Non-Hodgkin lymphoma: diagnosis and management

  • NICE guideline
  • NG52
  • Published: 
Download guidance (PDF)

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information about shared decision making.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Healthcare professionals should also follow our guidance on:

1.1 Diagnosis

Malignant lymphoma is an HIV indicator condition, as described in EuroTEST's HIV indicator conditions. Also see recommendations 1.1.5 and 1.1.8 in the NICE guideline on HIV testing.

Type of biopsy

1.1.1

Consider an excision biopsy as the first diagnostic procedure for people with suspected non-Hodgkin lymphoma.

1.1.2

Consider a needle core biopsy, taking the maximum number of cores of the largest possible calibre, for people with suspected non-Hodgkin lymphoma when the risk of a surgical procedure outweighs the potential benefits.

1.1.3

If a diagnosis is not possible after a needle core biopsy for people with suspected non-Hodgkin lymphoma, offer an excision biopsy (if surgically feasible) in preference to a second needle core biopsy.

1.1.4

Pathology departments should ensure that tissue from needle core biopsies is conserved so that further analysis can be done if needed.

Diagnosing B-cell lymphomas: gene testing strategies

1.1.5

Consider using fluorescence in situ hybridisation (FISH) to identify an MYC rearrangement in all people newly presenting with histologically high-grade B-cell lymphoma.

1.1.6

If an MYC rearrangement is found, use FISH to identify the immunoglobulin partner and the presence of BCL2 and BCL6 rearrangements.

Stratifying high-grade B-cell lymphomas using laboratory techniques

1.1.7

Do not use immunohistochemistry to assess the prognostic value associated with cell of origin in people with diffuse large B‑cell lymphoma.

1.1.8

Interpret FISH results (MYC, BCL2 and BCL6 rearrangements) in the context of other prognostic factors, particularly the person's age and International Prognostic Index (IPI).

1.1.9

Explain FISH results and their potential prognostic value to people with B‑cell lymphoma.

1.2 Staging using fluorodeoxyglucose-positron emission tomography-CT (FDG-PET-CT)

Confirming staging

1.2.1

Offer FDG‑PET‑CT imaging to confirm staging for people with:

  • stage 1 diffuse large B‑cell lymphoma by clinical and CT criteria

  • stage 1 or localised stage 2 follicular lymphoma if disease is thought to be encompassable within a radiotherapy field

  • stage 1 or 2 Burkitt lymphoma with other low-risk features.

1.2.2

For people with subtypes or stages of non‑Hodgkin lymphoma not listed in recommendation 1.2.1, consider FDG‑PET‑CT imaging to confirm staging if the results will change management.

Assessing response to treatment for diffuse large B-cell lymphoma

1.2.3

Do not routinely offer FDG‑PET‑CT imaging for interim assessment during treatment for diffuse large B‑cell lymphoma.

End-of-treatment assessment

1.2.4

Offer FDG‑PET‑CT imaging to assess response at completion of planned treatment for people with:

  • diffuse large B‑cell lymphoma

  • Burkitt lymphoma.

1.2.5

For people with subtypes of non-Hodgkin lymphoma not listed in recommendation 1.2.4, do not routinely offer FDG‑PET‑CT imaging to assess response at completion of planned treatment unless the results will change management.

1.2.6

Consider FDG‑PET‑CT imaging to assess response to treatment before autologous stem cell transplantation for people with high-grade non-Hodgkin lymphoma.

1.3 Treating follicular lymphoma

First-line treatment for stage 2A follicular lymphoma

1.3.1

Offer local radiotherapy as first-line treatment to people with localised, stage 2A follicular lymphoma.

1.3.2

Consider 'watch and wait' (observation without therapy) as first-line management for people with stage 2A follicular lymphoma:

  • who are asymptomatic and

  • when treatment with a single radiotherapy volume is not suitable.

1.3.3

Offer the same treatments that might be offered to people with advanced (stages 3 and 4), symptomatic follicular lymphoma (see the section on treating advanced, symptomatic follicular lymphoma) to people with stage 2A follicular lymphoma:

  • who are symptomatic and

  • when treatment with radiotherapy is not suitable.

Treating advanced, asymptomatic follicular lymphoma

1.3.4

Offer rituximab induction therapy to people with advanced (stages 3 and 4) follicular lymphoma who are asymptomatic.

In June 2026, this was an off-label use of rituximab. See NICE's information on prescribing medicines.

Treating advanced, symptomatic follicular lymphoma

All adults
Adults with a Follicular Lymphoma International Prognostic Index score of 2 or more
1.3.7

Obinutuzumab is recommended as an option for untreated advanced follicular lymphoma in adults with a Follicular Lymphoma International Prognostic Index score of 2 or more, as induction treatment with chemotherapy, then alone as maintenance therapy. For full details, see NICE's technology appraisal guidance on obinutuzumab (TA513, 2018).

