Lymphoma (Hodgkin and non-Hodgkin)

Hodgkin and non-Hodgkin lymphoma — recognition and care in Australia

By Dr HB Lo, FACRRM 8 min read

Lymphoma is a cancer of the lymphatic system — lymph nodes, spleen, and bone marrow. About 7,500 Australians are diagnosed each year. Hodgkin lymphoma affects young adults and people over 60; non-Hodgkin lymphoma is more common and heterogeneous.

Key warning signs are painless, firm lymph node swelling persisting four or more weeks — especially in the neck, armpit, or groin — with unexplained weight loss, drenching night sweats, or fever (B-symptoms).

Diagnosis requires excisional lymph node biopsy and PET-CT staging. Hodgkin lymphoma has approximately 90% five-year survival; non-Hodgkin varies widely by subtype.

What lymphoma is and why early recognition matters

Lymphoma is a cancer that arises from lymphocytes — a type of white blood cell — in the lymphatic system. The lymphatic system includes lymph nodes (glands), the spleen, thymus, and bone marrow, and it runs throughout the entire body. Because lymphocytes circulate widely, lymphoma can start almost anywhere and spread through the body.

According to the Australian Institute of Health and Welfare, approximately 7,500 Australians are diagnosed with lymphoma each year — around 660 with Hodgkin lymphoma and 6,800 with non-Hodgkin lymphoma. Five-year survival for Hodgkin lymphoma is approximately 90%; for non-Hodgkin lymphoma it varies widely by subtype but averages around 80% overall.

The GP’s role is to recognise the warning signs, refer urgently for biopsy and haematology assessment, support the patient through diagnosis and treatment, and provide shared survivorship care after treatment ends.

A. Core clinical — the AU general-practice framework

Hodgkin lymphoma versus non-Hodgkin lymphoma

Hodgkin lymphoma (HL) is defined by the presence of Reed-Sternberg cells — large, binucleated lymphoid cells — on a reactive immune background. It has a bimodal age distribution: a peak in young adults aged 15–35 years and a second peak in people over 60. HL is frequently associated with prior Epstein-Barr virus (EBV) infection. The WHO 2022 classification recognises classical HL (nodular sclerosis, mixed cellularity, lymphocyte-rich, lymphocyte-depleted) and the separate entity of nodular lymphocyte-predominant HL. Classical HL typically responds well to chemotherapy — ESMO guidelines outline current treatment approaches.

Non-Hodgkin lymphoma (NHL) is a heterogeneous group of more than 70 distinct subtypes, broadly divided by cell of origin (B-cell versus T-cell) and clinical behaviour (indolent versus aggressive). The most common subtypes in Australia:

  • Diffuse large B-cell lymphoma (DLBCL) — approximately 30%: aggressive but frequently curable; treated with R-CHOP-based regimens
  • Follicular lymphoma — approximately 20%: indolent (slow-growing), generally incurable but manageable over many years
  • Mantle cell lymphoma: intermediate to aggressive; characteristic cyclin D1 expression
  • Burkitt lymphoma: highly aggressive; oncological emergency; associated with EBV in certain subtypes
  • Marginal zone lymphoma (including MALT, splenic, nodal)
  • Peripheral and anaplastic large-cell T-cell lymphomas: rarer; variable prognosis
  • CLL/SLL overlap (chronic lymphocytic leukaemia / small lymphocytic lymphoma): see the related article on leukaemia recognition

Warning signs — when to refer urgently

Lymphadenopathy warranting urgent assessment (Cancer Council Australia; Lymphoma Australia):

  • Painless, firm or rubbery lymph node enlargement — particularly supraclavicular (above the collarbone), cervical (neck), axillary (armpit), or mediastinal (chest)
  • Persistence beyond four weeks without a clear infectious explanation
  • Progressive enlargement over weeks
  • Size greater than 1–2 cm, firm consistency, non-tender
  • B-symptoms: fever above 38 °C, drenching night sweats, and unintentional weight loss exceeding 10% of body weight in six months — present in 30–50% of lymphoma cases

