Investigations of lymphoma
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Investigations of lymphoma. FBE / CBC U&E LFT ESR LDH Beta 2 microglobulin Protein electrophoresis HIV and HTLV II serology. General blood tests. Look for:anaemia ,  WCC, lymphopenia , neutrophilia / neutropenia , eosinophilia. FBE.

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Investigations of lymphoma

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Investigations of lymphoma


FBE / CBC

U&E

LFT

ESR

LDH

Beta 2 microglobulin

Protein electrophoresis

HIV and HTLV II serology

General blood tests


Look for:anaemia, WCC, lymphopenia, neutrophilia/ neutropenia, eosinophilia

FBE


  • 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

U&E


LFT


  • Elevated in Hodgkin's disease and NHL

  • fairly non-specific and should not be used for screening

ESR

LDH

  • Bad prognosis if it is increase in Hodgkin’s disease and NHL


  • may be elevated and correlates with a poor prognosis in NHL

Beta 2 microglobulin


Protein electrophoresis


  • 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 noncleavedhistologies.

  • HTLV II serology is done for adult T-cell lymphoma-leukemia

HIV and HTLV II serology


  • Structural imaging (Conventional method of staging)

    • CT (neck to pelvis)

    • MRI

    • CXR

  • Functional imaging

    • PET scan

    • Gallium scan

    • Bone scan

Imaging


  • 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.

  • Mediastinallymphadenopathy, is a very common finding in classic Hodgkin disease, although it is uncommon in NodularLymphocyte-PredominantHodgkin'sDisease

CT (neck to pelvis)


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


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

MRI


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

CXR


  • 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

PET scan


  • the use is nearly all replaced by PET scan

Gallium scan (nuclear medicine)


Increased uptake of gallium in inguinal lesion before treatment


  • 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

Bone scan


  • 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

Histology


Specific CD marker


  • Lymph node 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

Histology


Lymph node sample


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


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.


  • 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 sample (trephine/aspirate)


  • 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

Bone marrow trephine


  • In some patients with NHL, the extranodal sites are the primary presenting sites, and the most common site is the GI tract.

Biopsy of extranodal sites


  • 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

Lumbar puncture (if symptoms or signs of CNS involvement are present)


involves splenectomy with biopsies of the liver and lymph nodes in the para-aortic, mesenteric, portal, and splenichilar regions.

Rarely done

Staging laparotomy


  • 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).

Pleural effusion sampling


Staging: Ann Arbor classification


In patients with stage I or II disease, the following factors are considered unfavourableand, if present, will increase the intensity of the recommended initial therapy:

  • Large mediastinaladenopathy

  • 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


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