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How to diagnose lymphoma

If you see a GP because you’re concerned about symptoms of Hodgkin lymphoma, they’ll ask about your health and carry out a simple physical examination.

If necessary, the GP will refer you to hospital for further tests.

In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of cancer and refer people for the right tests faster.

To find out if you should be referred for further tests for suspected Hodgkin lymphoma, read the NICE guidelines about recognition and referral for suspected cancer.

If you’re referred to hospital, a biopsy will usually be carried out, as this is the only way to confirm a diagnosis of Hodgkin lymphoma.

Lymph node biopsy

A lymph node biopsy involves removing some or all of an affected lymph node, which is then studied in a laboratory.

A biopsy is a small operation that can often be carried out under local anaesthetic. Sometimes, the affected lymph node isn’t easily accessible and a general anaesthetic may be required.

A pathologist (an expert in the study of diseased tissue) will then check the tissue sample for the presence of cancerous cells. If they find cancerous cells, they can also identify exactly which type of Hodgkin lymphoma you have, which is an important factor in planning your treatment.

Further testing

If a biopsy confirms a diagnosis of Hodgkin lymphoma, further testing will be needed to check how far the lymphoma has spread. This allows a doctor to diagnose the stage of your lymphoma.

Further tests may include:

  • blood tests – samples of blood will be taken throughout your diagnosis and treatment to check your general health, the levels of red and white cells and platelets in your blood, and how well organs such as your liver and kidneys are working
  • bone marrow sample – another biopsy may be carried out to see if the cancer has spread to your bone marrow; this involves using a long needle to remove a sample of bone marrow from your pelvis and can be done using a local anaesthetic
  • chestX-ray – this can check whether the cancer has spread to your chest or lungs
  • computerised tomography (CT) scan – this scan takes a series of X-rays that build up a 3D picture of the inside of the body to check the spread of the cancer
  • magnetic resonance imaging (MRI) scan – this scan uses strong magnetic fields to build up a detailed picture of areas of your body, to check the spread of the cancer
  • positron emission tomography (PET) scan – this scan measures the activity of cells in different parts of the body and can check the spread of the cancer and the impact of treatment; it’s usually taken at the same time as a CT scan to show precisely how the tissues of different sites of the body are working

Stages of Hodgkin lymphoma

When testing is complete, it should be possible to determine the stage of your lymphoma. “Staging” means scoring the cancer by how far it’s spread.

The main stages of Hodgkin lymphoma are:

  • stage 1 – the cancer is limited to 1 group of lymph nodes, such as your neck or groin nodes either above or below your diaphragm (the sheet of muscle underneath the lungs)
  • stage 2 – 2 or more lymph node groups are affected, either above or below the diaphragm
  • stage 3 – the cancer has spread to lymph node groups above and below the diaphragm
  • stage 4 – the cancer has spread through the lymphatic system and is now present in organs or bone marrow

Health professionals also add the letters “A” or “B” to your stage, to indicate whether or not you have certain symptoms.

“A” is put after your stage if you have no additional symptoms other than swollen lymph nodes. “B” is put after your stage if you have additional symptoms of weight loss, fever or night sweats.

Page last reviewed: 22 November 2021
Next review due: 22 November 2024

How to diagnose lymphoma

Rony Kampalath, MD, is a board-certified diagnostic radiologist specializing in imaging of the abdomen.

Most people with lymphoma first notice enlarged lymph nodes in their neck, armpits or groin. They also may have a fever, weight loss, and other vague symptoms that can mimic other diseases. Your healthcare provider may suspect lymphoma based on the symptoms you have or from scans of affected parts of your body.

How to diagnose lymphoma

Biopsy Is the First Step

To test for lymphoma, a healthcare provider will perform a core biopsy or an excisional biopsy, taking a small sample of tissue from the affected nodes or organs. The biopsy sample will be viewed under a microscope by a pathologist. Most patients will receive a lymph node biopsy, but if the lymphoma affects organs like the skin, brain, or the stomach, a biopsy from these organs may be required instead. If a doctor initially asks for a needle aspiration cytology (called FNAC) and it turns out to be lymphoma, it is worthwhile to do a biopsy to get more tissue for a more detailed diagnosis.