Emergency presentations requiring immediate referral:

  • Superior vena cava (SVC) obstruction — facial swelling, neck vein distension, breathlessness, arms swollen — classic complication of mediastinal lymphoma
  • Spinal cord compression — back pain with neurological signs, leg weakness, or urinary/bowel dysfunction
  • Tumour lysis syndrome in very aggressive NHL (Burkitt) — electrolyte crisis from rapid cell death; managed in hospital
  • Primary CNS lymphoma or CNS spread — headache, seizures, neurological changes in an immunosuppressed patient (particularly HIV or post-transplant)

GP workup before referral

The GP requests a first-line panel before or simultaneously with haematology referral:

  • Full blood count with differential and blood film — atypical lymphocytes, cytopenias
  • LDH (prognostic marker in aggressive lymphoma), uric acid (tumour lysis risk), β2-microglobulin (prognostic)
  • Renal and liver function, albumin
  • Immunoglobulins (monoclonal paraprotein in some subtypes)
  • Hepatitis B, C, and HIV serology (treatment planning and reactivation prophylaxis before chemotherapy)
  • EBV serology if HL, Burkitt, or HIV-associated lymphoma is suspected
  • Chest X-ray (mediastinal widening)
  • Excisional lymph node biopsy — not fine needle aspiration — arranged through surgical outpatient or haematology as urgently as feasible

B. Diagnosis and staging

Why excisional biopsy

Fine needle aspiration (FNA) provides individual cells but loses the nodal architecture. Lymphoma subclassification requires intact tissue — the spatial relationship of cells within the node — plus immunohistochemistry (IHC), fluorescence in situ hybridisation (FISH) for translocations, and molecular markers. An inconclusive FNA delays diagnosis and adds procedural risk. Core needle biopsy of easily accessible nodes may be acceptable in specific circumstances; excisional biopsy remains the standard for most presentations.

PET-CT and the Lugano criteria

Staging uses PET-CT with the Lugano classification (Cheson JCO 2014) — a system that maps disease from Stage I (single node region or single extranodal site) to Stage IV (widespread nodal or bone marrow involvement). PET-CT also assesses treatment response using the Deauville five-point scale — a score of 1 or 2 at end of treatment indicates complete metabolic response and is associated with excellent outcomes in HL. Bone marrow biopsy is increasingly omitted in HL and DLBCL when PET-CT provides sufficient staging information.

C. Treatment — an overview

Treatment is subspecialty-led by haematologists and medical oncologists. The GP’s role is to support the patient through treatment, manage side effects within GP scope, and liaise with the treating team.

Hodgkin lymphoma: The current Australian standard for classical HL is ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) or a variant, with radiation in selected cases. Response-adapted approaches — adjusting treatment intensity based on interim PET-CT — reduce toxicity in PET-negative patients. Advanced or relapsed HL may receive brentuximab vedotin (an antibody-drug conjugate targeting CD30), checkpoint inhibitors (pembrolizumab, nivolumab), or autologous stem-cell transplant. Outcomes for HL are generally excellent — approximately 90% five-year survival.

Diffuse large B-cell lymphoma: R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, prednisone) remains the standard first-line treatment for most patients. Polatuzumab-CHOP is increasingly used for high-intermediate and high-risk patients per ESMO DLBCL guidelines. Relapsed or refractory DLBCL may be treated with CAR-T cell therapy (axicabtagene ciloleucel, tisagenlecleucel) — now PBS-funded in Australia for eligible patients.

Follicular lymphoma: Watch-and-wait (active surveillance without treatment) is appropriate for asymptomatic, low-burden disease. Treatment when indicated includes rituximab-based immunochemotherapy. Follicular lymphoma is typically managed over a long time frame; most patients have multiple lines of treatment over years.

eviQ (Cancer Institute NSW) provides the current Australian treatment protocols for haematological malignancies used by treating teams.

