1. Investigations of lymphoma

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

3. 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

4. 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)

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

6. 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

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

8. Protein electrophoresis
Hodgkin disease
NHL
Increase gamma globulin
Monoclonal gammopathy
Hypogammaglobulinemia

9. 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

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

11. 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

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

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

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

15. 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.

16. 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

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

19. Increased uptake of gallium in inguinal lesion before treatment

20. 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

21. 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

22. 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

23. 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

24. 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

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

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

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

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

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

31. 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

32. 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

33. 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.

34. 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

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

36. 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).

37. Staging: Ann Arbor classification

38. 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.

40. 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)

41. 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