Determining the Type

The diagnosis of lymphoma is not enough information for a healthcare provider to give proper treatment. He or she must also determine which of the two main types of lymphoma — Hodgkin or non-Hodgkin lymphoma (NHL) — a patient has. The type of lymphoma can be identified by the physical appearance of the cancer cells under the microscope, or by using markers that identify special molecules on the lymphoma cells. It’s important that a pathologist skilled in lymphoma makes the determination.

Tests After Diagnosis

Once the diagnosis of lymphoma is clear, it becomes necessary to perform a number of tests to see how far the disease has spread and which organs are involved. Scans of different parts of the body, as well as a bone marrow test, may be done if the healthcare provider feels it is required. Also, some blood tests can show how advanced the disease is, and if the patient is fit for treatment with chemotherapy. Once these tests are done, the oncologist can discuss treatment options with the patient.

Home » Lymphoma Diagnosis: What You Need to Know

Because many symptomsВ associated with the most common blood cancerВ lymphoma are similar to other diseases, diagnosis is difficult. Lymphoma occurs when white blood cells called lymphocytes reproduce and grow excessively. Mostly it attacks the lymphatic system which is very important to the body’s immune system. The most common first symptom of the disease is painless swelling of the lymph nodes.

AnotherВ common symptom seemsВ like a common coldВ that will not go away.В Night sweats, chills or fevers, unexpected weight loss, loss of appetite, lack of energy or tiredness, itching or rash, coughing, difficulties in breathing, enlarged tonsils, or headaches are also lymphomaВ symptoms.

Physicians need to conduct a series of medical exams in order to make a diagnosis.

Complete Physical Examination for Lymphoma Diagnosis

Physicians usually start diagnostic procedures with a complete physical exam and a comprehensive medical history that includes family history. The physical examination will be particularly focused on a search for swollenВ lymph nodes and for other changes in the spleen or liver. The physician usuallyВ looks forВ infections that may first explain the swellings. AВ biopsy will be ordered if the doctor suspects lymphoma.

Biopsy to Diagnose Lymphoma

TheВ biopsy of tissueВ removed from the body is subject to a series of exams that result not only in the confirmation of the disease but also in the determination of its type, size, texture, and location. Results will help set appropriate treatment.

Types of Diagnosis Biopsies

Different types of biopsies can be conducted. The most common is the surgical excisional or incisionalВ of the suspectedВ lymphoma during which a part or all of the node is removed for analysis.В Fine needle aspiration, or core needle biopsy, is another procedure conducted via needle withoutВ surgery.

Additional Types of Biopsies

TheВ physician mightВ alsoВ order further biopsies to understand stage, extent and type of the disease. AВ bone marrow aspiration and biopsy willВ determineВ if the lymphoma has reached the bone marrow. A lumbar puncture or spinal tap is used to search for lymphoma cells in the cerebrospinal fluid ofВ the brain and spinal cord. В The pleural fluid sampling looks for signs of lymphoma in the chest. В Peritoneal fluid can indicate lymphoma in the abdomen.

Exams Conducted on Biopsy Samples

The tissue removed during a biopsy undergoes lab tests to help diagnosis and classify the type of lymphoma. Samples are analyzed by a pathologist who examines the cell size and shape; and forВ immunohistochemistry, flow cytometry,В cytogenetics,В molecular genetic, fluorescent in situ hybridization (FISH), andВ p olymerase chain reaction (PCR)В examinations.

Blood Tests to ComplementВ Lymphoma Diagnosis

Blood tests for diagnosis revealВ the types and amounts of cells and chemicals present in the blood. В Blood also helps determine the stage of the disease. The most common test is a complete blood count to count red and white blood cells. Platelets may indicate if the disease has affected the bone marrow. A blood chemistry test verifies kidney and liver function. Further tests may be used to examine if the patient is infected with viruses like hepatitis B,В hepatitis C, or human immunodeficiency virus (HIV).

Imaging Tests Used in Lymphoma Diagnosis

Imaging tests examine the abnormal areas that may be affected by the disease.

