Clinical Practice Guideline



Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists


Overview: Non-Hodgkin’s Lymphomas (NHL) are a heterogeneous group of malignancies of B or T cell that usually originate in lymph nodes but may originate in any organ of the body.


In 1993, new cases of NHL in the US were estimated to be 43,000, an incidence of 17.4 per 100,000 population.  This represents 4% of cancer incidence.  While there is a pre-adolescent peak in incidence, there is generally a logarithmic increase with age.  Several exposure agents (phenytoin, benzene and herbicides) as well as viral agents (Epstein-Barr virus and HTLV-I) have been documented to increase NHL incidence.


Because there is such histologic diversity among NHL, multiple classification schemes have been advanced.  Recently, the Working Formulation developed a morphologic classification scheme with prognostic relevance.  In this system, NHL are divided into low-, intermediate-, and high-grade status.  NHL is staged using the four-stage Ann Arbor classification outlined above for Hodgkin’s Disease.  Because lymphomas spread hematogenously, rather than continuously from lymph node areas as occur in HD, most lymphomas present in advanced stages (III or IV).


Many adverse prognostic factors have been documented, including anaplastic histologic subtype, advanced stage of disease (III or IV), extranodal disease (particularly CNS involvement), systemic B symptoms, tumor mass > 10 cm, elevated LDH, T-cell phenotype, nonrandom chromosomal abnormalities, and a high proliferative index (Ki-67 antigen).


Because of the wide variety of histologic subtypes of T and B cells, a number of cytotoxic agents have been used in the treatment of NHL in addition to radiotherapy and immunotherapy.  Predominantly combination regimes such as CHOP, CVP, and COP-BLAM have produced cure rates (5-year survival rates) ranging from 20% to 85%.  These cure rates are highly variable and dependent on the previously mentioned prognostic factors (particularly grade and stage at time of treatment).  Relapse rates up to 50% are common. Recently bone marrow transplantation has been used in refractory cases with limited success.


Aeromedical Concerns: If there is involvement of the CNS, then a risk for sudden incapacitation by seizure is present.  However, the greatest concern arises from the potentially rapid (weeks to months) degradation in mental and physical status when the lymphoma and/or the treatment protocol is aggressive.  Extranodal involvement of the lungs, liver, spleen, marrow, and heart are frequently seen with progression of disease.  Additionally, damage to the cardiopulmonary, neurologic, and reticuloendothelial systems may occur as a result of chemotherapy and radiotherapy.  Thorough staging and documentation of status are necessary for waiver consideration.


Treatment and Aeromedical Disposition: Initial presentation, as a minimum, should include Hematology/Oncology consultation CBC, CXR, ECG, PFT, staging and prognosis, with documentation of all medications and treatments, complications, and sequelae.


Experience: The US Air Force aircrew waiver file lists four members with NHL in remission and all received waivers (3 of the 4 received FCII waiver).  Although these numbers are small, the possibility of returning to flying status after effective treatment of NHL is good.  In civil aviation the airman would have to be in remission for approximately one yr.  Medical certification is not granted during any form of active treatment.  At present there are no separate statistical data on airmen with Non-Hodgkin’s Lymphoma.  Please refer to the FAA statistical data found under Hodgkin’s Lymphoma for the numbers.  




Deangelis LM. Current management of primary central nervous system lymphoma. Oncology 1995; 9(1):63-71.


Greer JP, Malon WR, List AF, McCurley TL. Non-Hodgkin’s lymphomas. Lee GR, Bithell, TC, Foerster J, Athens JW, Lukens JN (eds). Wintrobe’s Clinical Hematology 1993; 9:2054-2081.


Hartge P, Devesa SS, Fraumeni JF. Hodgkin’s and non-Hodgkin’s lymphomas Cancer 1994; 19-20:423-53.


Horning AJ. Hodgkin disease. Beutler E, Lichtman MA, Coller BS, Kipps TJ (eds). Williams Hematology. 1995; 5:1057-1075.



August 2, 2006