What is the diagnosis and management for a patient with an enlarged spleen (splenomegaly), prominent lymph nodes (lymphadenopathy), low platelet count (thrombocytopenia), and normal comprehensive metabolic panel (CMP), following a computed tomography (CT) scan and complete blood count (CBC)?

Diagnostic Approach for Lymphoproliferative Disorder with Splenomegaly and Lymphadenopathy

This patient requires an excisional lymph node biopsy immediately to establish a definitive tissue diagnosis, as the combination of widespread lymphadenopathy (largest periportal node 2.2 cm), splenomegaly (14.3 cm), and thrombocytopenia strongly suggests a lymphoproliferative disorder that cannot be adequately characterized without histopathology. 1

Immediate Diagnostic Workup

Tissue Diagnosis - Critical First Step

• Excisional lymph node biopsy is mandatory for any lymph node >1.5 cm in greatest transverse diameter 1
• The periportal lymph node at 2.2 cm short axis meets criteria for biopsy 1
• Provide adequate tissue for both formalin-fixed and fresh frozen samples to allow comprehensive immunohistochemistry, flow cytometry, and molecular studies 1
• Fine needle aspiration is insufficient—surgical excision provides architectural information essential for lymphoma subtyping 1

Essential Laboratory Studies

• Complete blood count with differential (already done, shows isolated thrombocytopenia) 1
• Lactate dehydrogenase (LDH) - elevated in many lymphoproliferative disorders 1
• Serum protein electrophoresis with immunofixation - to detect monoclonal protein (IgM in Waldenström's, other paraproteins in other lymphomas) 1, 2
• Beta-2 microglobulin - prognostic marker 1
• Hepatitis B and C serology, HIV testing - relevant for treatment planning 1

Bone Marrow Evaluation

• Bone marrow aspirate and biopsy are strongly recommended given the thrombocytopenia and concern for marrow involvement 1
• The biopsy sample should be adequate (goal of 20 mm unilateral core) 1
• If morphology is indeterminate, immunohistochemistry should be performed 1

Differential Diagnosis Based on Clinical Presentation

Most Likely Entities

Splenic Marginal Zone Lymphoma

• Classic presentation: splenomegaly as dominant feature, cytopenias from hypersplenism, bone marrow involvement common 3, 2
• Often presents with isolated splenomegaly and lymphadenopathy pattern similar to this case 2

Follicular Lymphoma (Primary Splenic)

• Can present with splenomegaly and widespread lymphadenopathy 3, 4
• Typically CD10-positive B-cell lymphoma 3
• Multimicronodular or multimacronodular splenic pattern 4

Waldenström's Macroglobulinemia

• Presents with lymphadenopathy, splenomegaly, and cytopenias 1
• Serum IgM monoclonal protein is diagnostic 1
• Bone marrow involvement typical 1

Hodgkin Lymphoma

• Can present with mediastinal and hilar lymphadenopathy (as seen on this CT) 1
• Thrombocytopenia can occur as paraneoplastic phenomenon (immune thrombocytopenia) 5
• Splenomegaly present in advanced stages 1

Critical Pitfall to Avoid

Do not assume isolated immune thrombocytopenic purpura (ITP) and treat empirically without tissue diagnosis - thrombocytopenia can be a paraneoplastic manifestation of lymphoma, particularly Hodgkin disease, and treating ITP while missing underlying malignancy delays definitive diagnosis and worsens outcomes 5

Staging After Tissue Diagnosis

Once histologic diagnosis is established:

Imaging Studies

• PET-CT scan is recommended for FDG-avid lymphomas (most aggressive lymphomas, Hodgkin lymphoma) 1
• The CT already performed shows widespread nodal involvement (mediastinal, hilar, retroperitoneal, gastrohepatic, periportal, axillary) suggesting at least Ann Arbor Stage III-IV disease 1
• Pericardial soft tissue densities require clarification—may represent additional nodal involvement 1

Spleen Assessment

• Spleen at 14.3 cm is enlarged (normal upper limit ~12-13 cm) 1
• Splenic involvement confirmed by size and clinical context 1
• For certain indolent lymphomas (splenic marginal zone lymphoma, primary splenic follicular lymphoma), splenectomy may be both diagnostic and therapeutic for stage I disease 3, 2

Management Framework

If Indolent Lymphoma (e.g., Splenic Marginal Zone, Follicular)

• Stage I disease: Splenectomy may be curative or provide long-term disease control 3, 2
• Advanced stage disease: Observation ("watch and wait") if asymptomatic, or rituximab-based therapy if symptomatic 1
• Thrombocytopenia from hypersplenism often improves post-splenectomy 3, 2

If Aggressive Lymphoma (e.g., Diffuse Large B-Cell)

• Combination chemoimmunotherapy (R-CHOP or equivalent) is standard 6
• Splenectomy not indicated as primary treatment 6

If Hodgkin Lymphoma

• Combined modality therapy: ABVD chemotherapy followed by involved-field radiotherapy for limited stage 1
• Advanced stage (III-IV): 6-8 cycles ABVD or escalated BEACOPP 1
• Thrombocytopenia typically resolves with treatment of underlying lymphoma 5

If Waldenström's Macroglobulinemia

• Rituximab plus alkylating agent (bendamustine preferred) or rituximab plus nucleoside analog for symptomatic disease 1
• Monitor for IgM flare with rituximab—consider plasmapheresis if hyperviscosity symptoms present 1

Key Clinical Pearls

• The normal CMP argues against significant tumor lysis or organ dysfunction but does not exclude lymphoma 1
• Isolated thrombocytopenia with normal white blood cell count and hemoglobin suggests either hypersplenism or immune-mediated destruction rather than marrow replacement, but bone marrow biopsy is still essential 1, 7
• Multiple nodal sites (mediastinal, retroperitoneal, axillary) indicate systemic disease requiring systemic therapy rather than local approaches 1
• Do not delay tissue diagnosis—the specific lymphoma subtype fundamentally determines treatment approach and prognosis 1