The most common tests areВ chest x-ray to search for swollen nodes in the chest, computed tomography (CT) scan that provides detailed images of the full body including soft tissues, CT-guided needle biopsy used to drive the biopsy needle into suspicious areas, and magnetic resonance imaging (MRI) scan to verify if the disease has spread to the brain or spinal cord. Ultrasound examines damage to the internal organs and existence of masses, positron emission tomography (PET) scan and gallium scan both determine the body parts with cancerous cells using radioactivity, and bone scan shows the damage caused by lymphoma in the bones.

In addition, heart and lung function may also be tested to determine the accurateВ type of treatment.

Note: Lymphoma News TodayВ is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

How to diagnose lymphoma

A lymphoma diagnosis is not difficult to determine once a patient and doctor begin to look for signs of cancer. However, lymphoma–especially non-Hodgkin lymphoma–can be something of a silent killer. Symptoms are frequently minor or nonexistent in the early stages. Furthermore, lymphoma symptoms mimic symptoms of common sickness that are familiar and not necessarily threatening to most patients.

Symptoms

Non-Hodgkin’s lymphoma symptoms are not specific to the disease. For this reason, it is very important that you tell your doctor during regular checkups about any symptoms that you might be experiencing. They include:

Unexplained weight loss
Sudden and unexpected weight loss of 10% or more of total body weight could be a cause for concern.

Swollen lymph nodes
Lymphoma may cause swelling of lymph nodes in the neck, chest, abdomen and on the skin. Lymph nodes in the neck frequently swell in cases of a sinus infection or can be symptomatic of the flu. But if they persist for a long time or occur apart from other sicknesses they might be cause for concern. Lymph node swelling in the armpits or abdomen might be cause for more immediate concern. Lymphoma may also cause swelling in the chest area which may interfere with breathing. Lymphomas of the skin often appear as itchy red or purple lumps. Swollen lymph nodes are usually tender and painful to some degree. However, in the case of non-Hodgkin lymphoma, lymph nodes might swell and become firm without any evident pain.

Recurring Fevers
Obviously, fever can be a sign of just about anything. When fever recurs for no apparent reason, especially in conjunction with other symptoms, it could be a sign of lymphoma.

Night sweats
These will usually occur in conjunction with a fever.

Fatigue / Lack of energy
Again, this can be related to many things but in combination with other symptoms might be significant.

Rashes
Itchy skin (pruritis) and rashes can be a sign of lymphoma.

Lymphoma Diagnosis

Once a physician has determined that symptoms are not related to minor infections or other causes, tests will be performed to determine if a patient has lymphoma. Diagnostic tests for lymphoma may include one or more of the following:

Blood tests
Blood test results cannot confirm lymphoma but they can signal that something is wrong. A high lymphocyte count or a high lactate dehydrogenase (LDH) count might be cause for further investigation. More on the myriad blood count tests can be found here.

Imaging
X-rays, CT scanning, MRI’s, PET scans, etc, may be used to look inside of the body to look for unusual growths.

Biopsy
A biopsy is the only way to truly confirm or deny the presence of lymphoma. Because a biopsy involves taking a tissue sample from a lymph node or other infected area and is, therefore, a surgical procedure, it is usually preceded by other tests such as those mentioned above. Pathologists examine the biopsy in several different ways to determine not only the presence of lymphoma but to also determine if it is malignant and to identify the type of lymphoma.

Bone marrow sample
Non-Hodgkin lymphoma frequently spreads to the bone marrow and therefore a bone marrow biopsy is a common diagnostic procedure.

Classification and Staging

Following a positive diagnosis, the medical team will classify and stage the lymphoma. Staging is outlined below. For more on lymphoma classification (determining the type of lymphoma) please see this page

Once non-Hodgkin’s lymphoma is identified, more tests must be done to find out if the cancer has spread throughout the body. This testing is called “staging”. Your doctor needs to know the stage of your disease to devise an appropriate treatment plan. Lymphoma staging may involve one or more of the following steps:

Clinical review
Prior test results will be reviewed in light of a diagnosis to help to determine staging.

Additional blood work. Blood tests may be done to determine kidney and liver function.

Lumbar Puncture
This is also known as a “spinal tap,” which involves the withdrawal and examination of spinal fluid. This is usually done in cases where a physician believes that the disease might have spread to the nervous system.

