2General blood tests FBE / CBC U&E LFT ESR LDH Beta 2 microglobulin Protein electrophoresisHIV and HTLV II serology
3FBELook for:anaemia, WCC, lymphopenia, neutrophilia/ neutropenia, eosinophiliaHodgkin diseaseNHLRBCAnaemia: anaemia of chronic disease / bone marrow infiltration / autoantibodies (positive warm Coombs test)Anaemia: bone marrow infiltration/ autoimmune hemolysis/ bleeding/ anaemia of chronic diseaseWBCLeukopenia due to bone marrow infiltrationLymphocytosis with circulating malignant cellsPlateletPlatelet counts may be increased or decreasedThrombocytopenia due to bone marrow infiltration or autoimmune cytopeniasOthersCytopenias: common in advance stagesPancytopenia due to bone marrow infiltration or autoimmune cytopenias
4U&ECheck serum creatitine and renal function: ureteric obstruction secondary to lymph node enlargement can cause renal impairmentCheck calcium, phosphate, and sodiumCheck renal function prior to treatmentHodgkin diseaseNHLHypercalcaemiaHypercalcaemia (in acute adult T-cell lymphoma)HypernatraemiaCheck serum creatinine for nephrotic syndrome (rare)Patient may have renal impairment due to obstruction (lymph node enlargement)
5LFT Hodgkin disease NHL ALP due to the presence of liver or bone involvement.Abnormal due to hepatic involvement, hypermetabolic tumour growth, chronic inflammation
6ESR LDH Elevated in Hodgkin's disease and NHL fairly non-specific and should not be used for screeningLDHBad prognosis if it is increase in Hodgkin’s disease and NHL
7Beta 2 microglobulinmay be elevated and correlates with a poor prognosis in NHL
9HIV and HTLV II serology HIV serology is done because antiviral therapies can improve disease outcomes in HIV-positive patients in NHL and HD.In NHL, HIV serology is done for patients with diffuse large cell immunoblastic or small noncleaved histologies.HTLV II serology is done for adult T-cell lymphoma-leukemia
10Imaging Structural imaging (Conventional method of staging) CT (neck to pelvis)MRICXRFunctional imagingPET scanGallium scanBone scan
11CT (neck to pelvis)It is the most widely used test for initial staging, assessing treatment response, and conducting follow-up carePossible abnormal findings include enlarged lymph nodes, hepatomegaly and/or splenomegaly, lung nodules or infiltrates, and pleural effusions.Mediastinal lymphadenopathy, is a very common finding in classic Hodgkin disease, although it is uncommon in Nodular Lymphocyte-Predominant Hodgkin's Disease
12Ct's showed lypmhadenopathy in the left inguinal node and the left iliac fossa
13MRIMRI is done when there is a suspicion of CNS involvement eg primary CNS lymphoma, or vertebral body involvement by lymphoma
14CXRCXR is more indicated for NHL eg for identification of hilar or mediastinal adenopathy, pleural or pericardial effusions, and parenchymal involvement
15PET scanconsidered to be essential to the initial staging of Hodgkin diseasecan be used for the initial evaluation of patients with NHLmore useful for post-treatment evaluation to differentiate early recurrences or residual disease from fibrosis or necrosis.
16PET scan Appears to be sensitive for detecting NHL in extranodal sites Reliability to detect bone marrow involvement is questionedBetter than gallium and equal to CT to detect disease sites in intermediate to high grade NHL and Hodgkin’sPET scan has a higher predictive value for relapse than classic CT scan imagingScarce availability so x always practical
18Gallium scan (nuclear medicine) the use is nearly all replaced by PET scan
19Increased uptake of gallium in inguinal lesion before treatment
20Bone scanIt is done if suspected BM involvement eg bone pain or elevated ALPIn NHL, one lesions are particularly associated with the acute form of adult T-cell lymphoma-leukemia and diffuse large B-cell lymphomas
21HistologyLight microscopy and H&E are the mainstay of pathologic diagnosisFlow cytometry: marked increased in monoclonal cells indicate lymphomaImmunoperoxidase: special staining using specific marker antibody to determine the type of lymphoma
22Specific CD marker Cells Markers T cell CD3, CD4, CD8 B cell CD20, immunoglobulin on surfaceHodgkin’s lymphomaCD45NK cellsCD16, CD56LymphoblastTerminal deoxynucleotidyl transferaseAll lymphocytesCD34
23Histology Lymph node sample Bone marrow sample Fine needle aspirationNeedle-core biopsy / incisional biopsyExcision biopsyBone marrow sampleTrephine / biopsyAspirateBiopsy of extranodal sitesLumbar punctureStaging laparotomyPleural effusion sampling
24Lymph node sample Fine needle aspiration Needle-core biopsy / incisional biopsyExcision biopsycan be used as initial diagnosis of HDinsufficient for establishing a diagnosis of NHLHas a limited role in establishing a diagnosis of NHL.Essential for diagnosis of HD and NHL
25Histopathologic image of Hodgkin's lymphoma. CD30 (Ki-1) immunostain.
