Recommended Workup for Suspected Lymphoma
The essential workup for suspected lymphoma begins with an excisional lymph node biopsy, followed by comprehensive imaging with CT scans of neck, thorax, abdomen, and pelvis, plus PET-CT scan, along with complete laboratory studies including blood counts, chemistry, and viral screening. 1
Initial Diagnostic Approach
Biopsy and Pathological Diagnosis
- An excisional lymph node biopsy is mandatory for accurate diagnosis and should be the first step in lymphoma workup 1
- Core biopsies should only be performed when lymph nodes are not easily accessible 1
- Fine needle aspirations are inappropriate for proper diagnosis and should only be used in rare emergency situations 2
- Fresh frozen tissue should be stored when possible to allow for additional molecular analyses 1
- The histological report should follow the World Health Organization classification 2
Laboratory Studies
- Complete blood count with platelets and differential 1
- Blood chemistry profile including: 2
- Lactate dehydrogenase (LDH)
- C-reactive protein (CRP)
- Alkaline phosphatase (AP)
- Liver enzymes
- Albumin
- Uric acid
- Renal function tests
- Erythrocyte sedimentation rate (ESR) testing 2
- Mandatory screening for hepatitis B (HBV), hepatitis C (HCV), and HIV 2
- Tumor lysis syndrome panel (serum LDH, uric acid, potassium, phosphates, calcium) 1
Imaging Studies
- Chest X-ray is mandatory 2
- Contrast-enhanced CT scan of the neck, chest, abdomen, and pelvis is required 2
- Baseline whole-body PET scan should be performed according to recommendations for staging and response assessment 2
- PET-CT is particularly valuable to: 1
- Confirm localized stage I/II disease
- Identify areas with high standardized uptake values suspected of disease transformation
- Serve as baseline for response assessment
Bone Marrow Assessment
- Given the high sensitivity of PET-CT for bone marrow involvement, a bone marrow biopsy is no longer indicated in patients undergoing PET-CT evaluation 2
- However, bone marrow biopsy must be performed if PET-CT is not available 2
Additional Evaluations Based on Clinical Presentation
- For suspected CNS involvement: lumbar puncture for cerebrospinal fluid analysis and CT/MRI scan of the head with contrast 1
- For suspected gastrointestinal involvement: gastrointestinal endoscopy, especially in limited stage I/II disease 1
- For male patients: evaluation for testicular involvement 1
Pre-treatment Examinations
- Electrocardiography (ECG) 2
- Echocardiography 2
- Pulmonary function tests 2
- Reproductive counseling for patients of reproductive age 2
- Serum pregnancy test for female patients of reproductive age 2
- Consultation with an ear, nose, and throat specialist including a fiberoptic nasolaryngoscopy (if PET-CT scan is not available at initial staging) 2
Staging and Risk Assessment
- Staging should be performed according to the Ann Arbor classification system 2
- After completion of staging, patients are allocated to one of three categories: limited, intermediate, and advanced stages 2
- For follicular lymphoma, the Follicular Lymphoma-specific International Prognostic Index (FLIPI) should be determined 2
Common Pitfalls and Caveats
- Inadequate biopsy specimens may lead to misdiagnosis - always ensure sufficient tissue is obtained through excisional biopsy 2
- Core needle biopsies and fine needle aspirations often provide insufficient material for accurate diagnosis and should be avoided when possible 2
- Initiating treatment before complete staging can compromise optimal therapy planning 2
- Failure to screen for viral infections (HBV, HCV, HIV) can lead to complications during treatment 2
- Bone marrow assessment is critical when PET-CT is unavailable to determine disease extent 2