Non-Hodgkin's Lymphoma

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	References
	Credits

What is non-Hodgkin's lymphoma?

Non-Hodgkin's lymphoma (NHL) is cancer of the cells of the lymphatic system. In non-Hodgkin's lymphoma, cells in the lymphatic system either divide and grow without order or control, or old cells do not die as cells normally do. Non-Hodgkin's lymphoma can start almost anywhere in the body. It may occur in a single lymph node, a group of lymph nodes, or an organ such as the spleen. Non-Hodgkin's lymphoma can spread to almost any part of the body, including the liver, bone marrow, and spleen.

Over time, lymphoma cells may replace the normal cells in the bone marrow. Bone marrow failure results in the inability to produce red blood cells that carry oxygen, white blood cells that fight infection, and platelets that stop bleeding.

Non-Hodgkin's lymphoma is different from Hodgkin's lymphoma and occurs about 8 times more often.

Are there different types of non-Hodgkin's lymphoma?

There are many different types of non-Hodgkin's lymphoma. Over the years, experts have used a variety of terms to classify these different types. Most often, they are grouped by how the cancer cells look under a microscope and how quickly they are likely to grow and spread. Aggressive lymphomas, also known as intermediate- and high-grade lymphomas, tend to grow and spread quickly and cause severe symptoms. Nonaggressive lymphomas, also called indolent or low-grade lymphomas, tend to grow quite slowly and cause fewer symptoms early in the disease course.

In an effort to increase the understanding of lymphoma and standardize treatment, experts in Europe and North America have revised the classification of lymphoma (Revised European-American Lymphoma Classification [REAL], published by the World Health Organization [WHO]).

What causes non-Hodgkin's lymphoma?

The cause of non-Hodgkin's lymphoma is not known. The incidence of NHL has continued to increase over the years. When a person has non-Hodgkin's lymphoma, abnormal rapid cell growth occurs. This abnormal growth may be triggered by an infection or exposure to something in the environment. Non-Hodgkin's lymphoma is not contagious.

• Non-Hodgkin's lymphoma is more common in men than in women.
• The likelihood of getting non-Hodgkin's lymphoma increases as you get older.
• Non-Hodgkin's lymphoma is most common among those who have an inherited immune deficiency, an autoimmune disease, or HIV. It also occurs among those who take medicines that impair the immune system following an organ transplant.
• Viral infections, such as with human T-lymphotropic virus type I (HTLV-1), hepatitis C, and Epstein-Barr virus, increases the risk of developing non-Hodgkin's lymphoma.
• Exposure to pesticides, solvents, or fertilizers increases the risk of developing non-Hodgkin's lymphoma.

What are the symptoms?

The most common symptom of non-Hodgkin's lymphoma is a painless swelling of the lymph nodes in the neck, underarm, or groin. Other symptoms may include:

• Unexplained fever.
• Night sweats.
• Extreme fatigue.
• Unexplained weight loss.
• Itchy skin.
• Reddened patches on the skin.
• Cough or shortness of breath.
• Pain in the abdomen or back.

How is non-Hodgkin's lymphoma diagnosed?

When non-Hodgkin's lymphoma is suspected, a piece of tissue (biopsy) is needed to confirm the diagnosis. This can sometimes be done by inserting a needle into a lymph node, but usually the entire lymph node must be removed. The piece of tissue is then analyzed under a microscope by a pathologist to see whether NHL is present.

How is it treated?

Treatment of non-Hodgkin's lymphoma depends on the type of lymphoma, the stage of the disease, and your age and general health. The treatment options are:

• Watchful waiting (surveillance).
• Radiation therapy.
• Chemotherapy.
• Monoclonal antibody therapy.
• Stem cell transplant plus chemotherapy.

Not all of these options are appropriate for all types of non-Hodgkin's lymphoma.

