What is the initial workup for suspected lymphoma in the Emergency Department (ED)?

Initial Workup for Suspected Lymphoma in the Emergency Department

The initial workup for suspected lymphoma in the Emergency Department should include a complete blood count, comprehensive metabolic panel, LDH, uric acid, HIV and hepatitis B/C screening, and appropriate imaging studies based on clinical presentation. 1, 2

Clinical Assessment

• Obtain a comprehensive history focusing on constitutional symptoms such as fevers, night sweats, unexplained weight loss, fatigue, and pruritus 2
• Perform a thorough physical examination with measurement of all accessible lymph node groups and assessment of spleen and liver size 2
• Document presence of B symptoms (fever >38°C, night sweats, weight loss >10% of body weight over 6 months) as these impact staging and prognosis 1, 2

Laboratory Studies

• Complete blood count with differential to assess for cytopenias or leukocytosis 1
• Comprehensive metabolic panel including liver and kidney function tests 1
• Lactate dehydrogenase (LDH) and uric acid levels as markers of tumor burden and for prognostic purposes 1
• HIV and hepatitis B/C screening as these infections can impact treatment decisions 1
• Consider protein electrophoresis for suspected B-cell lymphomas 1

Imaging Studies

• CT scan of neck, chest, abdomen, and pelvis with contrast is the minimum imaging requirement for suspected lymphoma in the ED 1
• Chest X-ray may be performed if CT is not immediately available 1
• PET-CT is preferred for staging but is typically not performed in the ED setting and should be arranged for outpatient follow-up 1, 2

Tissue Diagnosis

• Do not perform fine-needle aspiration as the sole diagnostic procedure for lymphoma as it is inadequate for definitive diagnosis 1, 2
• Arrange for excisional or incisional lymph node biopsy as the gold standard for diagnosis 1, 2
• Core needle biopsy should only be considered for patients with difficult-to-access lymph nodes (e.g., retroperitoneal) 1, 2
• Ensure adequate tissue is obtained for comprehensive pathologic evaluation including morphology, immunohistochemistry, flow cytometry, and molecular studies 2

Additional Considerations

• For patients with suspected high-risk features (bone marrow involvement, testicular involvement, spine or skull base lesions), consider diagnostic lumbar puncture with CSF analysis 1
• Bone marrow aspiration and biopsy should be arranged but are typically not performed in the ED 1
• Document presence of bulky disease (>6 cm) as this impacts staging and treatment decisions 1

Disposition Planning

• Consult hematology/oncology for all patients with strong suspicion of lymphoma 1
• Consider admission for patients with:
  • Significant B symptoms affecting functional status 1
  • Bulky disease causing airway compromise or organ dysfunction 1
  • Tumor lysis syndrome (elevated uric acid, hyperkalemia, hyperphosphatemia, hypocalcemia) 1
  • Superior vena cava syndrome or other oncologic emergencies 1
• For stable patients without emergent complications, arrange expedited outpatient follow-up with hematology/oncology 1

Common Pitfalls to Avoid

• Relying solely on physical examination for lymph node assessment 2
• Using fine-needle aspiration as the sole diagnostic procedure 1, 2
• Failing to obtain adequate tissue for comprehensive pathologic evaluation 1, 2
• Not screening for HIV and hepatitis B/C, which can impact treatment decisions 1
• Delaying consultation with hematology/oncology for patients with suspected lymphoma 1