Chemotherapy for Non-Hodgkin Lymphoma in Children

Chemotherapy (chemo) is the main treatment for non-Hodgkin lymphoma (NHL) in children and teens. Chemo drugs enter the bloodstream and can reach nearly all areas of the body, making this treatment very useful for cancers that spread widely, such as childhood NHL.

Chemo drugs used to treat non-Hodgkin lymphoma in children

Children and teens with NHL get a combination of several chemo drugs over a period of time. The number of drugs, their doses, and the length of treatment depend on the type and stage of the lymphoma. Some of the chemo drugs commonly used to treat childhood lymphoma include:

• Cyclophosphamide
• Vincristine
• Doxorubicin (Adriamycin)
• Prednisone
• Dexamethasone
• Cytarabine, also known as ara-C
• Methotrexate
• L-asparaginase, PEG-L-asparaginase (pegaspargase)
• Etoposide
• 6-mercaptopurine
• Ifosfamide

How is chemo given?

Doctors give chemo in cycles, in which a period of treatment is followed by a rest period to allow the body time to recover. Each chemo cycle generally lasts for several weeks.

Chemo drugs are usually given into a vein (IV) or taken by mouth. If there’s a chance the lymphoma may have reached the brain or spinal cord, chemo may also be given into the cerebrospinal fluid (known as intrathecal chemo).

Most chemo treatments are given in an outpatient setting (in the doctor’s office or clinic or hospital outpatient department), but some – especially at the start of treatment – may need to be given while the child stays in the hospital.

Often before chemo is about to start, surgery is done to insert a small plastic tube, called a central venous catheter (CVC) or venous access device (VAD), into a large blood vessel. The end of the tube stays just under the skin or sticks out in the chest area or upper arm. The CVC is left in place during treatment (often for many months) to give IV drugs such as chemo and to take blood samples. This lowers the number of needle sticks needed during treatment.

Possible risks and side effects of chemo

Chemo drugs can cause side effects. These depend on the type and dose of drugs given and how long treatment lasts.

Common chemo side effects can include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea or constipation
• Increased chance of infections (due to low white blood cell counts)
• Easy bruising or bleeding (due to low blood platelet counts)
• Fatigue (due to low red blood cell counts)

These side effects usually go away after treatment is finished. If serious side effects occur, the dose of chemo may need to be reduced or treatment may need to be delayed.

There are often ways to lessen these side effects. For example:

• Drugs can be given to help prevent or reduce nausea and vomiting.
• Infections can be very serious in children getting chemo. Drugs known as growth factors can be given to keep the blood cell counts higher.

Tumor lysis syndrome is a possible side effect of chemo in children who have large numbers of lymphoma cells in the body before treatment. It occurs most often with the first cycle of chemo. Killing the lymphoma cells releases their contents into the bloodstream. This can overwhelm the kidneys, which can’t get rid of all of these substances at once. Excessive amounts of certain minerals may also lead to heart and nervous system problems. The risk of tumor lysis syndrome happening can be lowered by making sure the child gets lots of fluids during treatment and by giving drugs such as bicarbonate, allopurinol, and rasburicase, which help the body get rid of these substances.

Side effects of certain chemo drugs

Some possible side effects occur only with certain drugs. For example:

Cyclophosphamide and ifosfamide can damage the bladder, which can cause blood in the urine. The risk of this can be lowered by giving the drugs with plenty of fluids and with a drug called mesna, which helps protect the bladder. These drugs can also damage the ovaries or testicles, which could affect fertility (the ability to have children).

Doxorubicin can damage the heart. Doctors try to reduce this risk as much as possible by limiting the doses of doxorubicin and by checking the heart with an echocardiogram (an ultrasound of the heart) during treatment. This drug can also cause skin damage if it should leak out of the vein while it is being given.

Vincristine and etoposide can cause nerve damage (neuropathy). Some patients may have tingling, numbness, weakness, or pain, particularly in the hands and feet.

Some chemo drugs, such as etoposide, can increase the risk of developing other cancers (especially leukemias) later in life. While this is a serious risk, it is not common, and the small increase in risk has to be weighed against the importance of chemotherapy in treating the lymphoma.

Be sure to ask your child’s doctor or nurse about any specific side effects you should watch for and about what you can do about them.

Along with the side effects listed above, there are possible long-term effects of chemo in children, such as possible effects on fertility later in life. These are described in Late and Long-term Effects of Treatment for Non-Hodgkin Lymphoma in Children.