Radiotherapy for lymphoma

This information is about radiotherapy treatment of lymphoma. You might also be interested in reading our top tips for having radiotherapy as shared by our Facebook community. 

On this page

What is radiotherapy?

How might radiotherapy be used to treat lymphoma?

Which lymphoma types can radiotherapy treat?

Types of radiotherapy

What do doctors consider when planning radiotherapy?

CT scans in the radiotherapy planning process

What dose of radiotherapy will I have? 

What is a treatment mask or shell (for radiotherapy to the head and neck area)?

What happens during a radiotherapy session?

Side effects of radiotherapy

Sun safety

Follow-up after radiotherapy

Late effects of radiotherapy

Frequently asked questions about radiotherapy

What is radiotherapy?

Radiotherapy is a treatment that uses one or more forms of a type of energy called radiation. It is a ‘local’ treatment, which means that it damages cells in the parts of your body that it targets – where the lymphoma is. Doctors target the treatment as precisely as possible to the lymphoma cells. Over the few weeks and months following treatment, they die off.

Although healthy cells surrounding the treatment area can also be affected by radiotherapy, they’re much more easily able to repair than the lymphoma cells. 

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How might radiotherapy be used to treat lymphoma?

Radiotherapy might be given with the aim of:

• getting rid of the lymphoma (curative radiotherapy)
• controlling symptoms or managing lymphoma (palliative radiotherapy).

Radiotherapy might be given alone or with other treatments. This depends on many factors, including your lymphoma type and stage. Read more about which types of lymphoma radiotherapy might be used to treat.

Radiotherapy to try to get rid of your lymphoma (curative radiotherapy)

Radiotherapy is often given with the aim of destroying all of the lymphoma (curative treatment). With curative radiotherapy, doctors are trying to send the lymphoma into remission (no evidence of lymphoma in your body).

Curative radiotherapy might be used to treat:

• Some types of slow-growing (low-grade) lymphomas that affect few areas of your body (early stage, stage 1 or 2). 
• Fast-growing (high-grade) lymphomas (stage 3 or 4), which are often treated with chemotherapy and then radiotherapy.
• Fast-growing (high-grade) lymphomas that are more widespread (advanced stage, stage 3 or 4). These lymphomas are usually treated with chemotherapy. However, you might have some radiotherapy afterwards.

Radiotherapy to control symptoms (palliative)

Sometimes, doctors use radiotherapy to control lymphoma or ease symptoms such as pain. This is known as palliative radiotherapy. 

It might also be used if spinal cord compression develops – this is rare, but serious. It happens if lymphoma puts pressure on the spine and stops the nerves from working properly.

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Which lymphoma types can radiotherapy treat?

Your medical team will tell you whether radiotherapy is a recommended option for you. The situations you might be offered it in include those outlined below. 

Classical Hodgkin lymphoma

If you have classical Hodgkin lymphoma that is at an:

• early stage – you might have radiotherapy alone or after a course of chemotherapy
• advanced stage – you might have radiotherapy if there are areas that seem not to have completely responded to chemotherapy.

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL)

If you have nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) that is at an: 

• Early stage and is in a place where it can be taken out (surgical removal) – you might be offered surgery. If there are lymphoma cells left behind after surgery, your medical team is likely to recommend a course of radiotherapy too. 
• Early stage and can’t be taken out – you might have radiotherapy to the part of your body affected by lymphoma. 

Non-Hodgkin lymphoma

You might be treated with radiotherapy if you have one of the following types of non-Hodgkin lymphoma:

Slow-growing (low-grade) non-Hodgkin lymphoma

If the lymphoma is:

• in just one area of your body, you might have curative radiotherapy
• more widespread, you might have palliative radiotherapy. This is often the case where the lymphoma treatment is to help control or manage the lymphoma, rather than to get rid of it.

Fast-growing (high-grade) lymphoma

If the lymphoma is at an:

• Early stage – doctors might recommend a course of chemotherapy before you have radiotherapy
• Advanced stage – chemotherapy is usually given. However, in some cases, you might have radiotherapy afterwards. Radiotherapy might also be used to treat areas that have not responded completely to chemotherapy.

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Types of radiotherapy

This section outlines the following types of radiotherapy, used in the treatment of lymphoma:

• Electron beam therapy
• Total body irradiation (TBI)
• Total skin electron radiotherapy (TSET)
• Proton beam therapy (PBT)

Electron beam therapy

Electron beam therapy uses tiny negatively charged particles. These are electrons, and they cannot travel far inside your body. You might therefore have electron beam therapy if the lymphoma is on, or near to, the surface of your skin, for example, skin (cutaneous) lymphoma.

