Stage 4 Lymphoma: What to Expect

A diagnosis of stage 4 lymphoma means that cancer has spread outside of the lymphatic system and into one or more organs. Stage 4 lymphoma is treatable.

As with most cancers, lymphoma’s progression is categorized into stages 1 through 4, with 4 being the most advanced. Staging helps provide a treatment roadmap for your healthcare provider.

This article will discuss the main types of lymphoma, and the symptoms associated with stage 4. It will also cover the treatments you can expect, and the estimated stage 4 lymphoma survival rate.

Types of Lymphoma

There are many types and subtypes of this disease. The two main forms are Hodgkin's and non-Hodgkin's lymphoma. Non-Hodgkin's lymphoma is the more common kind.

Lymphoma is caused by cancerous changes in lymphocytes. A main difference between Hodgkin's and non-Hodgkin's lymphoma is that the cancerous changes in Hodgkin's lymphoma produce large, abnormal cells called Hodgkin's cells and Reed-Sternberg cells. Non-Hodgkin's lymphoma does not produce these types of cells.

Hodgkin's Lymphoma

The lymphatic system contains B lymphocytes and T lymphocytes. Hodgkin's lymphoma typically, though not always, starts in B lymphocytes. Hodgkin's lymphoma can appear anywhere in the lymphatic system but usually starts above the diaphragm in the neck, armpits, or chest.

If you have stage 4 Hodgkin's lymphoma, the cancer has spread outside of the lymph system into organs such as the liver, lungs, or bone marrow.

There are several subtypes of Hodgkin's lymphoma. Classic Hodgkin's lymphoma is the most common form of this disease. Nine out of 10 people diagnosed with Hodgkin's lymphoma have classic Hodgkin's lymphoma.

Non-Hodgkin's Lymphoma

Non-Hodgkin's lymphoma can start in either B lymphocytes or T lymphocytes. B-cell lymphomas are more common than T-cell lymphomas. The two most common subtypes of non-Hodgkin's lymphoma are diffuse large B-cell lymphoma and follicular lymphoma.

If you have non-Hodgkin's lymphoma, the cancerous cells may be classified as indolent (slow-growing), or aggressive (fast-growing). Indolent lymphomas spread (metastasize) slowly. The most common form of indolent lymphoma is follicular lymphoma.

Aggressive lymphomas metastasize rapidly. The most common form of aggressive lymphoma is diffuse large B-cell lymphoma.

If you have stage 4 non-Hodgkin's lymphoma, the cancer has spread outside the lymphatic system into organs such as the liver, lungs, or bone marrow.

Diagnosing Stages of Lymphoma

There are several diagnostic tests used to determine the lymphoma stage. Testing can also help determine how you're responding to your current treatment for this disease. These tests vary, based on your symptoms.  

Swollen or enlarged lymph nodes will be biopsied (sampled) to confirm a diagnosis of Hodgkin’s or non-Hodgkin’s lymphoma. In many instances, the entire lymph node will be removed for laboratory testing. This ensures that enough tissue is available for analysis and diagnosis.

A bone marrow aspiration and biopsy will be done to determine if cancer has spread to the bones. Usually, the bone marrow is taken from the hip bone for this test.

A spinal tap (lumbar puncture) to remove and test cerebrospinal fluid may be done if your doctor suspects that lymphoma has spread to the brain.

Sampling of pleural fluid (fluid accumulating in the space between the lungs and ribs) or peritoneal fluid (fluid accumulating in the abdominal cavity) may be done to check for spread into the chest or stomach. Lymphoma can cause fluid buildup in these and other areas of the body. These tests use fluid extracted from the abdomen or chest to look for cancer cells.

Imaging tests will be done to identify enlarged lymph nodes and organs where cancer may have spread. They include:

• Chest X-ray
• Computed tomography (CT) scan: A cross-sectional detailed X-ray study
• Ultrasound: Uses sound waves to produce images
• Magnetic resonance imaging (MRI) scan: Uses magnetic fields
• Bone scan: Uses a radioactive tracer to look for bone damage and cancer
• Positron-emission tomography (PET) scan: Uses radioactive sugar to identify highly active cells

Blood tests can be helpful for determining the amount of spread you have, as well as issues with organ function. Blood tests include:

• Complete blood count (CBC): A too-low blood cell count may indicate that cancer cells are growing in the bone marrow.
• Blood chemistry test: This test provides information about liver and kidney function.
• Lactate dehydrogenase (LDH) test: LDH is an enzyme found in cells. Increased levels can indicate cell damage. LDH levels are elevated when lymphoma is in advanced stages.
  

