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Diagnostics of Hodgkin's lymphoma

Positive developments in diagnosis of malignant lymphoma have taken place in the last 10-15 years. New advancements in immunology and cytogenetics/DNA technology, especially use of immunophenotyping in diagnostics has facilitated better classification and certainty of diagnoses in some cases.  

Examinations

  • Evaluate the rate of growth of the disease and of any possible spontaneous remission. 
  • General status emphasizing findings of nodal tumor and hepato/splenomegaly. Findings may be drawn, with measurements, on a body contour for later comparison during treatment.
  • Record whether there have been B symptoms (weightloss, fever, pathological night sweats) or other general symptoms.  
  • Blood status with differential count of leukocytes, possibly blood smear, creatinine, urea, electrolytes, liver function tests, ESR, albumin, total protein, serum protein electrophoresis, serum iron, TIBC, beta-2 microglobulin, serological evaluation for CMV, HIV, hepatitis B/C, EBV.   
  • Urine tests (stix analysis and/or microscopy), protein electrophoresis.
  • Chest X-ray is taken routinely for all lymphoma types.

CT and ultrasound

  • Abdominal/pelvis CT are standard examinations for lymphoma evaluation.
  • Neck CT for clinical neck tumoror in the ear-nose-throat area where histology shows Hodgkin's lymphoma with diaphragm involvement. 
  • Thoracic/axillary CT. Consider supplementation with MRI or ultrasound with suspicion of involvementof chest wall or pericardium. 
  • Ultrasound of liver, spleen, paraaortal space is done in addition for all patiens with Hodgkin's lymphoma, especially in case of ambiguous findings on abdominal CT. 

Histopathological examinations

The WHO classification system uses a multiparametric approach to lymphoma classification involving a morphological examination, immunophenotype examination, molecular genetic, cytogenetic, and sometimes virological and clinical data combined. This combined evaluation creates the diagnostic foundation for the lymphoma type, or more specifically, the lymphoma entity.

  • A clonality examination either with immunophenotyping or molecular genetic examination is necessary to diagnose post-transplantation lymphoproliferative disease. 
  • Confirmation of Epstein-Barr virus is necessary to diagnose extranodal NK/T-cell lymphoma (nasal type).
  • Clinical information regarding mediastinal localization is necessary to diagnose mediastinal (thymic) large cell B-cell lymphoma.

Since it is not known in advance which pieces of information and parameters will create the basis for the diagnosis, the tissue must be sent by a standardized procedure to the pathologist together with relevant clinical information.

Relevant clinical information to be included for pathologist

  • Tissue type 
  • Purpose of the examination: diagnostic test, follow-up, suspicion of hematological disease
  • Disease localization: lymph node, extranodal, splenomegaly, hepatomegaly, leukemia
  • Disease debut
  • Short disease history: organ transplantation, HIV or Hepatitis C virus infection, long-term drug therapy such as methotrexate or diphenylhydantoin
  • The pathologist should always be informed of the risk of infection with hepatitis, mycobacteria, or HIV.

Bone marrow aspiration/biopsy

The cells in the blood and lymph system originate from stem cells in bone marrow. For lymphoma, a bone marrow examination is performed.

Blood and bone marrow smear

A smear can provide supplementary information to a bone marrow biopsy since the morphological evaluation of small cell lymphomas is more exact. For instanse diagnosing large granular T-lymphocyte leukemia is more difficult with a bone marrow biopsy alone.

Flow cytometric examination

A flow cytometric examination has two significant advantages:

  • Multiparametric immunophenotyping gives a more exact immunophenotype of cells. This is important if identification of co-expression of markers in the same cell population is wanted. A typical example of this is confirmation of restriction for immunoglobulin light chain expression in B-cell neoplasias.
  • The technique is also more sensitive for the identification of small tumor populations.

It is strongly recommended that the person responsible for the flow cytometry evaluates the morphology of the received material before it is analyzed, or has the morphology evaluated by a qualified person near at hand. In this way the panel of markers to be evaluated in flow cytometri can be narrowed an tailored to the relevant differential diagnosis. This will greatly increase the benefit of the examination.

Fine needle aspiration

Fine needle aspiration/biopsy will without question provide the quickest result/diagnosis.

Cytogenetic examination

This is not part of the routine examination for most cases of malignant lymphomas, but should be performed if there is suspicion of lymphoblastic lymphoma or Burkitt's lymphoma. Many types of malignant lymphoma are characterized by specific chromosomal abberations, and confirmation of these can clarify an otherwise difficult diagnosis.

PET-CTexamination

We emphasize that PET should be used primarily for patients where the result will have consequences for treatment. Newer studies for both aggressive non-Hodgkin lymphoma and Hodgkin's lymphoma show that PET performed after 2-4 chemotherapy cycles is a good method for monitoring the effect of the therapy and that patients not having a negative PET scan have a greater chance for progression or recurrence. It is still not well documented, however, that changing of treatment based on an early positive PET examination will improve the patient's prognosis, even if this appears probable. A possible consequence of a positive PET after 2-4 cycles is changing to another regimen and in some cases this may be followed by harvesting of stem cells and allowing the patient to undergo an autologous stem cell translant.

It is expected that use of PET/CT for lymphoma will increase significantly in coming years. PET examinations cost about 16,000 NOK each.

Heart, lung, and kidney function examinations

Patients undergoing chemotherapy and/or radiotherapy should have the function of organs at risk tested before treatment starts. Possible situations where organ function testing is appropriate are:

  • Lung function tests before full ABVD chemotherapy (bleomycin is toxic to the lungs in high doses)
  • Heart function examination (MUGA scintigraphy or echo examination) in elderly patients before CHOP chemotherapy (doxorubicin is cardiotoxic in high doses)
  • Renography with glomular filtration rate before radiation therapy to the retroperitoneum where parts of the kidneys are included in the field of radiation.

Explorative laparotomy

Explorative laparotomy is performed if the disease evaluation is ambiguous, and where clarification of this will provide significant therapeutic consequences.

Endoscopy

Endoscopy is performed for involvement of Waldeyer's ring and primary extranodal disease with positive or suspicion of gastrointestinal involvement. Upper endoscopy should in addition be carried out for symptomatic patiens with mantle cell lymphoma and marginal zone lymphomas regardless of localization and stage.

ENT examination

This is performed if there is involvement of lymph nodes on the neck and ear/nose/throat area.

Dental treatment

Patients who will be given radiation therapy to the oral cavity or chemotherapy that is expected to cause serious bone marrow suppression should be examined by a dentist for treating possible sites of infection. Patients are simultaneously instructed and given advice on oral hygiene.

Sperm banking

Men who will have chemotherapy or radiotherapy under the diaphragm must be informed of the possibility of sperm banking.

Ovarian tissue banking

Ovarian tissue banking is still considered experimental. Only a few children are born worldwide after reimplantation of ovarian tissue. An entire ovary or pieces of an ovary is removed and frozen. After freezing and thawing, sections of subcapsular ovarian tissue is implanted in the remaining ovary, skin, or freely in the abdominal cavity for later hormone stimulation and IVF. The upper age limit is 35 for extraction. Patients appropriate for this procedure are young women who will undergo treatment with a significant chance for infertility such as autologous and allogeneic stem cell transplantation and radiation therapy to the pelvic region and where the ovaries cannot be relocated out of the radiation field by ovariopexy.

Since the procedure itself probably poses an increased risk for premature menopause and infertility, it should not be offered to women who will complete more ordinary chemotherapy.

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