The radiotherapy (accelerator) machine has an ‘applicator’ connected to it. The applicator directs electrons to the area of your body to be treated. 

You usually have a first 'mark-up' appointment of around 20 to 30 minutes. You then have an appointment of about 10 to 15 minutes for each area of the body to be treated. Often, you have these as separate appointments, on different days.

When the machine is set up, the applicator is brought very close to you and might touch you – but you won’t feel anything during the treatment.

Typically, electron beam therapy is given as a number of separate treatments (fractions) over around 15 sessions. 

Total body irradiation (TBI)

With total body irradiation (TBI), radiotherapy is given to the whole body. 

If you need an allogeneic (donor) stem cell transplant, you might have TBI as part of your preparation for the transplant (conditioning treatment). Your medical team will tell you how you’ll be given your doses. For example, in just one single dose, or twice a day over a number of days.

The Clatterbridge Cancer Centre NHS Foundation Trust has more information about TBI. 

Total skin electron radiotherapy (TSET)

Total skin electron therapy (TSET) treats the whole surface of your skin. This type of radiotherapy uses electrons. It is sometimes called total skin electron irradiation (TSEI).

You might have TSET for a type of skin lymphoma called mycosis fungoides. It’s often given over 2 to 5 weeks.

Only a limited number of centres can offer TSET in the UK. If this is the most appropriate treatment for you, you can be referred to a centre that offers it. Depending on where you live, the nearest centre to you might be outside of your area, so you might need to travel to have treatment.

Proton beam therapy (PBT)

Proton beam therapy (PBT) is a type of radiotherapy that uses charged particles called protons. These can travel far enough in the body to be given directly to the lymphoma cells. You can find out more about proton beam therapy and how it works on the NHS website.

PBT is not available at many hospitals in the UK. It is available privately at some centres in the UK and in other countries. The exact techniques and treatments vary from centre to centre. 

PBT for adults (aged 25 or over) with lymphoma

At the moment, PBT is not widely available on the NHS for adults aged 25 or older with lymphoma. This is because NHS England state that, for this group of people: “There is as yet little evidence of improved treatment outcomes, such as better cancer control or reduced side-effects of PBT, when compared to conventional radiotherapy treatment.”

To access PBT on the NHS if you are aged 25 or older, a national panel of clinical experts considers the potential benefits of PBT to an individual. If you are interested in PBT, speak to your medical team – ideally before consenting to another form of radiotherapy.

PBT for children, teenagers and young adults

In some cases, PBT can lower the risk of late effects of radiotherapy – these are health problems that develop months or years after finishing treatment. 

In general, the younger you are, the more years of your life you have ahead of you. This means that there is usually more time for late effects to develop after treatment. For this reason, PBT is most useful for treating children, teenagers and young adults.

We have more information about lymphoma in children and young people.

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What do doctors consider when planning radiotherapy?

To make it as effective as possible, radiotherapy needs careful planning. Doctors also plan your treatment to lower the risk of side effects and late effects. 

You will need to go to the radiotherapy department to have your treatment planned out and each time you have radiotherapy.

When planning your treatment, radiotherapy professionals work with your consultant (oncologist or haematologist). They consider:

• Exactly where the lymphoma is – this area will receive most of your total dose of radiotherapy.
• Organs at risk – these are critical structures in the body such as the brain, heart, and salivary glands. Your treatment is planned to protect these organs from radiation.

You won’t receive radiotherapy to the rest of your body unless you are having total body irradiation (TBI) or total skin electron radiotherapy (TSET).

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CT scans in the radiotherapy planning process

Most radiotherapy treatment is planned using a computed tomography (CT) scan. You might hear this called a ‘CT planning scan’. Images from the scan are sent to a computer with specialist software to help plan your radiotherapy treatment.

How do doctors use the CT scan images to help plan my radiotherapy?

The CT scan gives images that are a bit like a detailed 3D map. This shows:

• where the lymphoma is
• the exact positions of nearby tissues and organs in your body.

Your radiotherapy team uses specialist computer software to work out the best way to direct the radiotherapy. This makes sure you have the right dose given to precisely the right place. Treatment is also planned to keep radiation to surrounding areas of your body low.