Symptoms of Stage 4 Lymphoma

The most common symptom of Hodgkin's and non-Hodgkin's lymphoma is swollen lymph nodes, which are usually painless. You may not notice you have swollen lymph nodes until you're in the later stages of the disease. If you have Hodgkin's lymphoma, drinking alcohol may make swollen lymph nodes painful.

If you’re in stage 4 lymphoma, your symptoms may vary, based on where the cancer has spread. For example, if cancer has traveled to the brain, you may have headaches or seizures.

If it has spread to the chest, you may have chest pain or trouble breathing. If it is affecting your stomach, you may have nausea or pain in that area. You may also feel full after eating very little food.

A group of symptoms known as B symptoms may be diagnosed in stages 2, 3, or 4. They are:

• Consistent or recurring fever of 100.4 degrees Fahrenheit or higher
• Soaking night sweats
• Unexplained weight loss of at least 10% of your body weight

Other symptoms of Stage 4 lymphoma include:

• Exhaustion or fatigue
• Chills
• Bruising or bleeding easily
• Frequent infections
• Itching
• Decreased appetite
• Pain caused by a tumor pressing on a nerve
  

Treatment

Recommended treatments will be based on several factors, including the type or subtype of lymphoma you have. They also include the goals of treatment, your age, overall health, and personal preferences.

Treatments during stage 4 are typically designed to shrink or eradicate (destroy completely) tumors. Treatment at this stage may include palliative care (reduces the discomfort of symptoms but is not curative).

An intense chemotherapy regimen is typically the first-line treatment for stage 4 Hodgkin's or non-Hodgkin's lymphoma. Chemotherapy kills cancer cells throughout the body and can be beneficial for attacking tumors wherever lymphoma spreads. Your response to treatment will be monitored throughout with imaging tests.

There are many different types of chemotherapy drugs. If you don’t respond well to treatment, your chemo drugs may be swapped out for other types. Radiation therapy may also be given as a follow-up to chemotherapy.

Immunotherapy may be administered, with or without chemotherapy. These medications boost your immune system, enabling it to better kill or slow down the growth of lymphoma cells.

Targeted therapy may be used when the cancerous cells have certain characteristics. Targeted therapy drugs hone in on the proteins on cancer cells that control their growth and spread. This treatment works differently than chemo. It may be effective when chemotherapy does not produce good results.

If you don’t respond well to treatment or your cancer comes back, your doctor may suggest a stem cell (bone marrow) transplant. Stem cell transplants help your bone marrow produce healthy cells.

Since chemo can destroy bone marrow cells, a stem cell transplant makes it possible for you to get stronger doses of chemotherapy and then have your bone marrow restored with a transplant. You may also have whole-body radiation done in conjunction with chemotherapy and a stem cell transplant and chemotherapy.

In addition to being used as an adjunct (add-on) treatment, radiation may be used during palliative care to reduce pain and ease the symptoms of stage 4 lymphoma.

Stage 4 Lymphoma Prognosis

Lymphoma is not a cookie-cutter disease. Many factors may have an impact on your potential prognosis. Your response to treatment, age, and overall health all play a role. The number of lymph node areas or organs affected may also have an impact.

The data used to compute the five-year relative survival rate for stage 4 lymphoma are based on the experiences of people who were diagnosed five or more years ago. Since treatments are always improving, this data may not take into account new treatments and, so, may not be able to predict what will happen in your case.

These numbers are based on data maintained by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database:

•  Stage 4 non-Hodgkin's diffuse large B-cell lymphoma has a five-year relative survival rate of 57%
• Stage 4 non-Hodgkin's follicular lymphoma has a five-year relative survival rate of 86%
• Stage 4 Hodgkin's lymphoma has a five-year relative survival rate of 82%
  

Summary

The two main types of lymphoma are Hodgkin's and non-Hodgkin's lymphoma. A diagnosis of stage 4 lymphoma for either type means that cancer has spread outside of the lymphatic system into other areas of the body.

Stage 4 lymphoma is treatable. Aggressive rounds of chemotherapy are often given as a first-line treatment for lymphoma at this stage.

The five-year relative survival rate for stage 4 lymphoma varies and ranges from 57% to 86% based on the type you have. These figures are estimates and not necessarily predictions of what will happen in your case.

A Word From Verywell

Finding out that you or a loved one has stage 4 lymphoma may make you feel like your world has just been turned upside down. Anticipating the treatments to come can also be exhausting and worrisome. It may not be easy.

But try to keep in mind that research into lymphoma is ongoing and robust. New treatments, such as immunotherapy and targeted therapy, have been game-changers for many people dealing with this disease. There are good reasons to maintain optimism, hope, and a positive outlook.