Referral for Suspected Lymphoma with Right Lower Quadrant Lymphadenopathy
Refer the patient to a surgical oncologist or general surgeon for excisional lymph node biopsy, as this is the gold standard diagnostic procedure for suspected lymphoma and provides adequate tissue architecture for definitive histologic evaluation and immunophenotyping. 1, 2
Primary Referral Pathway
Surgical Referral for Tissue Diagnosis
Excisional lymph node biopsy performed by a general surgeon or surgical oncologist is the preferred diagnostic approach for establishing an accurate pathologic diagnosis in suspected lymphoma, as it provides complete tissue architecture necessary for proper classification according to WHO criteria 1, 2, 3
General surgeons perform the majority (77%) of lymph node biopsies for lymphoma diagnosis, with ENT surgeons handling cervical and head/neck locations 3
Core needle biopsy may be adequate if diagnostic but remains less preferred than excisional biopsy for initial diagnosis 1
Fine-needle aspiration alone is insufficient for initial lymphoma diagnosis except in unusual circumstances when combined with immunohistochemistry and judged diagnostic by an expert hematopathologist 1, 2
Critical Advantage of Direct Surgical Referral
Patients referred directly for surgical biopsy reach final diagnosis in 1.25 months compared to 3 months for those undergoing needle biopsy first (P < 0.0001), significantly reducing investigative time 4
In patients with suspected lymphoma, needle biopsy demonstrates only 68% sensitivity and 71% specificity, missing nearly one-third of cases 4
Secondary Referral After Diagnosis
Hematology-Oncology Referral
Once tissue diagnosis confirms lymphoma, immediate referral to a hematologist-oncologist is essential for staging workup and treatment planning 5, 2
The hematology-oncology team coordinates the comprehensive staging evaluation including PET/CT, bone marrow biopsy (if indicated), and laboratory assessment 5, 1
Radiation Oncology Consultation
Radiation oncology consultation is indicated for early-stage (I/II) follicular lymphoma or Hodgkin lymphoma where involved-field radiotherapy may be curative 5, 2
Combined modality therapy with chemotherapy and radiation is standard for certain Hodgkin lymphoma presentations 2
Common Pitfalls to Avoid
Do not delay surgical biopsy by performing multiple rounds of needle biopsies, as this extends time to diagnosis without improving accuracy 4
Do not refer to interventional radiology for core needle biopsy as the initial diagnostic approach when excisional biopsy is feasible, as inadequate tissue sampling can necessitate repeat procedures 1, 4
Avoid starting corticosteroids before tissue diagnosis, as they can mask the histologic diagnosis of lymphoma or other malignancy 6
Do not dismiss the need for excisional biopsy even when fine-needle aspiration shows "reactive changes" or "normal," as these findings occurred in 18 of 32 cases (56%) that ultimately proved to be lymphoma 3
Pre-Referral Workup Considerations
While awaiting surgical consultation, the following can be initiated:
Complete blood count with differential to evaluate for cytopenias or abnormal lymphocyte populations 1, 6
Lactate dehydrogenase (LDH) as a prognostic marker 1
Comprehensive metabolic panel including liver and renal function 1
Contrast-enhanced CT of abdomen and pelvis to characterize the lymphadenopathy and assess for additional sites 1, 6
However, tissue diagnosis through surgical biopsy remains the priority and should not be delayed by extensive pre-operative testing 1, 2