Imaging
Chest x-rays and CT scans are common methods for observing the extent to which lymphoma has spread.

Laparotomy
This procedure, which involves examining vital organs through a surgical hole in the abdomen, is largely obsolete, having been replaced by non-invasive methods such as CT scanning.

Stages

The “Ann Arbor System” is the most widely used system for describing stages of non-Hodgkin’s lymphoma (except in the case of Cutaneous T-Cell Lymphoma – Mycosis Fungoids – Sezary Syndrome which has a separate staging system).

Stage I: If either of the following is present it means the disease is stage I
The lymphoma is in a lymph node or nodes in only 1 region, such as the neck, groin, underarm, and so on. The cancer is found only in 1 area of a single organ outside of the lymph system (IE).

Stage II: If either of the following is present it means the disease is stage II:
The lymphoma is in 2 or more groups of lymph nodes on the same side of (above or below) the diaphragm (the muscle that aids breathing and separates the chest and abdomen). For example, this might include nodes in the underarm and neck area but not the combination of underarm and groin nodes. The lymphoma extends locally from a single group of lymph node(s) into a nearby organ (IIE). It may also affect other groups of lymph nodes on the same side of the diaphragm.

Stage III: If either of the following is present it means the disease is stage III:

The lymphoma is found in lymph node areas on both sides of (above and below) the diaphragm. The cancer may also have extended into an area or organ next to the lymph nodes (IIIE), into the spleen (IIIS), or both (IIIE,S).

Stage IV: If either of the following is present it means the disease is stage IV:
The lymphoma has spread outside of the lymph system into an organ that is not right next to an involved node. The lymphoma has spread to the bone marrow, liver, brain or spinal cord, or the pleura (thin lining of the lungs).

Each Stage Is Also Assigned An A or B

The letter A is added if the person doesn’t have any symptoms of lymphoma.

The letter B is added (stage IIIB, for example) if any of the following symptoms are present:

  • Unexplained weight loss (more than 10% of weight)
  • Soaking night sweats
  • Unexplained fever > 100°

Related Reading

  • Gallium Scans – detailed information
  • MRI Scans – detailed information
  • PET Scan for Lymphoma

Sources: The American Cancer Society, American Society of Hematology, MedlinePlus
Photo: Pexels

In my case, my story will begin with how my cancer was NOT diagnosed. I was never one to go to doctors for little things, but in the fall of 1996, I began running a low grade fever, complete loss of appetite, general malaise and pelvic pain that persisted for seven months.

I went to my internist, who despite running a wide range of tests, wasunable to identify the reason, all tests were coming back relatively normal with only slight elevations in WBC and a few others. I had numerous colonoscopies and gastric tests, all coming back normal. My internist early on seemed to have decided that what ever was going on was psychological. yes, I was anxious and depressed, but, when one cant eat, has pain, feels sick and is being put thru test after test with long delays between each one, I don’t think this is out of the ordinary.

After a few months, this internist was going on sabbatical and she essentially fired me as a patient, saying “Your fine, I see no reason for you not to try to get pregnant, and I think its best if you don’t see another doctor in this practice while Im gone.” I responded angrily, “I am not fine and I really don’t think getting pregnant would be the best idea when I can barely eat and have pelvic pain.”

The GI doing all the procedures and tests never seemed to doubt me, and said things like– “They told us in medical school, you NEVER want to be a difficult-to-diagnose-patient,” “Something is definitely wrong, probably something autoimmune that is taking a while to show it self clearly.” In an attempt to alleviate the pain based on a hypothesis that something autoimmune was going on, he put me on a short course of steroids.

I’d lost a total of 35 pounds, looked like a concentration camp victim. Although my doctors couldn’t diagnose me, the mailman at my office was spreading rumors that I had cancer because of the massive weight loss.

I went to another internist, but the chart implying that I was nuts followed. This internist pulled me off the steroids as I was running a fever around 100 degrees. More tests including exploratory surgery. However, a day or two after the steroids were stopped, my pain stopped and gradually my appetite returned. (note: the steroids I was on are
included in lymphoma treatments–that’s why the symptoms stopped)

All throughout this entire episode, a groin node, where the leg meets the body was slightly enlarged- a little over 2 cm. The internists were aware of this but said it was nothing. It seemed to be growing and several months after the pain had stopped and my appetite had returned, I asked the internist to biopsy it. He insisted it was nothing and I had the feeling he thought I was nuts. I persisted and got the biopsy. It came back benign. I felt absolutely fine for two years.

