Referral for Suspected Lymphoma in Family Practice
Patients with abnormal bloodwork and suspected lymphoma should be referred to hematology for definitive diagnosis and management. 1
When to Refer to Hematology
Refer promptly to hematology when you have:
Abnormal complete blood count with peripheral blood smear findings suggestive of hematologic malignancy (elevated lactate dehydrogenase, abnormal lymphocyte morphology, unexplained cytopenias, or elevated white blood cell count with atypical cells) 1, 2
Palpable lymphadenopathy ≥1.5 cm, especially if firm, irregular, clustered, or fixed 1
Systemic symptoms ("B symptoms") including unexplained weight loss, fever, or drenching night sweats in combination with abnormal bloodwork 2
Unexplained nocturnal pruritus with hematologic abnormalities, as this can be an early warning sign of Hodgkin lymphoma or polycythemia vera 2
Initial Workup Before Referral
While arranging hematology referral, you should obtain:
- Complete blood count with manual differential and peripheral blood smear review 1, 2
- Lactate dehydrogenase (LDH) and erythrocyte sedimentation rate (ESR) as markers of hematologic disease activity 1, 2
- Comprehensive metabolic panel to assess for tumor lysis syndrome risk 1
- Ferritin levels, as iron deficiency can mimic or coexist with hematologic disorders 2
Critical Timing Considerations
Do not delay referral to perform extensive workup if lymphoma is strongly suspected. The British Association of Dermatologists and ASCO guidelines emphasize that patients with suspected hematologic malignancy should be referred promptly to hematology, and the specialist center should perform definitive diagnostic procedures (bone marrow biopsy, flow cytometry, cytogenetics) to avoid duplicate testing and delays in treatment. 1
What NOT to Do
Avoid performing bone marrow aspiration or biopsy in primary care if the patient will require referral to a hematology center, as this leads to duplicate procedures, patient discomfort, and delays 1
Do not order extensive imaging (CT, PET scans) before hematology consultation unless there are urgent clinical concerns requiring immediate evaluation 1
Information to Provide at Referral
When referring to hematology, send:
- All laboratory results including complete blood counts, chemistry panels, and LDH 1
- Peripheral blood smear findings 1
- Documentation of any palpable lymphadenopathy with measurements 1
- List of systemic symptoms and their duration 2
- Any pending test results (forward when available) 1
Special Circumstances Requiring Urgent Referral
Refer emergently (same-day or next-day) if:
- Severe cytopenias (hemoglobin <8 g/dL, platelets <50,000, absolute neutrophil count <1,000) suggesting bone marrow failure 3
- Rapidly enlarging lymphadenopathy or mediastinal mass causing compressive symptoms 1
- Tumor lysis syndrome (elevated uric acid, potassium, phosphate with acute kidney injury) 1
Alternative Referral Pathways
Dermatology referral is appropriate if the primary presentation is cutaneous lesions with suspected cutaneous lymphoma, though hematology involvement will ultimately be required for staging and systemic therapy 1, 2
General surgery may be needed for lymph node biopsy in cases of isolated peripheral lymphadenopathy, but coordinate with hematology first to determine if flow cytometry or other specialized testing should be arranged at the time of biopsy 4