26Histopathologic image of Hodgkin's lymphoma. Lymph node biopsy Histopathologic image of Hodgkin's lymphoma. Lymph node biopsy. H & E stain.
28Malignant B-cell lymphocytes seen in Burkitt's lymphoma, stained with hematoxylin and eosin (H&E) stain
29Histopathology of diffuse large B-cell lymphoma occurring in the tonsil. H&E stain.
30Histopathology of diffuse large B-cell lymphoma occurring in the tonsil. CD20 (L26) immunostain.
31Bone marrow sample (trephine/aspirate) lymphoma in the bone marrow is often patchy, so bilateral bone marrow biopsies is indicatedHD:Bone marrow involvement is more common in elderly individuals, in patients with advanced-stage disease, in the presence of systemic symptoms, and in patients with a high-risk histology.A bone marrow biopsy can be omitted in patients with stage I Hodgkin disease (Hodgkin's lymphoma) and some patients with stage II disease without hematologic abnormalities. For NHL, bone marrow sampling is done for staging rather than diagnosis
32Bone marrow trephineSensitive for the presence of lymphoma at light microscopy level when there are sufficient cells to be identified by the pattern they form or number of cells presentSensitivity can be increased by using CD marker to identify subgroup of lymphocytes, but because lymphocytes are normally present in BM, the pattern and number are important.PCR to detect presence of translocation or oncogenes can increase the sensitivity and give better measure of prognosis
33Biopsy of extranodal sites In some patients with NHL, the extranodal sites are the primary presenting sites, and the most common site is the GI tract.
34Lumbar puncture (if symptoms or signs of CNS involvement are present) CNS involvement with Hodgkin disease (Hodgkin's lymphoma) is exceedingly rareIn patient with NHL, it should be performed ifDiffuse aggressive NHL with bone marrow, epidural, testicular, paranasal sinus, nasopharyngeal involvement, or patient with two or more extranodal sites of disease.High-grade lymphoblastic lymphomaHigh-grade small noncleaved cell lymphomas (eg, Burkitt and non-Burkitt types)HIV-related lymphomaPrimary CNS lymphomaPatients with neurologic signs and symptoms
35Staging laparotomyinvolves splenectomy with biopsies of the liver and lymph nodes in the para-aortic, mesenteric, portal, and splenic hilar regions.Rarely done
36Pleural effusion sampling Sampling of a pleural effusion by thoracentesis and examination of the cells obtained may be useful in the evaluation of Hodgkin disease (Hodgkin's lymphoma).
38Stage Ia single lymph node area (I) or single extranodal site (IE).Stage II2 or more lymph node areas on the same side of the diaphragm (II or IIE).Stage IIIlymph node areas on both sides of the diaphragm (III or IIIE or IIIs or IIIS)Stage IVdisseminated or multiple involvement of the extranodal organs.Involvement of the liver or the bone marrow is considered stage IV disease.
40BThe presence of 1 or more of the following:Fever (temperature >38°C)Drenching night sweatsUnexplained loss of more than 10% of body weight within the preceding 6 monthsAAbsence of the aboveXThe presence of bulky diseaseEContiguous involvement of extranodal sites (eg, involvement of the lung parenchyma due to direct extension of large mediastinal lymphadenopathy)
41In patients with stage I or II disease, the following factors are considered unfavourable and, if present, will increase the intensity of the recommended initial therapy:Large mediastinal adenopathyAn ESR result (a general marker of inflammation) 50 mm/h or higher, if the patient is otherwise asymptomatic OR ESR > 30 if hv B symptomsMore than 3 sites of disease involvementThe presence of B symptomsThe presence of extranodal diseaseAge above 50 at diagnosis