You might also be given a contrast agent, which is a type of dye given to make the CT image clearer. Usually, this is given as an injection into one of your veins. Sometimes, it’s given as drink, depending on which area of your body is being treated. 

If you are having radiotherapy to your chest

You might be asked to take a deep breath in and hold it for around 20 seconds during your CT planning scan and treatment sessions. This technique is called ‘deep inspiration breath hold’. It is only used in certain circumstances. The purpose is to reduce the impact of movement due to breathing in the area being treated. This helps to limit the dose of radiation organs such as the heart receive. The Respire website has information to help you learn to use the deep breath hold technique.

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What dose of radiotherapy will I have?

Radiotherapy doses are measured in units known as ‘Gray’ (Gy). The total dose is split into separate treatments (fractions). The dose you are given will always be within limits of radiation that are known to be safe. 

Your radiotherapy dose is calculated depending on the aim of your treatment.

With curative radiotherapy, treatment is usually given over a few weeks. The reason for spreading it out is to give healthy cells a chance to repair between fractions. Lymphoma cells are most sensitive to radiotherapy when they are dividing, but they do not all divide at the same time. Giving treatment over separate sessions also increases the likelihood of the treatment reaching the lymphoma cells at a time when they are most sensitive to radiotherapy, ie when they are dividing.

With palliative radiotherapy, just one dose can be effective. However, sometimes, a longer course might be recommended.

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What is a treatment mask or shell (for radiotherapy to the head and neck area)?

If you have radiotherapy to the head and neck area, you will probably have a thin plastic mask (shell) made. The mask helps to:

• get you into the same position each time you have treatment
• keep you still during each treatment
• reduce the dose of radiation to surrounding structures in your body – this helps to minimise side effects and the risk of late effects.

Once it’s made, radiographers mark reference points on it. They use these to line up the radiotherapy beams during treatment. You wear the same mask each time you have treatment.

The proton beam therapy treatment sessions themselves took longer than I’d thought. I was usually at the hospital for about 2 hours a day. A lot of the time was spent getting me into a specific position in my radiotherapy mask.

Emma, treated with radiotherapy for Hodgkin lymphoma

How is the shell made?

The shell is usually made from a plastic sheet. The plastic is softened in warm water for a couple of minutes to make it flexible – it can then be shaped around you. The sheet is gently laid over your face. You need to stay still while it cools and sets into the shape of your face. This takes a few minutes. 

Most people say that the process doesn’t feel unpleasant. However, you might be given a custom moulded cushion to go underneath your head and neck during the process. 

You have an appointment lasting around 20 to 30 minutes to make the shell. Then you have your CT planning scan on the same day, once the shell has solidified. For most people, it’s not an unpleasant experience – some patients have even likened it to a spa treatment! You can usually play your own music if you find this more relaxing.

Elizabeth Smith, Therapeutic Radiographer

I had to wear a tight-fitting mask over my face, neck, and shoulders to keep me very still. The radiotherapy itself was only about 7 minutes, but I had the mask on for about 20 minutes for set up.  

Linda, treated with radiotherapy for Burkitt lymphoma

What if I’m nervous about wearing the mask?

Some people find the thought of wearing a radiotherapy mask daunting. However, most people find it OK, even if they feel nervous beforehand. 

Holes in the shell over your mouth let you breathe easily. Depending on the area being treated, extra holes can be cut out over your eyes and nose.

Talk to your medical team if you feel uneasy about wearing the mask. They’re used to talking through worries and concerns, and can give you suggestions to help you feel more relaxed.

If your mask feels uncomfortable, let a member of your medical team know – this helps to give them an opportunity to adjust it for you.

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What happens during a radiotherapy session?

Once you are in the radiotherapy room, you usually lie down on a specialist couch.

The radiotherapy team:

• Check that you're comfortable and go through with you what to expect.
• Take around 5 to 10 minutes getting you into exactly the right position to receive the radiotherapy.
• Dim the lights so that they can see the laser beams more easily. You might notice these as coloured beams coming from different points around the room – they guide the radiographer in getting you and the machine into the correct position.
• Turn on the lights fully and then leave the room.
• Switch on the radiotherapy machine. The machine gives you an accurate dose of radiation.
• Watch you on CCTV while you are having your treatment. They can see and hear you the whole time, and you can hear them too. If you need to call for attention, you can raise your hand.
• Sometimes take low dose 2D or 3D verification images during the treatment session to check that you’re in the correct position. 
• Come back into the room at the end of the treatment session and help you get up.