Treating advanced, relapsed or refractory follicular lymphoma

Systemic anticancer therapy
After 2 or more systemic anticancer therapies
Chimeric antigen receptor T-cell (CAR-T) therapy
1.3.14

Lisocabtagene maraleucel is recommended as an option for treating large B-cell lymphoma, including follicular lymphoma grade 3B, that is refractory to, or has relapsed within 12 months after first-line chemoimmunotherapy, in adults for whom an autologous stem cell transplant would be considered suitable. For full details, see NICE's technology appraisal guidance on lisocabtagene maraleucel (TA1048, 2025).

Consolidation with stem cell transplantation

Autologous stem cell transplantation
1.3.16

Offer consolidation with autologous stem cell transplantation for people with follicular lymphoma in second or subsequent remission (complete or partial) who:

  • have not already had a transplant and

  • are fit enough for transplantation.

Allogeneic stem cell transplantation
1.3.17

Consider consolidation with allogeneic stem cell transplantation for people with follicular lymphoma in second or subsequent remission (complete or partial):

  • who are fit enough for transplantation and

  • for whom a suitable donor can be found and

  • who had an autologous stem cell transplantation that did not result in remission or cannot have an autologous stem cell transplantation (for example, because stem cell harvesting is not possible).

Treating transformed follicular lymphoma

1.3.19

Consider consolidation with autologous stem cell transplantation for people:

  • with transformation of previously diagnosed follicular lymphoma that has responded to treatment and

  • who are fit enough for transplantation.

1.3.20

Consider consolidation with autologous or allogeneic stem cell transplantation for people:

  • with transformation of follicular lymphoma who need more than 1 line of treatment for a response and

  • who are fit enough for transplantation.

1.3.21

Do not offer consolidation with high-dose therapy and autologous or allogeneic stem cell transplantation to people with concurrent follicular lymphoma and diffuse large B-cell lymphoma that have responded to first-line treatment.

1.4 Treating marginal zone lymphoma

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma

Localised disease
1.4.3

Consider 'watch and wait' (observation without therapy), unless high-risk features are present, for people:

  • with gastric MALT lymphoma that responds clinically and endoscopically to H. pylori eradication therapy and

  • who have residual disease shown by surveillance biopsies of the stomach.

1.4.4

For people with residual MALT lymphoma after H. pylori eradication therapy who are at high risk of progression [H. pylori-negative at initial presentation or t(11:18) translocation], consider:

1.4.5

For people with progressive gastric MALT lymphoma, offer:

Disseminated disease
1.4.7

Offer chemotherapy (for example, chlorambucil or CVP) in combination with rituximab to people with disseminated gastric MALT lymphoma who need treatment (for example, people who are symptomatic or with threatened vital organ function).

In June 2026, this was an off-label use of rituximab. See NICE's information on prescribing medicines.

1.4.8

Consider 'watch and wait' (observation without therapy) for people with disseminated gastric MALT lymphoma who:

  • are asymptomatic and

  • do not have threatened vital organ function.

Non-gastric MALT lymphoma

1.4.9

For people with non-gastric MALT lymphoma, take into account the following before recommending any treatment:

  • site of involvement and potential for organ dysfunction

  • whether it is localised or disseminated

  • the morbidity associated with any treatment proposed

  • the person's overall fitness.

1.4.10

Offer chemotherapy (for example, chlorambucil or CVP) in combination with rituximab to people with non-gastric MALT lymphoma:

1.4.11

Consider radiotherapy for people with localised disease sites of non-gastric MALT lymphoma at any stage.

1.4.12

Consider 'watch and wait' (observation without therapy) for people:

  • with clinically non-progressive, localised non-gastric MALT lymphoma that is unlikely to result in vital organ dysfunction and

  • who are asymptomatic and

  • when treatment with radiotherapy is not suitable.

All marginal zone lymphoma

1.5 Treating mantle cell lymphoma

First-line treatment

1.5.1

Offer chemotherapy in combination with rituximab as first-line treatment for people with advanced mantle cell lymphoma who are symptomatic, taking the person's fitness into account when deciding the intensity.

In June 2026, this was an off-label use of rituximab. See NICE's information on prescribing medicines.

1.5.2

Consider cytarabine-containing immunochemotherapy for people with advanced mantle cell lymphoma who are fit enough to tolerate an intensive approach.

In June 2026, this was an off-label use of cytarabine. See NICE's information on prescribing medicines.

1.5.3

Consider radiotherapy for people with localised stage 1 or 2 mantle cell lymphoma.

1.5.4

Consider 'watch and wait' (observation without therapy) until disease progression for people with clinically non-progressive mantle cell lymphoma:

  • who are asymptomatic and

  • when treatment with radiotherapy is not suitable.

