Lymphoma is a cancer of lymphocytes, the white blood cells that help the immune system work. The two broad groups are Hodgkin lymphoma and non-Hodgkin lymphoma, and each includes subtypes that behave differently. A lymph node or tissue biopsy establishes the subtype, while scans help determine the stage. Some lymphomas need prompt treatment with the aim of cure, while selected slow-growing lymphomas can be monitored until treatment is likely to help. [1–5]
By Dr Raman Narang, Consultant Medical & Hemato-Oncologist, New Delhi
Two people may both have enlarged lymph nodes and be told they have stage IV lymphoma. One may have classical Hodgkin lymphoma and start treatment with the aim of cure. The other may have an indolent follicular lymphoma and be offered monitoring if they feel well and the disease is causing no problems. If you are seeking lymphoma treatment in Delhi, start by asking for the exact subtype on the biopsy report. It often tells you more about the next step than the stage alone. [1, 3, 5]
1. What are the symptoms of lymphoma?
Lymphoma can cause a painless lump in the neck, armpit, or groin. Some people have unexplained fever, drenching night sweats, weight loss, fatigue, or itching. Lymphoma can also start outside the lymph nodes, including in the stomach, skin, or other organs. Symptoms then depend on the area involved. For example, enlarged nodes in the chest can cause cough or breathlessness. [1, 3–5]
Doctors use the term B symptoms for unexplained fever above 38°C, drenching night sweats, or unexplained loss of more than 10% of body weight over six months. Tell your team when these symptoms started and how often they occur. In India, infections such as tuberculosis can also cause persistent lymph node enlargement, fever, and weight loss. A lump that persists or grows deserves assessment, and a tissue sample may be needed to establish the cause. Rapidly worsening breathlessness or swelling of the face and neck needs urgent medical assessment. [1, 3]
2. How are Hodgkin and non-Hodgkin lymphomas classified?
Lymphoma classification starts with which cell the cancer arose from and what the tissue looks like. For non-Hodgkin lymphoma, the team also considers whether the disease typically grows slowly or quickly. The table shows common examples. The full pathology classification contains many more subtypes. [1, 2]
| Group | Main subtypes and what they mean |
|---|---|
| Classical Hodgkin lymphoma | Includes nodular sclerosis, mixed cellularity, lymphocyte-rich, and lymphocyte-depleted subtypes. These share a broad treatment pathway. Stage, risk features, and response often guide treatment more than the microscopic subtype. |
| Nodular lymphocyte-predominant lymphoma | A distinct disease that often grows slowly and may be treated differently from classical Hodgkin lymphoma. Reports may use nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) or nodular lymphocyte-predominant B-cell lymphoma (NLPBL), depending on the classification system. |
| Indolent B-cell non-Hodgkin lymphoma | Includes many follicular lymphomas, marginal zone lymphomas, and small lymphocytic lymphoma. Some patients can be monitored initially. Symptoms, blood counts, and effects on organs help determine when treatment should start. |
| Aggressive B-cell non-Hodgkin lymphoma | Includes diffuse large B-cell lymphoma (DLBCL), certain high-grade B-cell lymphomas, and Burkitt lymphoma. Prompt assessment is important. Burkitt lymphoma has its own treatment regimens. |
| Mantle cell lymphoma | A distinct B-cell lymphoma with variable behaviour. It has its own treatment pathway, shaped by disease features, fitness, and how quickly the lymphoma is progressing. |
| T-cell and NK-cell lymphomas | Include peripheral T-cell lymphoma, anaplastic large-cell lymphoma, and extranodal NK/T-cell lymphoma. The exact subtype matters because treatments differ considerably. |
3. How is lymphoma diagnosed, staged, and risk-assessed?
An excisional biopsy, which removes an accessible lymph node, is often preferred because it preserves the structure of the tissue needed for classification. A core needle biopsy may be appropriate when removing a node is impractical or the abnormal tissue is deep inside the body. A fine-needle aspiration alone is usually insufficient for a first lymphoma diagnosis. An experienced haematopathologist may use immunohistochemistry, flow cytometry, or selected genetic tests to identify the subtype. [1, 2]
PET-CT is commonly used to stage classical Hodgkin lymphoma, DLBCL, and other lymphomas that take up the PET tracer well. CT may be more appropriate for some other subtypes. Blood tests assess blood counts, kidney and liver function, and markers such as LDH. A bone marrow biopsy is used selectively, depending on the subtype and whether it would add information. [1, 3, 4]
Stage describes where lymphoma is found. Early-stage disease is generally limited to one or a few lymph node regions or a localised site. Advanced-stage disease can involve lymph nodes on both sides of the diaphragm or organs such as the bone marrow or liver. Risk assessment adds other information. In classical Hodgkin lymphoma, a large mass or other risk features can change the plan. In DLBCL, the International Prognostic Index (IPI) combines factors such as age, stage, LDH, daily functioning, and sites of involvement outside lymph nodes. [1, 3, 4]
4. How is Hodgkin lymphoma treated?
Early-stage classical Hodgkin lymphoma is often treated with combination chemotherapy, such as ABVD, with focused radiation in selected patients. An interim PET-CT can help guide decisions in some treatment protocols. If omitting radiation is an option, ask how that choice may affect the risk of relapse and the potential long-term side effects. [1, 3]
Advanced classical Hodgkin lymphoma is usually treated with the aim of cure. Options can include nivolumab plus AVD or brentuximab vedotin plus AVD. A PET-guided ABVD-based approach remains appropriate in some settings. Age, fitness, lung health, possible side effects, and access all matter when choosing a regimen. [1, 3]
If classical Hodgkin lymphoma returns or does not respond adequately, options may include further drug treatment, autologous stem cell transplantation using the patient’s own stem cells, or medicines such as checkpoint immunotherapy or brentuximab vedotin. The sequence depends on the first treatment and how the lymphoma responded. Nodular lymphocyte-predominant lymphoma has a separate pathway. Selected patients with localised disease may receive radiation, while others may need rituximab-based treatment. [1, 3]