How long does each radiotherapy session take?

The total time for each treatment session is typically around 10 to 20 minutes. Most of this time is spent getting you into position. The radiotherapy treatment itself takes only a few minutes. 

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Side effects of radiotherapy

Tiredness (fatigue) is a common side effect of radiotherapy. Very often, the tiredness worsens with each treatment. However, it usually starts to get better within a couple of weeks of finishing treatment.  

Other side effects of radiotherapy depend on which part of your body is treated, as well as the type and dose of radiotherapy you have.

The side effects we cover in this information are a general guide. However, your medical team will talk to you about side effects you might get. They can give you a guide as to when they’re likely to start and how long they might go on for. They will also talk to you about any possible late effects you might have. 

Side effects of radiotherapy can include:

• tiredness (fatigue)
• sore skin in the area treated
• sore mouth (oral mucositis) if your head or neck area is treated
• feeling and being sick (nausea) if your brain, stomach or bowel is treated
• diarrhoea or urinary changes if your tummy (abdomen) or pelvis area is treated
• hair loss (which can be temporary) in areas of your body treated
• reduced fertility, if treatment is given to your pelvic area (just below your belly button).

Most radiotherapy departments have Review Radiographers – these are Therapeutic Radiographers who specialise in side effect management. You might see them during the course of your treatment. They will give you their contact details in case you have any radiotherapy related concerns after finishing your treatment course. Radiotherapy side effects usually peak after the course of treatment. Although you shouldn’t experience any new side effects, the ones you do have could worsen  before they improve. It can take a number of weeks to feel ‘normal’ again.

Elizabeth Smith, Therapeutic Radiographer

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Sun safety

After radiotherapy, your skin in the area treated might be more sensitive to ultraviolet (UV) light. This means that you might burn more easily in the sun in these areas.

Your medical team will give you sun safety advice specific to your situation. In some cases, however, you won’t receive much radiation to the skin. You will therefore be advised to just follow general sun safety guidance.

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Follow-up after radiotherapy

After finishing your lymphoma treatment, you will have follow-up appointments. During these, you have conversations with your doctor, nurse or specialist therapeutic radiographer about your physical health and emotional wellbeing. You might also have a physical examination and blood tests.

If you need a PET (positron emission tomography) scan, this will need to be at least 3 months after you finish your course. This is because the radiotherapy is still working in your body during this time. It also causes inflammation, which can confuse the PET scan results.

Your schedule of follow-up depends on several factors. These include the type of lymphoma you were treated for and how long it’s been since you had treatment. If you were treated as part of a clinical trial, your follow-up will depend on the schedule set out in the trial.

I am now in remission. Recovery isn’t just physical, it’s emotional too. I’m feeling a bit unsure of myself at the moment, going from weekly, if not bi-weekly blood tests to 3-monthly blood tests, but I suppose I need to adjust to my new norm again. The specialist nurses are on the end of the phone if I am anxious about anything or have any questions. 

Linda, treated with radiotherapy for Burkitt lymphoma

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Late effects of radiotherapy

Late effects are health problems that happen because of your lymphoma treatment. However, they don’t appear until months or years after you’ve finished treatment.

Not everyone gets late effects. However, your doctor should talk to you about any possible late effects you might be at risk of before you start your treatment. Knowing about these can help you to take any necessary precautions to help minimise the risks. It can also help you to seek advice early if you notice any signs or symptoms that your medical team advise you to be aware of.

The management of late effects has become a focus of research. Many departments now have specialised late effects services. Even if the department you’re treated at doesn’t have its own service, they should be able to refer you to another regional service.

Late effects of radiotherapy can include:

• dental problems because of an increased risk of tooth decay if you had radiotherapy to your head or neck
• eye problems, such as dry eyes and cataracts (cloudy patches in the lens of your eye that can lower your vision) if you’ve had radiotherapy to an area that includes one or both of your eyes
• heart problems, if your heart was in or near the area treated with radiotherapy
• dry mouth, if your salivary glands received radiotherapy
• reduced fertility, if you had radiotherapy to your tummy (abdomen) and the areas just below your belly button (your pelvis)
• lung problems, leading to coughing and shortness of breath, if you had radiotherapy to your chest
• thyroid problems, leading to an underactive thyroid (hypothyroidism). This can make you feel cold and tired, and make you gain weight easily. The risk of developing hypothyroidism is higher in the first five years after treatment but remains increased after this time
• a small risk of developing another (‘second’) cancer many years later.

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