Frequently Asked Questions

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The cause of non-Hodgkin's lymphoma (NHL) is unknown. The incidence of NHL has continued to increase over the years. When a person has non-Hodgkin's lymphoma, abnormal rapid cell growth occurs. This abnormal growth may need a "trigger" to start, such as an infection or exposure to something in your environment. NHL is not contagious and is not caused by injury.¹

Symptoms of non-Hodgkin's lymphoma (NHL) depend on the area of the body affected by the disease. The most common symptom is a painless swelling of the lymph nodes in the neck, underarm, or groin. Other symptoms may include:

• Unexplained fever.
• Night sweats.
• Extreme fatigue.
• Unexplained weight loss.
• Itchy skin.
• Reddened patches on the skin.
• Cough or shortness of breath.
• Pain in the abdomen or back.

In non-Hodgkin's lymphoma (NHL), either abnormal cells in the lymphatic system divide and grow without order or control or old cells do not die normally. Lymphatic tissue is present in many areas of the body, so non-Hodgkin's lymphoma can start almost anywhere in the body.

Non-Hodgkin's lymphoma may occur in a single lymph node, a group of lymph nodes, or an organ. And it can spread to almost any part of the body, including the liver, bone marrow, and spleen. Doctors classify NHL into stages based on where the lymphoma is growing in the body.

Over time, lymphoma cells may replace the normal cells in the bone marrow. Bone marrow failure results in the inability to produce red blood cells that carry oxygen, white blood cells that fight infection, and platelets that stop bleeding.

Long-term survival depends on the type of non-Hodgkin's lymphoma and the stage of the disease when it is diagnosed. Approximately 81 out of 100 people diagnosed with non-Hodgkin's lymphoma are alive 1 year after the disease is diagnosed. That number drops to about 63 out of 100 at 5 years and 49 out of 100 at 10 years.²

No one knows exactly what increases your risk of getting non-Hodgkin's lymphoma (NHL). Experts do agree that the disease is not caused by injury and is not contagious. The following risk factors may increase your chances of having the disease. But most people with these risk factors do not ever have non-Hodgkin's lymphoma, and many people who have non-Hodgkin's lymphoma do not have any of these risk factors.¹

• Being male. NHL is more common in men than in women.
• Age. The likelihood of getting NHL increases as you get older.
• Impaired immune system. NHL is most common among those who have an impaired immune system, an autoimmune disease, or HIV or AIDS. It also occurs among those who take immunosuppressant medicines, such as medicines following an organ transplant.
• Viral infection. A viral infection, such as Epstein-Barr virus, increases the risk of developing NHL.
• Bacterial infection. Infection with Helicobacter pylori increases the risk of lymphoma involving the stomach.
• Environmental exposure. Exposure to agricultural pesticides or fertilizers, solvents and other chemicals, rubber processing, asbestos, and arsenic increases the risk of developing NHL.

Call your doctor to schedule an appointment if you have had any symptoms for longer than 2 weeks, such as:

• Painless swelling in the lymph nodes in the neck, underarm, or groin.
• Unexplained fever.
• Drenching night sweats.
• Extreme fatigue.
• Unexplained weight loss in the past 6 months.
• Itchy skin.
• Cough or shortness of breath.
• Pain in the abdomen or back.

Watchful Waiting

Watchful waiting (surveillance) is a period after the diagnosis of some types of non-Hodgkin's lymphoma (NHL) when little or no treatment is used. Watchful waiting is not appropriate for aggressive or high-grade lymphoma. Watchful waiting does not mean that your doctor is giving up or refusing to give you treatment. During this time you will:

• Have regularly scheduled appointments with your doctor.
• Receive periodic medical tests, including scans and blood tests.
• Be told which symptoms to report to your doctor immediately.

Watchful waiting is often as effective as immediate aggressive treatment for some types of NHL. People with advanced low-grade, indolent lymphomas often live a long time without symptoms.^{3, 4}

Watchful waiting ends when one of the following occurs:

• Symptoms develop.
• Lymphoma tumor size is larger than 2 in. (5.1 cm) and growing.
• Organs do not function normally.

Who To See

Doctors who can help diagnose non-Hodgkin's lymphoma (NHL) include:

• Family medicine doctor.
• Internist.
• Surgeon.
• Nurse practitioner.

When NHL is suspected, a tissue sample (biopsy) is needed to make a diagnosis. A biopsy for non-Hodgkin's lymphoma is usually taken from a lymph node, but other tissues may be sampled as well. A surgeon will remove a sample of tissue so that a pathologist can examine it under a microscope to check for cancer cells.

