Investigations of lymphoma

General blood tests FBE / CBC U&E LFT ESR LDH Beta 2 microglobulin Protein electrophoresis HIV and HTLV II serology

FBE Look for:anaemia, WCC, lymphopenia, neutrophilia/ neutropenia, eosinophilia Hodgkin disease NHL RBC Anaemia: anaemia of chronic disease / bone marrow infiltration / autoantibodies (positive warm Coombs test) Anaemia: bone marrow infiltration/ autoimmune hemolysis/ bleeding/ anaemia of chronic disease WBC Leukopenia due to bone marrow infiltration Lymphocytosis with circulating malignant cells Platelet Platelet counts may be increased or decreased Thrombocytopenia due to bone marrow infiltration or autoimmune cytopenias Others Cytopenias: common in advance stages Pancytopenia due to bone marrow infiltration or autoimmune cytopenias

U&E Check serum creatitine and renal function: ureteric obstruction secondary to lymph node enlargement can cause renal impairment Check calcium, phosphate, and sodium Check renal function prior to treatment Hodgkin disease NHL Hypercalcaemia Hypercalcaemia (in acute adult T-cell lymphoma) Hypernatraemia Check serum creatinine for nephrotic syndrome (rare) Patient may have renal impairment due to obstruction (lymph node enlargement)

LFT Hodgkin disease NHL ALP due to the presence of liver or bone involvement. Abnormal due to hepatic involvement, hypermetabolic tumour growth, chronic inflammation

ESR LDH Elevated in Hodgkin's disease and NHL fairly non-specific and should not be used for screening LDH Bad prognosis if it is increase in Hodgkin’s disease and NHL

Beta 2 microglobulin may be elevated and correlates with a poor prognosis in NHL

Protein electrophoresis Hodgkin disease NHL Increase gamma globulin Monoclonal gammopathy Hypogammaglobulinemia

HIV 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

Imaging Structural imaging (Conventional method of staging) CT (neck to pelvis) MRI CXR Functional imaging PET scan Gallium scan Bone scan

CT (neck to pelvis) It is the most widely used test for initial staging, assessing treatment response, and conducting follow-up care Possible 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

Ct's showed lypmhadenopathy in the left inguinal node and the left iliac fossa

MRI MRI is done when there is a suspicion of CNS involvement eg primary CNS lymphoma, or vertebral body involvement by lymphoma

CXR CXR is more indicated for NHL eg for identification of hilar or mediastinal adenopathy, pleural or pericardial effusions, and parenchymal involvement

PET scan considered to be essential to the initial staging of Hodgkin disease can be used for the initial evaluation of patients with NHL more useful for post-treatment evaluation to differentiate early recurrences or residual disease from fibrosis or necrosis.

PET scan Appears to be sensitive for detecting NHL in extranodal sites Reliability to detect bone marrow involvement is questioned Better than gallium and equal to CT to detect disease sites in intermediate to high grade NHL and Hodgkin’s PET scan has a higher predictive value for relapse than classic CT scan imaging Scarce availability so x always practical

Gallium scan (nuclear medicine) the use is nearly all replaced by PET scan

Increased uptake of gallium in inguinal lesion before treatment

Bone scan It is done if suspected BM involvement eg bone pain or elevated ALP In NHL, one lesions are particularly associated with the acute form of adult T-cell lymphoma-leukemia and diffuse large B-cell lymphomas

Histology Light microscopy and H&E are the mainstay of pathologic diagnosis Flow cytometry: marked increased in monoclonal cells indicate lymphoma Immunoperoxidase: special staining using specific marker antibody to determine the type of lymphoma

Specific CD marker Cells Markers T cell CD3, CD4, CD8 B cell CD20, immunoglobulin on surface Hodgkin’s lymphoma CD45 NK cells CD16, CD56 Lymphoblast Terminal deoxynucleotidyl transferase All lymphocytes CD34

Histology Lymph node sample Bone marrow sample Fine needle aspiration Needle-core biopsy / incisional biopsy Excision biopsy Bone marrow sample Trephine / biopsy Aspirate Biopsy of extranodal sites Lumbar puncture Staging laparotomy Pleural effusion sampling

Lymph node sample Fine needle aspiration Needle-core biopsy / incisional biopsy Excision biopsy can be used as initial diagnosis of HD insufficient for establishing a diagnosis of NHL Has a limited role in establishing a diagnosis of NHL. Essential for diagnosis of HD and NHL

Histopathologic image of Hodgkin's lymphoma. CD30 (Ki-1) immunostain.

Histopathologic image of Hodgkin's lymphoma. Lymph node biopsy Histopathologic image of Hodgkin's lymphoma. Lymph node biopsy. H & E stain.

Malignant B-cell lymphocytes seen in Burkitt's lymphoma, stained with hematoxylin and eosin (H&E) stain

Histopathology of diffuse large B-cell lymphoma occurring in the tonsil. H&E stain.

Histopathology of diffuse large B-cell lymphoma occurring in the tonsil. CD20 (L26) immunostain.

Bone marrow sample (trephine/aspirate) lymphoma in the bone marrow is often patchy, so bilateral bone marrow biopsies is indicated HD: 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

Bone marrow trephine Sensitive 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 present Sensitivity 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

Biopsy 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.

Lumbar puncture (if symptoms or signs of CNS involvement are present) CNS involvement with Hodgkin disease (Hodgkin's lymphoma) is exceedingly rare In patient with NHL, it should be performed if Diffuse aggressive NHL with bone marrow, epidural, testicular, paranasal sinus, nasopharyngeal involvement, or patient with two or more extranodal sites of disease. High-grade lymphoblastic lymphoma High-grade small noncleaved cell lymphomas (eg, Burkitt and non-Burkitt types) HIV-related lymphoma Primary CNS lymphoma Patients with neurologic signs and symptoms

Staging laparotomy involves splenectomy with biopsies of the liver and lymph nodes in the para-aortic, mesenteric, portal, and splenic hilar regions. Rarely done

Pleural 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).

Staging: Ann Arbor classification

Stage I a single lymph node area (I) or single extranodal site (IE). Stage II 2 or more lymph node areas on the same side of the diaphragm (II or IIE). Stage III lymph node areas on both sides of the diaphragm (III or IIIE or IIIs or IIIS) Stage IV disseminated or multiple involvement of the extranodal organs. Involvement of the liver or the bone marrow is considered stage IV disease.

B The presence of 1 or more of the following: Fever (temperature >38°C) Drenching night sweats Unexplained loss of more than 10% of body weight within the preceding 6 months A Absence of the above X The presence of bulky disease E Contiguous involvement of extranodal sites (eg, involvement of the lung parenchyma due to direct extension of large mediastinal lymphadenopathy)

In 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 adenopathy An ESR result (a general marker of inflammation) 50 mm/h or higher, if the patient is otherwise asymptomatic OR ESR > 30 if hv B symptoms More than 3 sites of disease involvement The presence of B symptoms The presence of extranodal disease Age above 50 at diagnosis