Vaccinating before chemotherapy

Per ATAGI, inactivated vaccines should be administered at least two weeks before chemotherapy begins where planned care allows. This includes influenza, pneumococcal, and Shingrix. Live vaccines are contraindicated during and for a defined period after chemotherapy. Anti-CD20 agents (rituximab) profoundly impair vaccine responses — ideally vaccinate before the first cycle.

D. Australian operations

MBS: Consultations, pathology, and imaging follow standard MBS items. Chemotherapy is administered in public or private oncology centres. CAR-T cell therapy is hospital-funded. PBS: Rituximab, brentuximab vedotin, pembrolizumab, nivolumab, and axicabtagene ciloleucel are PBS-listed for specific indications under Authority Required prescriptions — haematologist-initiated.

AHPRA and consent: Treatment for lymphoma, particularly with curative intent, involves significant toxicities including nausea, hair loss, infection risk, and organ-specific effects. Informed consent is the treating team’s responsibility. GPs support patients in understanding and navigating their treatment.

Patient support: Lymphoma Australia provides patient information, a helpline, peer-support networks, and resources in multiple languages. Cancer Council Australia provides the 13 11 20 cancer information and support line.

E. Special populations

Young adults with HL: Fertility preservation is strongly recommended before gonadotoxic chemotherapy — sperm banking, oocyte or embryo freezing — through a fertility specialist. Discuss before treatment begins.

Older adults: Treatment intensity is modified based on functional status, comorbidities, and performance score. Geriatric assessment tools guide oncology decision-making. Palliative-intent treatment is discussed when curative treatment is not appropriate.

HIV-positive patients: HIV-associated lymphoma (including primary CNS lymphoma, Burkitt, and plasmablastic lymphoma) is managed with antiretroviral therapy optimised concurrently with chemotherapy — specialist infectious-diseases and haematology co-management is essential.

Post-transplant lymphoproliferative disorder (PTLD): Can occur in solid-organ or stem-cell transplant recipients on immunosuppression. Watch for B-symptoms, lymphadenopathy, and unexplained weight loss in transplant patients. Early referral to haematology and transplant medicine is required.

Survivorship care

Long-term follow-up after lymphoma treatment addresses:

  • Cardiac monitoring: anthracyclines (doxorubicin) carry cumulative cardiotoxicity risk; annual cardiovascular risk factor review and symptom assessment. Echocardiogram at intervals in selected patients.
  • Pulmonary function: bleomycin lung toxicity — baseline spirometry and DLCO at diagnosis; annual symptom check.
  • Second malignancies: particularly relevant in Hodgkin lymphoma treated with chest radiation — elevated risk of breast cancer (start annual mammography 8–10 years post-radiation or at age 40, whichever is first) and thyroid cancer.
  • Thyroid function: annual TSH if chest or neck radiation received.
  • Bone health: corticosteroid-containing regimens may affect bone density — baseline DXA at diagnosis of ongoing risk.
  • Mental health: anxiety, depression, and fear of recurrence are common. Mental Health Care Plans and psychology referral are appropriate. Lymphoma Australia’s peer support reduces isolation.
  • Immunisation review: particularly for those who had stem-cell transplant — complete revaccination schedule from 6–12 months post-engraftment.

When to escalate

From GP to haematology or emergency:

  • Suspected lymphoma — persistent painless lymphadenopathy with or without B-symptoms → urgent excisional biopsy and haematology referral
  • SVC obstruction or spinal cord compression → immediate emergency referral
  • Febrile neutropenia during chemotherapy → same-day emergency department; declare immunosuppressed status at triage
  • Relapse symptoms during or after treatment → return to haematology
  • Survivorship complications — cardiac symptoms, new lymphadenopathy, breast or thyroid concerns → relevant specialist

What this article is and is not

This is general health information drawn from Cancer Council Australia, Lymphoma Australia, AIHW cancer data, ESMO guidelines, and current published evidence. It is not personal medical advice and does not create a doctor–patient relationship. Lymphoma management requires specialist haematology and oncology input. If you are concerned about lymphadenopathy or other symptoms, speak with your GP.