Non-Hodgkin's lymphoma is usually treated by a medical oncologist or a hematologist. If you require radiation therapy, you will also see a radiation oncologist.

To prepare for your appointment, see the topic Making the Most of Your Appointment

If non-Hodgkin's lymphoma (NHL) is suspected, your doctor will ask about your medical history and perform a physical examination. This exam includes checking for enlarged lymph nodes in your neck, underarm, and groin.

A tissue sample (biopsy) is needed to make a diagnosis. A biopsy for non-Hodgkin's lymphoma is usually taken from a lymph node, but other tissues may be sampled as well.

A bone marrow aspiration and biopsy will be done to find out if lymphoma cells are present in the bone marrow.

Your doctor may also order other tests, including:

• Blood tests, such as a chemistry screen to measure the levels of several substances in the blood and a CBC (complete blood count) to provide information about the kinds and numbers of cells in the blood.
• A chest X-ray to provide a picture of organs and structures within the chest, including the heart and lungs, the blood vessels of the chest, and the thin sheet of muscle (diaphragm) that separates the chest cavity from the abdominal cavity.
• A CT scan (computed tomography) or MRI (magnetic resonance imaging) to provide detailed pictures of the organs and structures in the chest, abdomen, and pelvis.
• PET scan (positron emission tomography) to show areas of increased metabolic activity. Metabolic activity refers to all of the chemical processes that take place in the body, such as using sugars for energy. Metabolic activity is generally high in cancer cells.
• Flow cytometry which checks the types of cells in a biopsy sample. This test helps your doctor find out the type of lymphoma.
• Lumbar puncture (also called a spinal tap) to find out whether lymphoma cells are in the fluid (cerebrospinal fluid, or CSF) surrounding your brain and spinal cord.
• Multigated acquisition (MUGA) scan which is a type of cardiac blood pool scan. A cardiac blood pool scan shows how well your heart is pumping blood to the rest of your body. A MUGA scan can show whether your heart is strong enough to tolerate certain types of chemotherapy, like doxorubicin.

Early Detection

At this time, there are no special tests recommended for early detection of non-Hodgkin's lymphoma. The best strategy for early diagnosis is to see your doctor if you develop signs or symptoms of NHL.

Different types of treatment are used for different types of non-Hodgkin's lymphoma (NHL). Treatment of NHL depends on:

• The stage of the disease.
• The type of lymphoma. The kind of treatment you have will depend on whether you have B-cell or T-cell lymphoma and whether it is fast-growing or slow-growing.
• The size of the tumor and whether it is greater than 10 cm (3.9 in.). It also matters where the lymphoma is located and what organs are involved.
• Your general health.
• Whether you have had lymphoma in the past (recurrent disease). Although lymphoma that has come back (recurred) may be controlled, it often is not curable.

Initial treatment

Treatment recommendations that may be appropriate when you are first diagnosed with non-Hodgkin's lymphoma include:

• Watchful waiting (surveillance), a period of time after the diagnosis of some types of NHL when little or no other treatment is used. Watchful waiting gives as good or better results than more aggressive treatment for some types of NHL. Your doctor may discuss watchful waiting with you if you have an advanced, low-grade (indolent) lymphoma.^{3, 4} Watchful waiting is not appropriate for aggressive lymphoma or less aggressive lymphoma that has gotten larger or is causing symptoms.
• Radiation therapy, which is often the treatment of choice for early-stage, indolent NHL. Radiation therapy may be used alone or combined with other treatment options for more advanced NHL.
• Medicines, such as chemotherapy or monoclonal antibody therapy, which often cure NHL. Even when cure is not possible, treatment with medicines may allow you to live a long time without symptoms.

If you have recently been diagnosed with non-Hodgkin's lymphoma, you may experience a wide variety of emotions. Most people experience some denial, anger, and grief. Other people may have fewer emotions. There is no "normal" or "right" way to react to a diagnosis of lymphoma. There are many steps you can take to help with your emotional reactions. You may find that talking with family and friends helps you with your emotions. Some people may find that spending time alone is what they need.

