The three main types of lymphoma are Hodgkin lymphoma, non-Hodgkin B-cell lymphoma, and non-Hodgkin T-cell lymphoma. These categories are based on which type of immune cell becomes cancerous: B-cell lymphomas and T-cell lymphomas are grouped under the non-Hodgkin umbrella, while Hodgkin lymphoma is its own distinct category defined by the presence of specific abnormal cells. Non-Hodgkin lymphoma accounts for about 3.8% of all new cancer cases in the U.S., making it far more common than Hodgkin lymphoma.
Hodgkin Lymphoma
Hodgkin lymphoma is a cancer of B cells, but it behaves so differently from other B-cell lymphomas that it gets its own category. The defining feature is a distinctive abnormal cell called a Reed-Sternberg cell, a large cell (up to 100 microns) with a two-lobed or multi-lobed nucleus and a prominent center. What makes Hodgkin lymphoma unusual is that these malignant cells are relatively few in number. The bulk of a Hodgkin tumor is actually made up of normal inflammatory cells that surround the cancer cells, which is one reason it took so long historically to understand what was driving the disease.
Hodgkin lymphoma tends to spread in an orderly, predictable pattern from one group of lymph nodes to the next. It most commonly appears in younger adults (ages 20 to 39) and again in adults over 65. The classic symptoms, known as “B symptoms,” include unexplained fevers, drenching night sweats, and significant weight loss. Not everyone with Hodgkin lymphoma develops these, but their presence or absence helps doctors determine how aggressive treatment needs to be.
Hodgkin lymphoma generally has high cure rates, particularly when caught early. It was one of the first cancers for which combination treatment proved highly effective.
Non-Hodgkin B-Cell Lymphoma
B-cell lymphomas make up about 85% of all non-Hodgkin lymphomas in the United States, making this by far the largest category. Within it, dozens of subtypes exist, but two dominate.
Diffuse large B-cell lymphoma (DLBCL) is the single most common type of non-Hodgkin lymphoma, accounting for roughly 1 in every 3 cases. It’s considered aggressive, meaning it grows quickly, but that fast growth also makes it more responsive to treatment. DLBCL can arise in lymph nodes or in organs outside the lymphatic system, such as the stomach or brain. Doctors further classify DLBCL by its cell of origin, distinguishing between tumors that resemble germinal center B cells and those that resemble activated B cells, because this distinction affects prognosis and treatment response.
Follicular lymphoma is the second most common subtype, making up about 1 in 5 lymphomas in the U.S. Unlike DLBCL, follicular lymphoma is typically slow-growing (indolent). Many people live with it for years. In some cases, doctors may recommend a “watch and wait” approach rather than immediate treatment, monitoring the disease closely and starting therapy only when symptoms develop or the disease progresses. A small percentage of follicular lymphomas can transform into DLBCL over time, which is one reason ongoing monitoring matters.
Other notable B-cell subtypes include mantle cell lymphoma, marginal zone lymphoma, and Burkitt lymphoma, each with its own behavior and treatment approach.
Non-Hodgkin T-Cell Lymphoma
T-cell lymphomas are far less common than their B-cell counterparts, making up most of the remaining 15% of non-Hodgkin cases. They arise from T cells, a different branch of the immune system responsible for directly attacking infected or abnormal cells. T-cell lymphomas tend to be more difficult to diagnose and, in many cases, harder to treat.
Several distinct subtypes fall under this heading:
- Cutaneous T-cell lymphoma (CTCL) affects the skin and often shows up first as itchy patches or plaques. The two most recognized forms are mycosis fungoides and Sézary syndrome. Because the early stages look like eczema or psoriasis, diagnosis can be delayed.
- Anaplastic large cell lymphoma (ALCL) comes in two forms. The ALK-positive form is more common in younger people and tends to respond better to treatment. A rare form of ALCL has also been linked to certain breast implants.
- Adult T-cell leukemia/lymphoma is caused by a long-term infection with a virus called HTLV-1 and is most common in parts of Japan, the Caribbean, and Central Africa.
- Extranodal NK/T-cell lymphoma is linked to Epstein-Barr virus infection and often begins in the nasal passages, sometimes causing facial swelling or nosebleeds.
How Lymphoma Type Is Determined
A biopsy is the only way to confirm lymphoma and identify its type. The gold standard is a surgical excisional biopsy, which removes an entire lymph node or a large section of tissue. This gives pathologists a full view of the tissue’s architecture, which is critical for distinguishing between subtypes. In a large European study, excisional biopsies led to a definitive diagnosis 98.1% of the time, compared to 92.3% for core needle biopsies.
The difference matters most for certain subtypes that are harder to pin down on a small tissue sample. T-cell lymphomas and Hodgkin lymphoma in particular presented diagnostic challenges on needle biopsies, largely because their identification depends on seeing how the cells are arranged within the broader tissue structure. One subtype of Hodgkin lymphoma, nodular lymphocyte-predominant Hodgkin lymphoma, was diagnosed less than half as often on needle biopsy compared to surgical excision.
Once tissue is obtained, pathologists use a combination of microscopic examination, immune cell markers (such as CD30 and CD15 for Hodgkin lymphoma), and sometimes gene expression analysis to classify the lymphoma precisely. Getting the subtype right is essential because treatment strategies vary dramatically between an indolent follicular lymphoma, an aggressive DLBCL, and a Hodgkin lymphoma.
Shared Symptoms Across All Types
Despite their biological differences, the three main types of lymphoma often present with overlapping symptoms. Painless swelling of lymph nodes in the neck, armpit, or groin is the most common first sign. The B symptoms (fever, night sweats, unexplained weight loss) can occur across all types, though they are formally used in staging for Hodgkin lymphoma. Fatigue and itching are also common.
The location of symptoms sometimes hints at the type. Hodgkin lymphoma frequently starts in the upper body, particularly the chest and neck. T-cell lymphomas may show up as skin changes before any lymph node swelling. B-cell lymphomas can appear almost anywhere, including organs outside the lymphatic system. But none of these patterns are reliable enough for diagnosis on their own, which is why biopsy and lab analysis remain essential for every suspected case.