What is the next step in management for a patient with a diagnosis of lymphoma, presenting with cervical lymphadenopathy, intermittent low-grade fever, night sweats, and unintentional weight loss?

Next Step in Management for Lymphoma with Cervical Lymphadenopathy and B Symptoms

Following excisional biopsy confirmation of lymphoma, the immediate next step is comprehensive staging with CT scans of the neck, chest, abdomen, and pelvis, along with bone marrow biopsy, complete blood count, ESR, LDH, liver enzymes, and albumin. 1, 2

Mandatory Staging Procedures

The staging workup must include:

• CT imaging of neck, chest, and abdomen - This is obligatory for all lymphoma patients to determine disease extent 1

• Bone marrow aspiration and biopsy - Required to assess marrow involvement 1

• Complete blood count and ESR - Essential baseline hematologic parameters 1

• Blood chemistry panel including:

  • LDH (lactate dehydrogenase) 1
  • Liver enzymes (AP, ALT, AST) 1
  • Albumin 1
  • Glucose 1
  • TSH (thyroid-stimulating hormone) 1

• PET-CT scan - Should be strongly considered as it provides superior staging accuracy and is increasingly standard for lymphoma evaluation 1, 2

• Infectious disease screening - HIV, hepatitis B and C testing 1

Pre-Treatment Assessments

Before initiating therapy, the following evaluations are mandatory:

• Cardiac function tests (echocardiogram or MUGA scan) - Required to identify patients at risk for chemotherapy-related cardiotoxicity 1
• Pulmonary function tests - Mandatory prior to treatment, particularly important given bleomycin use in many regimens 1
• ENT consultation - Should be considered given the cervical/head and neck involvement 1
• Fertility counseling - Essential for this 25-year-old male, as chemotherapy and radiotherapy can cause permanent fertility damage; sperm banking should be discussed 1

Clinical Context and Risk Stratification

This patient presents with B symptoms (fever, night sweats, weight loss), which are critical prognostic indicators:

• B symptoms indicate more advanced disease and affect staging classification (adding "B" designation to the stage) 1, 3
• The presence of B symptoms combined with cervical lymphadenopathy is highly characteristic of lymphoma 2
• For Hodgkin lymphoma specifically, elevated ESR thresholds differ based on B symptom presence: >30 mm/h with B symptoms versus >50 mm/h without 1

Staging System Application

Once staging is complete, the Ann Arbor staging system will be applied 1:

• Stage I-II: Limited disease
• Stage III-IV: Advanced disease
• Risk factors that influence treatment category include: large mediastinal mass, elevated ESR, number of nodal areas involved (≥3-4 depending on protocol), age, and extranodal disease 1

Important Caveats

Do not proceed with staging laparotomy - This is explicitly not recommended in modern lymphoma management 1

Timing is critical - All staging procedures should be completed expeditiously before treatment initiation, as the presence of B symptoms indicates active, symptomatic disease requiring prompt intervention 2, 3

PET-CT superiority - While CT alone is mandatory, PET-CT detects additional lesions and changes clinical stage in a significant proportion of patients, making it the preferred imaging modality when available 1, 2, 4

The specific treatment regimen (ABVD for Hodgkin lymphoma or R-CHOP for diffuse large B-cell NHL) will be determined only after the histologic subtype is confirmed from the excisional biopsy and complete staging establishes whether the patient has limited, intermediate, or advanced stage disease 1, 2, 5.