If your reaction is interfering with your ability to make decisions about your health, it is important to talk with your doctor. Your cancer treatment center may offer psychological or financial services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other people who may have had similar feelings can be very helpful.

You may use home treatment to help you manage the side effects that may happen with NHL or its treatment.

Ongoing treatment

Schedule regular follow-up examinations with your doctor after you have been treated for non-Hodgkin's lymphoma. Follow-up care is an important part of the overall treatment plan. During regular follow-up care:

• You will probably be seen every 3 to 4 months for the first 2 years and then every 6 months until it has been 5 years since your diagnosis. After that, you will only need annual checkups if you have had no relapse.
• Changes in health can be discussed with your doctor. To monitor your health, your doctor may obtain lab tests, such as a chemistry screen and CBC, and imaging tests, such as a chest X-ray or CT scan.

Report to your doctor any problems you have, as soon as they appear. If you are having a problem, you may need to make some new appointments.

Treatment if the condition gets worse

You may be offered the following treatment options if your disease progresses:

• Radiation therapy may be used alone or in combination with other treatments if non-Hodgkin's lymphoma (NHL) recurs. Targeted radiation therapy uses monoclonal antibodies to deliver radiation directly to lymphoma cells.
• Chemotherapy often effectively treats recurrent NHL. Sometimes a person may take one type of chemotherapy for several cycles and later be switched to different medicines if the first medicines are no longer working.
• Stem cell transplant (bone marrow transplant) is often used to treat recurrent lymphoma. Stem cell transplant may be offered as part of standard treatment or in a clinical trial. Talk with your doctor to see if a clinical trial may be available for your type of recurrent disease.
• Biological therapy may be used to treat recurrent lymphoma.

What to think about

Survival rates have improved as a result of clinical trials. Clinical trials provide evidence about new medicines and treatments that may help people who have non-Hodgkin's lymphoma live longer and have a better quality of life. If you are interested in taking part in a clinical trial, check with your doctor to see if there are any clinical trials available in your area.

Your doctor may use the term "remission" instead of "cure" when talking about the effectiveness of your treatment. Although many people with non-Hodgkin's lymphoma are successfully treated, the term remission is used because cancer can return. It is important to discuss the possibility of recurrence with your doctor.

Even after effective treatment for NHL, you may be at slightly higher risk for other types of cancer, especially melanoma, lung, brain, kidney, and bladder cancers. Be watchful for any symptoms of cancer.

For more information about specific treatments, see the following topics:

• Non-Hodgkin's lymphoma – Health Professional Information [NCI PDQ]
• Non-Hodgkin's lymphoma - Patient Information [NCI PDQ]

There is no known way to prevent non-Hodgkin's lymphoma (NHL). Most people with NHL do not have known risk factors.

During treatment for any stage of non-Hodgkin's lymphoma (NHL), you can use home treatment to help manage the side effects that may accompany NHL or its treatment. Home treatment may be all that is needed to manage the following common problems. If your doctor has given you instructions or medicines to treat these symptoms, be sure to follow them. In general, healthy habits such as eating a balanced diet and getting enough sleep and exercise may help control your symptoms.

• Home treatment for nausea or vomiting includes watching for and treating early signs of dehydration, such as a dry mouth, sticky saliva, and reduced urine output with dark yellow urine. Your doctor also may prescribe medicines to control nausea and vomiting. For more information on how to deal with these side effects, see:

  Cancer: Controlling nausea and vomiting from chemotherapy.

• Home treatment for diarrhea includes resting your stomach and being alert for signs of dehydration. Check with your doctor before using any nonprescription medicines for your diarrhea.
• Home treatment for constipation includes gentle exercise along with adequate intake of fluids and a diet that is high in fruits, vegetables, and fiber. Check with your doctor before using a laxative for your constipation.
• Home treatment for fatigue includes making sure you get extra rest while you are receiving chemotherapy or radiation therapy. Let your symptoms be your guide. You may be able to stick to your usual routine and just get some extra sleep. Fatigue is often worse at the end of treatment or just after treatment is completed.
• Home treatment for a sore mouth includes changing your diet, rinsing your mouth with liquid medicines, and putting a baking soda paste or nonprescription medicine on mouth sores.