In terms of public opinion, every last doc I saw thru this ordeal was on the published lists of “best docs” in the city. Do I take these lists seriously anymore– NO.

Then a 4cm node popped up on the other leg. This time the Drs were worried, did the biopsy pretty fast. First impression was lymphocyte predominant Hodgkins. The pathologist had compared it with the earlier tissue and told me that an error had been made– both biopsies looked the same. He was not 100% sure of his diagnosis and sent it to other
experts to review– came back as an aggressive NHL lymphoma difficult to classify or grade, either an unusual marginal zone or unusual bcl-2 cd10 neg follicular that looks like its been caught in the act of converting from indolent to aggressive lymphoma.

The third group of docs at the NCI cancer ctr where I was treated decided it was a follicular grade 3 lymphoma with diffuse areas. No other tumors were seen on CT or PET. I was put at stage 2 because the tumor that had been misdiagnosed was on the other leg. From what I heard from one of the docs, the tumor board was pretty outraged at the earlier
misdiagnosis- the cancer had been obvious- the one doc was annoyed as he felt they charted it so as to protect the first pathologist rather than put was actually said in the meeting about how blatant the error was.

The mailman was right, the doctors were wrong. I was not totally crazy, I had cancer. Although I was VERY angry and scared about what the misdiagnosis would mean in terms of my eventual outcome I did not sue for malpractice.

I had 3 rounds of CHOP, pelvic radiation and then rituxan. I had been trying to convince my doc to give me R-CHOP as Id read about it, and he initially refused saying it wasnt proven. Then he and my rad onc went to ASH 99 saw the abstracts and my rad onc suggested I should also have rituxan– I told him, he needed to talk to my onc about it, as Id already asked. After they discussed it, my onc agreed to give me a course of 4 rituxan after the radiation.

So far, its been close to 6 years, and, thankfully, I have stayed in remission.

My advice from my experience– ALWAYS GET SECOND OPINIONS ON BIOPSIES. Dont stay with doctors who get frustrated because they cant make a diagnosis and then treat you like a hypochondriac when your body is telling you something big time is wrong, youve lost 35 pounds, have pain and are running a low grade fever.

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How to diagnose lymphoma

Some types of lymphoma are more aggressive and difficult to treat than others, but the earlier lymphoma is diagnosed, the better the chances of survival. Tests are done to pinpoint the disease, and to determine what type and subtype it is and how far along it has progressed. Knowing why and how these tests are performed can help you plan for what’s ahead. In general, a diagnosis of non-Hodgkin or Hodgkin’s lymphoma begins with a physical exam and involves blood tests, imaging exams, and biopsies.

Physical Examination

Whether you see your doctor because you’ve not been feeling well or your doctor notices something during a routine visit, all diagnoses begin with a review of your medical history and a physical examination. During your physical exam, your doctor will likely check the following:

Lymph nodes. Lymph nodes are spread throughout your body, acting as filters to remove toxins from the lymph as it circulates. Swollen lymph nodes, particularly in your neck, under your arms, and in your groin, are a sign of infection or inflammation somewhere in your body. In someone with lymphoma, cancerous tumors can form and enlarge the nodes.

Liver and spleen. Your doctor may press down on your abdomen, checking to see if your spleen or your liver is enlarged, which can be due to tumor growth.

Skin. You may have a rash or itchy skin, or jaundice (yellowing) of the skin due to liver involvement.

Temperature. You may have a fever, usually a low-grade fever.

Blood and Cytogenetic Tests

Blood tests can tell your doctor a lot about how well your body is working. There is no specific test for lymphoma, but blood tests can help rule out other illnesses, such as infections. The most common blood tests done during a physical exam for suspected lymphoma are:

Chemistry panels: These tests look at various components, such as how much protein, glucose (sugar), and cholesterol, is in your blood.

