I have a history of non‑Hodgkin lymphoma, cervical intraepithelial neoplasia grade 2/3, night sweats, low‑grade fever, bone pain, gastrointestinal symptoms, and elevated CA 19‑9 and CA 15‑3; my provider says I don’t have cancer—what should I do?

Your Provider's Assessment Requires Immediate Verification Through Objective Testing

Given your concerning constellation of symptoms—history of non-Hodgkin lymphoma, cervical dysplasia, persistent B symptoms (night sweats, low-grade fever), bone pain, GI symptoms, and elevated tumor markers (CA 19-9, CA 15-3)—you must obtain tissue diagnosis through excisional lymph node biopsy or imaging with PET-CT to definitively rule out lymphoma recurrence or new malignancy, regardless of your provider's clinical impression. 1, 2

Why Your Symptom Pattern Demands Further Investigation

Your clinical presentation includes multiple red flags that mandate objective evaluation:

Constitutional "B Symptoms" Are Hallmark Lymphoma Features

• Fevers above 101°F (38.3°C), drenching night sweats, and unexplained weight loss >10% over 6 months are defining characteristics of lymphoma and should trigger immediate staging workup in anyone with lymphoma history 1, 2
• These symptoms specifically indicate more advanced or active disease and are incorporated into formal staging classifications 1
• The presence of B symptoms in a patient with prior non-Hodgkin lymphoma history represents potential relapse until proven otherwise 1

Bone Pain and GI Symptoms Suggest Extranodal Involvement

• Bone pain may indicate bone marrow involvement, which occurs frequently in non-Hodgkin lymphoma and requires evaluation 1, 3
• GI symptoms are particularly concerning given that 15-30% of certain lymphoma subtypes (like mantle cell lymphoma) involve the gastrointestinal tract 1
• Your symptom complex mirrors the presentation patterns described for systemic lymphoma 1, 4

Elevated Tumor Markers Require Explanation

• While CA 19-9 and CA 15-3 are not specific for lymphoma, their elevation in the context of your other symptoms and cancer history demands investigation for malignancy 1
• These markers, combined with constitutional symptoms, create a clinical picture that cannot be dismissed without objective testing 1

The Diagnostic Algorithm You Must Follow

Step 1: Obtain Definitive Tissue Diagnosis

An excisional or incisional lymph node biopsy is the gold standard—fine-needle aspiration is inadequate for initial or recurrent lymphoma diagnosis 1, 2

• The biopsy must provide adequate tissue for morphology, immunohistochemistry, flow cytometry, and molecular studies reviewed by an experienced lymphoma pathologist 1, 2
• If accessible lymphadenopathy is present, this should be biopsied immediately 1, 2
• Core-needle biopsy can be considered only when excisional biopsy is not feasible, but a nondiagnostic sample must be followed by excisional biopsy 1

Step 2: Comprehensive Imaging Evaluation

PET-CT is the mandatory staging modality for FDG-avid lymphomas and should be performed before any treatment decisions 1, 2

• PET-CT of chest, abdomen, and pelvis is required to assess for nodal and extranodal disease 1, 2
• This imaging can detect bone marrow involvement and is considered adequate for determination of marrow disease without biopsy in many cases 1
• CT scanning alone is insufficient for FDG-avid lymphoma subtypes 2

Step 3: Mandatory Laboratory Assessment

The following tests are non-negotiable for lymphoma evaluation 1, 2:

• Complete blood count with differential (to assess for cytopenias or lymphocytosis) 1, 3
• Comprehensive metabolic panel including LDH (elevated LDH indicates high tumor burden) 1
• Hepatitis B and C testing (required before immunotherapy regimens) 1
• Beta-2 microglobulin levels 1
• Assessment for tumor lysis syndrome if high tumor burden suspected (uric acid, phosphate, calcium, potassium) 1

Step 4: Bone Marrow Evaluation

Bone marrow biopsy with adequate trephine specimen should be obtained for staging, particularly given your bone pain 1

• Both peripheral blood and bone marrow must be carefully evaluated for malignant cells 1
• Bone marrow aspiration with biopsy provides critical staging information 1, 2

Step 5: Site-Specific Evaluation Based on Symptoms

Given your GI symptoms, consider endoscopy with biopsies if lymphoma is confirmed, as GI tract involvement occurs in 15-30% of certain lymphoma subtypes and can be present even without gross abnormalities 1

Critical Pitfalls to Avoid

Do Not Accept Clinical Reassurance Without Objective Data

• Physical examination alone is inadequate for lymph node assessment and disease exclusion 2
• Your provider's clinical impression, while valuable, cannot definitively exclude malignancy in the face of your symptom constellation 1, 2
• Non-malignant causes for lymphadenopathy and symptoms should be considered, but only after appropriate workup 1

Do Not Delay Diagnostic Workup

• Lymphomas are often curable with timely diagnosis and appropriate therapy 4, 5
• Delayed diagnosis can result in disease progression and worse outcomes 4
• Your history of non-Hodgkin lymphoma places you at risk for relapse, and surveillance should be ongoing 1, 4

Do Not Assume Symptoms Are Unrelated

• The combination of constitutional symptoms, bone pain, GI symptoms, and elevated tumor markers in a patient with lymphoma history represents a unified clinical picture requiring investigation 1
• Autoimmune manifestations can occur with certain lymphoma subtypes and should not distract from the primary concern 3

Immediate Action Steps

1. Request referral to a hematologist-oncologist immediately for evaluation of possible lymphoma recurrence 1, 4
2. Insist on PET-CT imaging as the first-line staging modality 1, 2
3. Obtain tissue diagnosis through excisional biopsy of any accessible abnormal lymph nodes 1, 2
4. Complete mandatory laboratory workup including CBC, comprehensive metabolic panel, LDH, and hepatitis screening 1, 2
5. Document all B symptoms carefully including fever patterns, night sweat frequency, and weight loss percentage 1

Special Considerations for Your History

Prior Cervical Intraepithelial Neoplasia

• While your cervical dysplasia history is important, it does not explain your systemic symptoms 6, 7
• Lymphoma can rarely involve the cervix, but this would not account for your constitutional symptoms without systemic disease 6, 7

Lymphoma Surveillance Requirements

• Patients with prior non-Hodgkin lymphoma require ongoing surveillance with history, physical examination, and imaging at regular intervals 1, 4
• Recurrence of B symptoms should prompt immediate evaluation regardless of scheduled follow-up timing 1

Your symptom pattern is too concerning to accept reassurance without objective testing. Advocate firmly for the diagnostic workup outlined above, and consider seeking a second opinion from a hematologist-oncologist if your current provider is unwilling to pursue appropriate evaluation. 1, 2, 4