Other issues that may arise include:

• Hair loss. This can be emotionally distressing. Not all chemotherapy medicines cause hair loss, and some people have only mild thinning that is noticeable only to them. Talk to your doctor about whether hair loss is an expected side effect with the medicines you will take.
• Sleep problems. If you find you have trouble sleeping, having a regular bedtime, getting some exercise during the day, avoiding naps, and using other tips to relieve sleep problems may help you sleep more easily.

Many people with lymphoma face emotional issues because of their disease or its treatment.

• The diagnosis of any type of cancer and the need for treatment can be very stressful. You may be able to reduce your stress by expressing your feelings to others. Learning relaxation techniques may also help you reduce your stress.
• Your feelings about your body may change following a diagnosis of cancer and the need for treatment. Adapting to your body image changes may involve talking openly about your concerns with your partner and discussing your feelings with your doctor. Your doctor may also be able to refer you to organizations that can offer additional support and information.
• To prevent weight loss and conserve your strength, it is important to eat well during treatment for cancer.

Not all forms of cancer or cancer treatment cause pain. If pain occurs, many treatments are available to relieve it. If your doctor has given you instructions or medicines to treat pain, be sure to follow them. You may use home treatment for pain to improve your physical and mental well-being. Be sure to discuss any home treatment you use for pain with your doctor.

Your doctor may prescribe medicines that will affect the growth of non-Hodgkin's lymphoma and relieve your symptoms. Treatment depends on:

• The stage of the disease.
• The type of lymphoma. The kind of treatment you have will depend on whether you have B-cell or T-cell lymphoma and whether it is fast-growing or slow-growing.
• The size of the tumor and whether it is greater than 10 cm (3.9 in.). It also matters where the lymphoma is located and what organs are involved.
• Your general health.
• Whether you have had lymphoma in the past (recurrent disease). While lymphoma that has come back (recurred) may be controlled, it often is not curable.

For more information about medication treatments, see the following topics:

• Non-Hodgkin's lymphoma – Health Professional Information [NCI PDQ]
• Non-Hodgkin's lymphoma - Patient Information [NCI PDQ]

Medication Choices

Chemotherapy often cures aggressive forms of non-Hodgkin's lymphoma. Even when cure is not possible, such as with indolent lymphoma, chemotherapy may allow you to live a long time without symptoms. A combination of chemotherapy medicines is generally more effective than a single drug. The most commonly used combination is called CHOP, which combines cyclophosphamide, doxorubicin, vincristine, and prednisone.

Your doctor may recommend that you try treatment with a medicine known as a monoclonal antibody (such as rituximab). This medicine is used with CHOP for B-cell lymphomas and helps you live a long time without symptoms.⁵

Other medicine combinations include:

• Chlorambucil or fludarabine.
• Cyclophosphamide, vincristine, and prednisone (CVP).
• Cyclophosphamide, vincristine, procarbazine, and prednisone (COPP).
• Fludarabine, mitoxantrone, and dexamethasone (FND).
• Gemcitabine, dexamethasone, cisplatin (GDP).

What To Think About

Depending on the type and the stage of the lymphoma, chemotherapy may be used alone or in combination with radiation therapy.

Sometimes a person may take one chemotherapy combination for several cycles and later switch to a different one if the first treatment combination does not seem to be working.

Chemotherapy causes many side effects. These side effects are usually temporary and go away when treatment is stopped. Your doctor may prescribe medicines to control nausea and vomiting from chemotherapy. Older adults may find side effects more difficult to tolerate. Side effects may also cause more problems if you have other diseases, such as diabetes, chronic lung disease, or coronary artery disease. You may not be able to become pregnant or father a child after chemotherapy treatment. Discuss fertility issues with your doctor before starting treatment. Chemotherapy medicines can also cause birth defects. If you are pregnant or wish to father a child, discuss the risk of birth defects with your doctor before using any chemotherapy medicine.

Survival rates have improved as a result of clinical trials. Clinical trials provide evidence about new medicines and treatments that may help people who have non-Hodgkin's lymphoma live longer and have a better quality of life. If you are interested in taking part in a clinical trial, check with your doctor to see if there are any clinical trials available in your area.

