From the Guidelines
The diagnostic steps for suspected lymphoma should begin with a thorough clinical evaluation, including a complete physical examination and relevant laboratory tests, followed by imaging studies such as PET-CT for FDG-avid lymphomas, and a definitive diagnosis requires a lymph node biopsy, preferably an excisional biopsy, as recommended by the Lugano classification 1. When lymphoma is suspected, the first step is to perform a complete physical examination focusing on enlarged lymph nodes, along with blood tests including complete blood count, lactate dehydrogenase, and liver function tests.
- Imaging studies such as CT scans, PET scans, or MRIs help determine the extent of disease.
- The definitive diagnosis requires a lymph node biopsy, preferably an excisional biopsy where the entire node is removed for pathological examination, as stated in the Lugano classification 1.
- Bone marrow biopsy may also be necessary to assess disease spread, although a bone marrow biopsy is no longer indicated for Hodgkin lymphoma if a PET-CT is performed, unless it is necessary for identifying a discordant histology in non-Hodgkin lymphoma 1. Treatment depends on the lymphoma type, stage, and patient factors.
- For Hodgkin lymphoma, ABVD chemotherapy is commonly used, typically administered every two weeks for 2-6 months.
- For aggressive non-Hodgkin lymphomas like diffuse large B-cell lymphoma, R-CHOP is standard, given in 21-day cycles for 6-8 cycles.
- Indolent lymphomas may be managed with watchful waiting, single-agent Rituximab, or Bendamustine-Rituximab combinations. Throughout treatment, patients need regular monitoring for treatment response and side effects, including complete blood counts before each chemotherapy cycle, interim PET/CT scans, and cardiac monitoring for anthracycline-containing regimens.
- Treatment decisions should be individualized based on lymphoma subtype, disease stage, patient age, and comorbidities, with care coordinated through a multidisciplinary team including hematologists/oncologists, radiation oncologists, and pathologists. The Lugano classification provides a framework for the initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma, emphasizing the importance of a thorough clinical evaluation, appropriate imaging studies, and a definitive diagnosis through lymph node biopsy 1.
From the FDA Drug Label
Prior to First Infusion: Screen all patients for HBV infection by measuring HBsAg and anti-HBc before initiating treatment with RITUXAN Obtain complete blood counts (CBC) including platelets prior to the first dose.
The diagnostic steps for suspected lymphoma include screening for HBV infection and obtaining complete blood counts (CBC), but the provided drug label does not directly address the diagnostic steps for lymphoma. Treatment options for lymphoma are described, including the use of rituximab in combination with chemotherapy for certain types of lymphoma, such as diffuse large B-cell lymphoma and follicular lymphoma 2.
From the Research
Diagnostic Steps for Lymphoma
- Lymphoma is a group of malignant neoplasms of lymphocytes with more than 90 subtypes, and an open lymph node biopsy is preferred for diagnosis 3
- The Lugano classification system incorporates symptoms and the extent of the disease as shown on positron emission tomography/computed tomography to stage lymphoma 3
- Positron emission tomography/computed tomography (PET/CT) is superior to computed tomography (CT) and PET alone in nodal evaluation and detection of extranodal disease 4
- Bone marrow biopsy and aspirate (BMAB) is considered the gold standard to detect lymphomatous bone marrow involvement, but PET/CT may be a noninvasive alternative in some cases 5
Treatment Options for Lymphoma
- Chemotherapy treatment plans differ between the main subtypes of lymphoma, with non-Hodgkin lymphoma treated with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) with or without rituximab (R-CHOP), bendamustine, and lenalidomide 3
- Hodgkin lymphoma is treated with combined chemotherapy with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), Stanford V, or BEACOPP with radiotherapy 3
- Subsequent chemotherapy toxicities include neuropathy, cardiotoxicity, and secondary cancers, and should be considered in the shared decision-making process to select a treatment regimen 3
Staging and Prognosis
- Accurate initial staging of patients with non-Hodgkin lymphoma and Hodgkin lymphoma is critical for the selection of an appropriate treatment 4
- The Revised International Prognostic Index score is used to determine the prognosis of patients with lymphoma 5
- Bone marrow involvement detected by BMAB is associated with lower progression-free survival and overall survival, while PET/CT-detected bone marrow involvement is associated with overall survival only 5, 6