For Australian support: Lymphoma Australia, Cancer Council 13 11 20, HealthDirect, Better Health Channel.

Sources cited

  1. AIHW — Cancer data in Australia 2024
  2. Cancer Council Australia — Lymphoma
  3. Lymphoma Australia
  4. WHO Classification of Haematolymphoid Tumours 2022 (Alaggio et al. 2022)
  5. Cheson BD et al. — Lugano classification (JCO 2014)
  6. ESMO — Hodgkin lymphoma guidelines 2024
  7. ESMO — DLBCL guidelines 2024
  8. eviQ — Cancer treatments online (Cancer Institute NSW)
  9. ATAGI — Vaccination for immunocompromised people (Australian Immunisation Handbook)
  10. HealthDirect — Lymphoma
  11. Better Health Channel — Lymphoma

Frequently asked questions

  • What does a lymphoma lump feel like and where does it appear?

    Lymphoma typically causes lymph nodes that are painless, firm or rubbery in consistency, not attached to overlying skin, and slowly enlarging. They most commonly appear in the neck, above the collarbone, in the armpit (axilla), and in the groin. Painful or tender lymph nodes are more commonly caused by infection. A lymph node that is painless, larger than 1–2 cm, persistent for more than four weeks, and not explained by an obvious infection warrants assessment by your GP. Supraclavicular (above the collarbone) lumps carry a higher suspicion for serious underlying disease regardless of size.

  • What are B-symptoms and why do they matter?

    B-symptoms are a specific set of systemic symptoms used to stage lymphoma: unexplained fever above 38 °C, drenching night sweats (soaking clothing and bedding), and unintentional weight loss of more than 10% of body weight over six months. When B-symptoms are present alongside lymphadenopathy, they increase the urgency of investigation — B-symptoms indicate more advanced or aggressive disease in lymphoma staging and affect treatment planning. They also occur in tuberculosis and some other serious infections, so their presence alone is not diagnostic of lymphoma.

  • Why does my GP want an excisional biopsy rather than a needle biopsy?

    Fine needle aspiration (FNA) collects individual cells from a lymph node but cannot preserve the architecture of the node — the way the cells are organised within the tissue. Lymphoma diagnosis, and distinguishing between subtypes, depends on examining that architecture under microscopy plus specialised immunohistochemical and molecular testing. A core needle biopsy may be acceptable in some circumstances and for some subtypes, particularly where the node is difficult to access surgically. An excisional biopsy — removal of the whole node — remains the standard for most suspected lymphoma because it provides the most complete diagnostic material and reduces the chance of an inconclusive result.

  • What is PET-CT and why is it used for lymphoma?

    PET-CT (positron emission tomography combined with computed tomography) combines a metabolic scan with a structural scan. Lymphoma cells are metabolically active and take up a glucose-like tracer used in PET imaging, appearing as bright spots. PET-CT is used both for staging — mapping the extent of disease across the body — and for assessing treatment response, using the Lugano criteria and Deauville five-point scoring system. A Deauville score of 1–2 at the end of treatment indicates a complete metabolic response. PET-CT has largely replaced bone marrow biopsy in Hodgkin lymphoma and diffuse large B-cell lymphoma staging when the scan is informative.

  • What does 'survivorship care' mean after lymphoma treatment?

    Most people treated for lymphoma, particularly Hodgkin lymphoma, live for many years after treatment. Survivorship care means monitoring for late effects of treatment — including heart and lung toxicity from certain chemotherapy regimens and radiation, increased risk of second cancers (particularly breast and thyroid after chest radiation in HL), thyroid dysfunction, fertility impacts, and psychological effects. Your GP plays a central role in survivorship alongside the haematology team: annual cardiovascular risk review, skin checks, regular blood tests, age-appropriate cancer screening, mental health support, and immunisation review (particularly for those who received treatment affecting the immune system).

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.