Consolidation with stem cell transplantation

1.5.6

Consider consolidation with autologous stem cell transplantation for people:

  • with chemosensitive mantle cell lymphoma (that is, there has been at least a partial response to induction chemotherapy) and

  • who are fit enough for transplantation.

Maintenance strategies

1.5.7

Consider maintenance rituximab, every 2 months until disease progression, for people with newly diagnosed mantle cell lymphoma:

  • who are not fit enough for high-dose chemotherapy and

  • whose disease has responded to R‑CHOP-based immunochemotherapy.

    In June 2026, this was an off-label use of rituximab. See NICE's information on prescribing medicines.

1.5.8

Consider maintenance rituximab, every 2 months for 3 years, for people with newly diagnosed mantle cell lymphoma who are in remission after cytarabine-based induction and high-dose chemotherapy.

In June 2026, this was an off-label use of rituximab. See NICE's information on prescribing medicines.

Treating relapsed or refractory mantle cell lymphoma

CAR-T therapy

1.6 Treating diffuse large B-cell lymphoma

First-line systemic anticancer therapy

Radiotherapy in first-line treatment

1.6.2

Consider consolidation radiotherapy delivering 30 Gy to sites involved with bulk disease at diagnosis for people with advanced diffuse large B‑cell lymphoma that has responded to first-line immunochemotherapy. Balance the possible late effects of radiotherapy with the possible increased need for salvage therapy if it is omitted when deciding if the therapy is suitable.

Central nervous system prophylaxis

1.6.3

Explain to people with diffuse large B‑cell lymphoma that they have an increased risk of central nervous system lymphoma if the testis, breast, adrenal gland or kidney is affected.

1.6.4

Explain to people with diffuse large B‑cell lymphoma that they may have an increased risk of central nervous system lymphoma if they meet 2 or more of the following criteria, and that their level of risk increases with the number of factors involved:

  • elevated lactate dehydrogenase (LDH)

  • age over 60 years

  • poor performance status (ECOG score of 2 or more)

  • more than 1 extranodal site involved

  • stage 3 or 4 disease.

1.6.5

Offer central nervous system-directed prophylactic therapy to people with diffuse large B‑cell lymphoma:

  • that involves the testis, breast, adrenal gland or kidney, or

  • who have 4 or 5 of the factors associated with increased risk of central nervous system relapse listed in recommendation 1.6.4.

1.6.6

Consider central nervous system-directed prophylactic therapy for people with diffuse large B‑cell lymphoma who have 2 or 3 of the factors associated with increased risk of central nervous system relapse listed in recommendation 1.6.4.

Treating relapsed or refractory diffuse large B-cell lymphoma

Systemic anticancer therapy
1.6.7

Glofitamab plus gemcitabine and oxaliplatin is recommended as an option for treating relapsed or refractory diffuse large B-cell lymphoma in adults if they have had 1 line of treatment only and are not eligible for an autologous stem cell transplant. For full details, see NICE's technology appraisal guidance on glofitamab (TA1113, 2025).

1.6.9

For medicines recommended as options for treating relapsed or refractory diffuse large B-cell lymphoma in adults after 2 or more systemic treatments, only if they have had polatuzumab vedotin, or if polatuzumab vedotin is contraindicated or not tolerated, see NICE's technology appraisal guidance on:

CAR-T therapy
1.6.12

Lisocabtagene maraleucel is recommended as an option for treating large B-cell lymphoma, including diffuse large B-cell lymphoma, that is refractory to, or has relapsed within 12 months after first-line chemoimmunotherapy, in adults for whom an autologous stem cell transplant would be considered suitable. For full details, see NICE's technology appraisal guidance on lisocabtagene maraleucel (TA1048, 2025).

1.6.13

Axicabtagene ciloleucel is recommended as an option through the Cancer Drugs Fund for treating diffuse large B-cell lymphoma in adults for whom an autologous stem cell transplant is suitable if it has relapsed within 12 months after first-line chemoimmunotherapy or is refractory to first-line chemoimmunotherapy. For full details, see NICE's technology appraisal guidance on axicabtagene ciloleucel (TA895, 2023).

Salvage therapy and consolidation with stem cell transplantation

Salvage therapy
1.6.15

Offer salvage therapy with multi-agent immunochemotherapy to people with relapsed or refractory diffuse large B‑cell lymphoma who are fit enough to tolerate intensive therapy, and:

  • explain that the aim is to enable consolidation with autologous or allogeneic stem cell transplantation, but it is also beneficial even if not followed by transplantation

  • consider R‑GDP immunochemotherapy, which is as effective as other commonly used salvage regimens and less toxic.

Autologous stem cell transplantation
1.6.16

Offer consolidation with autologous stem cell transplantation to people:

  • with chemosensitive diffuse large B‑cell lymphoma (that is, there has been at least a partial response to chemotherapy) and

  • who are fit enough for transplantation.

