Who should be screened for lymphoma?

Lymphoma Screening Recommendations

There is currently no recommended routine screening for lymphoma in asymptomatic individuals without specific risk factors. Instead, diagnosis is typically made when patients present with symptoms or findings suggestive of lymphoma 1.

Diagnostic Approach for Suspected Lymphoma

Initial Clinical Assessment

• Evaluate for constitutional symptoms including fever, night sweats, weight loss, alcohol intolerance, pruritus, and fatigue 2
• Perform thorough physical examination of all lymphoid regions, with special attention to the abdomen for hepatosplenomegaly and masses 2
• Document performance status as it impacts treatment decisions and prognosis 2

High-Risk Populations Requiring Closer Monitoring

• Individuals with:
  • Autoimmune diseases (particularly Sjögren's syndrome and Hashimoto's thyroiditis) 3
  • Family history of hematological malignancies 3
  • HIV infection 3
  • History of organ transplantation or immunosuppression 4
  • Prior radiation treatment 3
  • Occupational exposures (farm workers, painters) 3

Laboratory Evaluation When Lymphoma is Suspected

• Complete blood count with differential to assess for cytopenias 2
• Comprehensive metabolic panel including liver and renal function tests 2
• Lactate dehydrogenase (LDH) and uric acid levels as markers of tumor burden 2
• Hepatitis B, C, and HIV screening (mandatory before initiating rituximab therapy) 2
• Protein electrophoresis for B-cell lymphomas 5

Imaging Studies

• PET/CT scan (skull base to mid-thigh) is essential for initial staging 2, 1
• Diagnostic contrast-enhanced CT of neck, chest, abdomen, and pelvis if PET/CT is not immediately available 2
• PET-CT is superior to conventional CT for detecting both nodal and extranodal disease sites 1

Definitive Diagnosis

• Excisional lymph node biopsy is the preferred diagnostic method 2, 1
• Core needle biopsy should only be performed when excisional biopsy is not feasible 2, 1
• Fresh frozen and formalin-fixed samples should be obtained for adequate pathological evaluation 5
• The histological report should include diagnosis according to the WHO classification with appropriate immunohistochemistry 5

Staging and Risk Assessment

• Ann Arbor classification system is used for staging 5, 2
• International Prognostic Index (IPI) should be calculated for prognostic purposes 5
• Bone marrow biopsy is required for complete staging but may be omitted in certain circumstances such as negative PET scan 2, 1
• For Hodgkin lymphoma, PET-CT can replace bone marrow biopsy as it is more sensitive for detecting bone marrow involvement 1

Common Pitfalls to Avoid

• False-positive rate with PET scans exceeds 20%, which can lead to unnecessary investigations 1
• Relying solely on CT for FDG-avid lymphomas may result in understaging 1
• Fine needle aspirations or core biopsies alone may not provide sufficient material for accurate diagnosis 5
• Routine surveillance imaging in remission patients has not been shown to improve survival outcomes 1

Follow-up Recommendations

• History and physical examination every 3 months for 2 years, every 6 months for 3 more years, and then once a year 5
• Blood count and LDH at 3,6,12, and 24 months, then only as needed for evaluation of suspicious symptoms 5
• Evaluation of thyroid dysfunction in patients with irradiation to the neck at 1,2, and at least at 5 years 5
• Women who received chest irradiation at premenopausal age should be screened for secondary breast cancers 5