5. How is non-Hodgkin lymphoma treated?
The first question is whether the lymphoma needs treatment now, followed by which treatment fits the exact subtype. Surgery usually provides tissue for diagnosis. Medicines and, in selected cases, radiation are the main treatments. [1, 4, 5]
| Subtype or clinical setting | What the team usually discusses |
|---|---|
| DLBCL | Treatment usually aims for cure. R-CHOP is a common regimen. Polatuzumab vedotin plus R-CHPis another first-line option for selected patients. The stage, risk group, pathology, and fitness guide the choice. |
| Follicular or marginal zone lymphoma | Selected patients without symptoms or threatened organ function can start with active monitoring. Localised disease may be suitable for radiation. When more widespread disease needs treatment, options can include an anti-CD20 antibody such as rituximab, alone or with other medicines. |
| Gastric MALT lymphoma | In selected patients with localised disease associated with Helicobacter pylori, treating the infection can be the first step. Follow-up endoscopy and biopsy help assess the response. |
| Burkitt and other rapidly growing lymphomas | Treatment can be urgent. The exact subtype determines the regimen and whether treatment to protect the brain and spinal fluid is needed. The team also assesses the risk of tumour lysis syndrome, which can occur when many cancer cells break down quickly. |
| T-cell and NK-cell lymphomas | Treatment is subtype-specific. For example, CD30 can help guide treatment in some T-cell lymphomas, while extranodal NK/T-cell lymphoma often requires a different combination of medicines and radiation. |
For selected patients with relapsed or refractory large B-cell lymphoma, options can include CAR T-cell therapy, a bispecific antibody, or autologous stem cell transplantation. The timing of relapse, response to prior therapy, and access to specialist treatment help determine which option fits. [1, 4]
What I look for clinically before recommending treatment
I first check whether the biopsy names a specific subtype and whether enough tissue was available for the tests that could change treatment. If the lymphoma is aggressive, I look for anything that needs attention before the first cycle, such as pressure on an organ or a high risk of tumour lysis. If it is slow-growing, I ask what we expect treatment to improve today. For someone considering monitoring, I explain what we will follow and what would prompt treatment.
How the next step is decided
| If the reports show… | The next discussion is about… |
|---|---|
| A suspicious lymph node without a definitive diagnosis | Choosing a biopsy that can provide enough tissue for classification |
| Classical Hodgkin lymphoma | Stage, risk features, and whether chemotherapy alone or chemotherapy with radiation is appropriate |
| DLBCL or another aggressive subtype | How promptly to start treatment and which regimen fits the pathology and risk group |
| Indolent lymphoma without symptoms or organ problems | Whether monitoring is appropriate and what changes would trigger treatment |
| Lymphoma that returns after initial therapy | Whether to repeat the biopsy and which further treatment is appropriate |
What to bring to a lymphoma consultation in Delhi
- Biopsy report, including immunohistochemistry, and details for obtaining the slides or tissue block.
- Flow cytometry or genetic test reports, if performed.
- PET-CT or CT reports and the original scan images.
- Recent blood counts, LDH, and kidney and liver function results.
- Dates and details of previous chemotherapy, radiation, immunotherapy, or transplant.
- A record of fevers, night sweats, weight changes, and any questions about fertility before treatment.
Frequently asked questions
Can stage IV lymphoma be cured?
Many patients with advanced classical Hodgkin lymphoma or DLBCL are treated with the aim of cure. For some advanced indolent lymphomas, treatment is more often aimed at long-term disease control. The exact subtype is central to understanding what stage IV means. [1, 3–5]
Does an abnormal PET-CT prove that I have lymphoma?
Infection and inflammation can also show increased uptake on PET-CT. A tissue biopsy usually establishes the diagnosis and identifies the subtype. [1, 2]
Is it safe to wait before treating lymphoma?
Active monitoring can be appropriate for selected slow-growing lymphomas. It involves planned visits and clear criteria for starting treatment. Aggressive lymphomas generally require prompt evaluation and treatment planning. [1, 4, 5]
Does everyone with lymphoma need a stem cell transplant?
Transplant is used in specific settings. For example, it may be considered for eligible patients with certain lymphomas that return after initial treatment. The subtype, response to further treatment, and availability of other options guide that decision. [1, 3, 4]
At your consultation, ask for the exact subtype, stage, and treatment goal in writing. If treatment is recommended, ask why it should start now and how the team will assess response. If monitoring is recommended, ask what symptoms or test results would bring the next appointment forward.
This page is for general education. Individual treatment decisions require review of your biopsy, scans, symptoms, and overall health by your treating team.
Clinical references
- European Society for Medical Oncology. Lymphomas: ESMO Clinical Practice Guideline for Diagnosis, Treatment and Follow-up. 2025.
- World Health Organization. WHO Classification of Haematolymphoid Tumours, 5th edition. See also the International Consensus Classification of Mature Lymphoid Neoplasms for differences in terminology.
- National Cancer Institute. Hodgkin Lymphoma Treatment (PDQ). Health Professional Version.
- National Cancer Institute. Aggressive B-Cell Non-Hodgkin Lymphoma Treatment (PDQ). Health Professional Version.
- National Cancer Institute. Indolent B-Cell Non-Hodgkin Lymphoma Treatment (PDQ). Health Professional Version.