An accurate assessment of individuals with suspected lymphoma requires a range of investigations depending on the presenting symptoms.
A guide for general practitioners (PDF, 1004KB) has been developed to support diagnosis and management in primary health care settings.20
Investigations for suspected NHL include:3, 20
- full medical history, with particular examination of risk factors
- physical examination
- FBE, Serum LDH, ESR
- chest x-ray
- CT or PET-CT (optional)
- lymph node biopsy (as per indications)
- endoscopic ultrasound (gastric MALT lymphoma)
- head CT or brain MRI and lumbar puncture to analyse cerebrospinal fluid (MCL and DLBCL).
Less than 1% of individuals presenting with peripheral lymphadenopathy will actually have a malignancy. Enlarged intra-abdominal or retroperitoneal nodes however are usually malignant.15 Initial investigations of a full blood count and chest X-ray should be performed prior to biopsy. Other malignancies should be considered such as a head and neck cancer or breast cancer in the case of axillary lumps in women.15
Current guidelines outline the following indications to guide the use of lymph node biopsy:15
- age 40 years or older
- supraclavicular location
- node diameter greater than 2.25 cm
- firm hard texture
- lack of tenderness
- present more than a few weeks.
Fine needle aspiration (FNA) is the biopsy investigation of choice in the initial triage for individuals presenting with peripheral lymphadenopathy where other diagnoses have been ruled out. This should be followed by flow cytometry studies.15 if the FNA outcome is reported as lymphoma then excisional lymph node biopsy is required for a definitive diagnosis, sub-typing and clinical management.15 Current NCCN guidelines recommend incisional or excisional lymph node biopsy to establish a diagnosis of NHL.3
While some lymphomas can be diagnosed with morphology outcomes alone, most require exploration of further variables to ensure an accurate diagnosis. It is essential that although not all tests are required in every case, advanced laboratory services, specifically immunophenotyping and molecular techniques, should be available and accessible to support the diagnosis of lymphoma.7
Access the Clinical practice guidelines for the diagnosis and management of lymphoma,15 and discuss the investigations and actions that are recommended for a person presenting with:
- Peripheral lymphadenopathy
- Intracavity presentation
- Constitutional (B) symptoms (weight loss and fever).
Identify the potential concerns of a person being assessed for symptoms indicative of lymphoma.
Follow up diagnostic investigations
Additional investigations may be required if presenting symptoms are suggestive of specific organ involvement (e.g. CT scan, chest X-ray). Best practice indicates referral to a clinical haematologist or medical oncologist. A pathologist must be involved in the complex diagnostic process associated with lymphoma.15
Bone marrow aspiration and trephine (BMAT) provides reporting of the extent and the pattern of marrow involvement, along with the cell type. BMAT is indicated for staging at initial diagnosis and in rare circumstances for the primary diagnosis and sub-typing of lymphoma in individuals with no other accessible disease.3, 15, 18
BMAT is not recommended for the primary diagnosis of lymphoma because of frequent histological discordance between marrow and other sites. It is recommended that the procedure be carried out by haematologists (trained or in training), or other medical practitioners specifically trained in this technique.15
Outline the information and resources you would provide for a person to prepare them for the following tests investigating a haematological malignancy and the associated nursing considerations:
- Fine Needle Aspiration
- excisional lymph node biopsy
- Bone Marrow Aspiration and Trephine
- PET scan.