Allogeneic stem cell transplantation
1.6.17

Consider consolidation with allogeneic stem cell transplantation:

  • for people with chemosensitive diffuse large B‑cell lymphoma (that is, there has been at least a partial response to chemotherapy) that relapses after autologous stem cell transplantation or

  • when stem cell harvesting is not possible.

1.7 Treating Burkitt lymphoma

First-line treatment

1.7.1

Offer intensive immunochemotherapy to people with Burkitt lymphoma who are fit enough to tolerate it.

1.7.2

If intensive immunochemotherapy will be offered to a person with Burkitt lymphoma, consider using one of the following:

  • R‑BFM

  • R‑CODOX‑M/R‑IVAC

  • R‑HyperCVAD (HDMTX)

  • R‑LMB.

1.7.3

For people with low-risk Burkitt lymphoma, consider using the less intensive DA‑EPOCH‑R regimen with intravenous methotrexate, intrathecal methotrexate or both.

1.7.4

Offer less intensive immunochemotherapy to people with Burkitt lymphoma who are not fit enough to tolerate intensive chemotherapy.

1.7.5

If less intensive immunochemotherapy will be offered to a person with Burkitt lymphoma, consider using one of the following, alone or with intravenous methotrexate, intrathecal methotrexate or both:

  • R‑CHOP

  • R‑CHEOP

  • DA‑EPOCH‑R.

1.8 Treating relapsed or refractory high-grade B-cell lymphoma

CAR-T therapy

1.8.2

Lisocabtagene maraleucel is recommended as an option for treating large B‑cell lymphoma, including high-grade B-cell lymphoma, that is refractory to or has relapsed within 12 months after first-line chemoimmunotherapy, in adults for whom an autologous stem cell transplant would be considered suitable. For full details, see NICE's technology appraisal guidance on lisocabtagene maraleucel (TA1048, 2025).

1.9 Treating relapsed or refractory primary mediastinal large B-cell lymphoma

CAR-T therapy

1.9.1

Lisocabtagene maraleucel is recommended as an option for treating large B-cell lymphoma, including primary mediastinal large B-cell lymphoma, that is refractory to or has relapsed within 12 months after first-line chemoimmunotherapy, in adults for whom an autologous stem cell transplant would be considered suitable. For full details, see NICE's technology appraisal guidance on lisocabtagene maraleucel (TA1048, 2025).

1.10 Treating Waldenstrom's macroglobulinaemia

1.11 Treating peripheral T-cell lymphoma

First-line treatment

1.11.1

Consider CHOP chemotherapy as first-line treatment for people with peripheral T‑cell lymphoma.

Consolidation therapy

1.11.2

Consider consolidation with autologous stem cell transplantation for people:

  • with chemosensitive peripheral T‑cell lymphoma (that is, there has been at least a partial response to first-line chemotherapy) and

  • who are fit enough for transplantation.

1.12 Information and support

1.12.1

If 'watch and wait' (observation without therapy) is suggested for a person with non-Hodgkin lymphoma:

  • explain to them (and their family members or carers, as appropriate) what this involves and why it is being advised

  • address any increased anxiety that results from this approach.

1.12.2

Explain to people with low-grade non-Hodgkin lymphoma (and their family members or carers, as appropriate) the possibility of transformation to high-grade lymphoma.

1.12.3

Ensure that people with non-Hodgkin lymphoma have:

  • a named key worker at diagnosis and during treatment and

  • contact details for the specialist team after treatment.

1.12.4

Discuss exercise and lifestyle with people with non-Hodgkin lymphoma from diagnosis onwards.

1.13 Follow-up for people with diffuse large B-cell lymphoma

1.13.1

For people in complete remission after first-line treatment with curative intent for diffuse large B‑cell lymphoma:

  • offer regular clinical assessment

  • consider stopping regular clinical assessment aimed at detecting relapse 3 years after completing treatment for people in ongoing complete remission

  • offer urgent appointments to people who experience a recurrence of lymphoma symptoms or new symptoms that suggest disease relapse

  • do not offer LDH surveillance for detecting relapse

  • do not offer routine surveillance imaging (including chest X‑ray, CT and PET‑CT) for detecting relapse in people who are asymptomatic.

1.14 Survivorship

1.14.1

Give people with non-Hodgkin lymphoma and their GPs end-of-treatment summaries, and discuss with them their personal and general risk factors, including late effects related to their lymphoma subtype or its treatment.

1.14.2

Give people with non-Hodgkin lymphoma when they complete treatment information about how to recognise possible relapse and late effects of treatment.

1.14.3

Consider switching surveillance of late effects of treatment to nurse-led or GP-led services 3 years after a person with non-Hodgkin lymphoma completes a course of treatment.