thin muscle that helps us to breathe. It is located between the chest and the abdomen.
• Stage III (three) means that the lymphoma involves areas above the diaphragm and below the diaphragm.
• Stage IV (four) means that the lymphoma involves organs outside of the lymph nodes and spleen, such as the bone marrow, bones, liver and lungs.

How is non-Hodgkin lymphoma treated?

Treatment is based on the specific type and stage of non-Hodgkin lymphoma. Once we make a diagnosis and the staging is complete, we will begin to plan treatment, which always involves chemotherapy. Chemotherapy is the use of drugs to kill the rapidly dividing cancer cells or keep them from growing. Radiation is rarely used.

Chemotherapy for non-Hodgkin lymphoma

Most children will require treatment with chemotherapy. Many of the chemotherapy drugs we give require placement of a special type of IV called a central line. A pediatric surgeon places this special IV in the operating room while the patient is asleep so they don’t experience any discomfort. The central line can stay in for the duration of therapy and then we remove it.

Different treatment protocols use different chemotherapy drugs. Once we have decided on your child’s treatment plan, your child’s doctors and nurses will explain what to expect from each of the drugs.

Sometimes doctors will need extra tests, such as heart and lung function tests, before chemotherapy to monitor potential side effects.

Radiation therapy for non-Hodgkin lymphoma

If treatment for your child includes radiation therapy, you will meet with our pediatric radiation oncologist (cancer doctor) early in the treatment course to find out what to expect. In the case of non-Hodgkin lymphoma, we rarely give radiation treatments after chemotherapy treatments are complete. If needed, they are given at the Anschutz Cancer Pavilion, across the street from Children’s Colorado.

Why choose us for treatment of non-Hodgkin lymphoma?

Our Center for Cancer and Blood Disorders has a specialized group of doctors who are national leaders in the treatment of lymphoma. We offer cutting-edge and proven treatment protocols for lymphoma with excellent outcomes. We often have clinical trials available to consider as treatment options. Treatment planning involves a multidisciplinary team, led by a pediatric oncologist. Other specialists who work as part of the team include pediatric surgeons, a pediatric radiation oncologist, pediatric pathologists, pediatric radiologists and pediatric oncology nurses and advance practice providers.

We also have a Wellness Program comprised of social workers, child life specialists, and a child psychologist on the team who provide advice and support to patients and their families who are coping with the stress of cancer.

In the unusual case where lymphoma doesn’t respond to treatment or comes back after treatment, further treatment options are available. In this situation, treatment may involve high-dose chemotherapy with stem cell transplant, which we provide through our bone marrow transplantation program. We sometimes provide treatment through our Experimental Therapeutics Program, which offers new, cutting-edge therapies for diseases that are more difficult to treat.

Our Center participates in the Children’s Oncology Group (COG). The COG is a clinical trials group supported by the National Cancer Institute. The COG is the world’s largest organization devoted exclusively to childhood and adolescent cancer research. The COG brings together more than 8,000 experts in childhood cancer at more than 200 leading children’s hospitals, universities and cancer centers across North America, Australia, New Zealand and Europe.

If a clinical trial through COG is available to treat your child’s non-Hodgkin lymphoma, we will likely ask if you would like your child to participate. If a clinical trial is not available, if we do not feel that study participation is the best option for your child, or if you prefer not to participate, then we will provide you with the best available treatment based on the results of the latest treatment studies.

Read more about our cancer research.

Learn more about Piper's journey

Helpful resources

• The Wellness Program at Children’s Hospital Colorado identifies and addresses all the psychosocial needs of patients and families affected by cancer.
• The Center for Cancer and Blood Disorders provides resources for families to help them cope and adapt to changes in their routines caused by a cancer diagnosis.
• The Children’s Oncology Group supports research to cure all forms of childhood cancers.
• The National Cancer Institute provides in-depth information about non-Hodgkin lymphoma.
• The Leukemia and Lymphoma Society, Rocky Mountain Chapter offers support to patients and families affected by lymphoma and raises funds for research.