Your doctor may use the term "remission" instead of "cure" when talking about the effectiveness of your treatment. Although many people with non-Hodgkin's lymphoma are successfully treated, doctors use the term remission because cancer can return. It is important to discuss the possibility of recurrence with your doctor.

Surgery is not used to treat non-Hodgkin's lymphoma.

What to think about

Because of recent improvements in body scans (such as the CT scan, MRI, and PET scan), exploratory surgery is rarely used to stage NHL.

Radiation therapy is often the treatment of choice for early-stage or nonaggressive (indolent) non-Hodgkin's lymphoma (NHL). Radiation therapy may be used alone or combined with other treatment options, such as chemotherapy, for later or more advanced NHL.

Stem cell transplant (also called bone marrow transplant) is used to treat relapsed aggressive NHL. One study showed that stem cell transplant improved survival rates in people with aggressive NHL.⁶

A growth factor called G-CSF may be used along with chemotherapy for newly diagnosed NHL. G-CSF is a protein that is produced naturally in the body. G-CSF can help you tolerate chemotherapy better and have less risk for serious infections.

What to think about

Radiation therapy often cures early-stage or nonaggressive (indolent) non-Hodgkin's lymphoma.

Survival rates have improved as a result of clinical trials. Clinical trials provide evidence about new medicines and treatments that may help people who have non-Hodgkin's lymphoma live longer and have a better quality of life. If you are interested in taking part in a clinical trial, check with your doctor to see if there are any clinical trials available in your area.

Your doctor may use the term "remission" instead of "cure" when talking about the effectiveness of your treatment. Although many people with non-Hodgkin's lymphoma are successfully treated, doctors use the term remission because cancer can return. It is important to discuss the possibility of recurrence with your doctor.

Palliative care

If your non-Hodgkin's lymphoma gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different from care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

Non-Hodgkin's lymphoma is often a progressive condition. If you have been diagnosed with NHL, you may wish to discuss with your family and your doctor the health care and other legal issues that arise near the end of life.

A time may come when your goals or the goals of your loved ones may change from treating or curing an illness to maintaining comfort and dignity. You may find it helpful and comforting to state your health care choices in writing (with an advance directive or living will) while you are still able to make and communicate these decisions. Think about your treatment options and which kind of treatment will be best for you. You may wish to choose a health care agent to make and carry out decisions about your care if you become unable to speak for yourself. For more information, see the topic Care at the End of Life.

Organizations

Citations

1. Fisher RI, et al. (2005). Non-Hodgkin's lymphomas. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., pp. 1957–1997. Philadelphia: Lippincott Williams and Williams.

2. American Cancer Society (2005). Cancer Facts and Figures 2005, pp. 1–21. Atlanta: American Cancer Society. Also available online: http://www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf.

3. Evans LS, Hancock BW (2003). Non-Hodgkin lymphoma. Lancet, 362(9378): 139–146.

4. Ardeshna KM, et al. (2003). Long-term effect of a watch and wait policy versus immediate systemic treatment for asymptomatic advanced-stage non-Hodgkin lymphoma: A randomised controlled trial. Lancet, 362(9383): 516–522.

5. Coiffier B, et al. (2002). CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. New England Journal of Medicine, 346(4): 235–242.

6. Milpied N, et al. (2004). Initial treatment of aggressive lymphoma with high-dose chemotherapy and autologous stem-cell support. New England Journal of Medicine, 350(13): 1287–1295.

Other Works Consulted

• American Joint Committee on Cancer (2002). Lymphoid neoplasms. AJCC Cancer Staging Manual, 6th ed., pp. 393–406. New York: Springer-Verlag.

• Bierman PJ, et al. (2008). Non-Hodgkin’s lymphomas. In L Goldman, D Ausiello, eds., Cecil Textbook of Medicine, 23rd ed., pp. 1408–1419. Philadelphia: Saunders Elsevier.

• Copson ER, Kerr JP (2006). Non-Hodgkin’s lymphoma (diffuse large B cell lymphoma), search date April 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

• Foon KA, Fisher RI (2006). The non-Hodgkin lymphomas. In MA Lichtman et al., eds., Williams Hematology, 7th ed., pp. 1407–1459. New York: McGraw-Hill.