Peripheral blood smear: This test looks at how your red blood cells, white blood cells, and platelets appear under a microscope.

Complete blood count (CBC): Blood checked for a CBC can tell your doctor how many red and white blood cells you have, as well as your hemoglobin (iron) and hematocrit levels.

Cytogenetic analysis: This specialized test looks for chromosomal changes in lymphocytes.

Flow cytometry: This can be done on blood, tissue or bone marrow. It studies the cells for certain characteristics of lymphocytes and can help determine the type and specific subtype of lymphoma. Knowing the specific subtype helps the doctor plan treatment.

Other tests to more fully characterize the subtype could include:

Fluorescence in situ hybridization (FISH): These lab tests can reveal genetic abnormalities in the cells from blood and bone marrow samples.

Immunophenotyping: This test identifies specific proteins on the surface of abnormal lymphocytes, which helps the cancer team narrow down the best treatment for your type of lymphoma.

Karyotype test: This test looks at the number of chromosomes and can identify chromosomal changes in blood and bone marrow cells.

Lymph Node Biopsy

You may need a lymph node biopsy to collect the cells necessary to perform some of the cell and chromosome tests. The biopsy can be done on an entire node that has been surgically removed (an open biopsy), or on a small section of tissue that has been removed from the node (a needle biopsy). The node or tissue is sent to a lab and examined for cancer cells. Looking at the cells themselves and performing other lab tests is the only way to diagnose the type of lymphoma.

An open biopsy requires either a local anesthetic or general anesthetic. The surgeon makes an incision over the area and removes the node or nodes, then sutures (stitches) the incision closed. Or, your surgeon could use a laparoscope, a long, narrow tube with a camera on one end. You would receive a general anesthetic for this procedure. After making a small incision, the surgeon inserts the scope and advances it to the lymph node. Using special tools through the tube, the surgeon removes tissue from the node but the node remains in place.

A needle biopsy is the least invasive method, but doctors do not perform it as frequently as an open biopsy because the results are sometimes not as accurate. After giving you a local anesthetic to numb the area, the doctor inserts a needle into the lymph node and removes some of the tissue.

Bone Marrow Aspiration

Your doctor may want you to have a bone marrow aspiration for testing in the lab. Bone marrow tissue is inside bone. It contains stem cells, which can become fat, cartilage, bone, and different types of blood cells.

The test is usually an out-patient procedure performed by a hematologist or oncologist. The doctor removes the marrow from the posterior iliac crest—towards your back at the top part of your hip. After numbing the area with a local anesthetic, the doctor inserts a sterile needle into the bone and withdraws some of the bone marrow. The procedure takes about 10 minutes.

Bone marrow aspiration can be painful, so your doctor may recommend using an ice pack on the site for the next few days to reduce pain and swelling.

Lumbar Puncture

Often called a spinal tap, a lumbar puncture provides samples of cerebrospinal fluid, or CSF. This fluid flows around the spinal cord and brain. Lumbar taps are not a routine test, but your doctor may recommend one to help with diagnosis.

After administering local anesthetic to numb the skin, your doctor inserts a needle into the spinal canal and removes some CSF.

Imaging Tests

Traditional radiographs (X-rays), ultrasound, CT scan (computed tomography), MRI (magnetic resonance imaging), and PET scan (positron emission tomography) are all imaging tests. These tests can help your doctor determine how far the lymphoma has progressed—the stage of cancer.

Bone Scans

If you are experiencing bone pain or your doctor suspects the cancer has reached your bones, a bone scan can confirm or rule this out. A radiology specialist administers an imaging-specific medicine to you. The medicine shows up on a computer monitor as it circulates and travels to the bone.

Waiting for Results

It can take several days or a couple of weeks to gather all information from the tests and confirm the diagnosis. Blood test results may be available the same day, but imaging, biopsy and cytogenetic tests take longer because of the test time and complexity, as well as additional specialists to analyze the information and report it to your doctor.

Ask your doctor beforehand when you might expect the test results, as well as how you will receive them. For example, will it be your doctor or someone else from your doctor’s office calling you with the results? Should you schedule another appointment to discuss the results in person rather than receiving a phone call? Arranging this ahead of time may help ease some anxiety while you wait for results.