Diagnostic and Treatment Approach to Lymphoma

Diagnostic Workup

The World Health Organization recommends an excisional lymph node biopsy providing adequate tissue for histopathological examination, including immunohistochemistry studies with CD20 for proper subtyping, according to the WHO classification 1, 2
Surgical specimen/excisional lymph node biopsy is essential for diagnosis, providing enough material for fresh frozen and formalin-fixed samples, as stated by the American Society of Clinical Oncology 1, 2
Fine needle aspirations or core biopsies are inadequate for proper diagnosis and should only be used in rare emergency situations, as recommended by the National Comprehensive Cancer Network 1
The histological report should follow the World Health Organization classification with appropriate immunohistochemistry, according to the College of American Pathologists 1

Complete staging requires a CT scan of thorax, abdomen, and pelvis, as well as bone marrow aspirate and biopsy, complete blood count, LDH, uric acid, and screening for HIV and hepatitis B/C, as recommended by the European Society for Medical Oncology 1, 3, 4
The Ann Arbor staging system is used with mention of bulky disease, according to the American Joint Committee on Cancer 1
For prognostic purposes, the International Prognostic Index (IPI) is used for large cell lymphomas, and the Follicular Lymphoma-specific International Prognostic Index (FLIPI) is used for follicular lymphomas, as stated by the International Prognostic Index Project 1, 2

For limited stage follicular lymphoma, radiotherapy is the treatment of choice with curative potential, as recommended by the American Society for Radiation Oncology 2, 4
For advanced stage follicular lymphoma, treatment should be initiated upon symptoms, and primary chemotherapy options include combination regimens such as COP or CHOP, as stated by the National Comprehensive Cancer Network 2, 4
For large cell non-Hodgkin's lymphoma, R-CHOP given every 21 days for 8 cycles is the standard for CD20+ large-cell NHL of all stages, according to the American Society of Clinical Oncology 1, 6

Radiological tests should be performed after every 2-4 cycles of therapy, after completion of treatment, and whenever there are doubts about adequate response, as recommended by the European Society for Medical Oncology 1, 4
Patients with incomplete or lacking response should be evaluated for early salvage regimens, according to the International Conference on Malignant Lymphoma 1, 4
History and physical examination should be performed every 3 months for 2 years, every 6 months for 3 more years, and then once a year, with attention to transformation and secondary malignancies, as stated by the American Society of Clinical Oncology 1, 7
Laboratory monitoring should include blood count and LDH at 3, 6, 12, and 24 months, and then only as needed for evaluation of suspicious symptoms, according to the College of American Pathologists 1, 7
Imaging surveillance should include minimal adequate radiological examinations at 6, 12, and 24 months after treatment, as recommended by the European Society for Medical Oncology 1, 7