Initial Workup for Suspected Lymphoma in the Emergency Department

Clinical Assessment

The American College of Physicians recommends obtaining a comprehensive history focusing on constitutional symptoms such as fevers, night sweats, unexplained weight loss, fatigue, and pruritus in patients with suspected lymphoma 2
A thorough physical examination with measurement of all accessible lymph node groups and assessment of spleen and liver size is necessary for patients with suspected lymphoma 2
Documenting the presence of B symptoms (fever >38°C, night sweats, weight loss >10% of body weight over 6 months) is crucial as these impact staging and prognosis, according to the National Comprehensive Cancer Network 2

A complete blood count with differential is recommended to assess for cytopenias or leukocytosis in patients with suspected lymphoma, as suggested by the American Society of Clinical Oncology 1
Comprehensive metabolic panel including liver and kidney function tests is necessary for patients with suspected lymphoma, according to the European Society for Medical Oncology 1
Lactate dehydrogenase (LDH) and uric acid levels should be measured as markers of tumor burden and for prognostic purposes in patients with suspected lymphoma, as recommended by the National Comprehensive Cancer Network 1
HIV and hepatitis B/C screening is essential for patients with suspected lymphoma, as these infections can impact treatment decisions, according to the Centers for Disease Control and Prevention 1

A CT scan of neck, chest, abdomen, and pelvis with contrast is the minimum imaging requirement for suspected lymphoma in the ED, as recommended by the American College of Radiology 2
PET-CT is preferred for staging but is typically not performed in the ED setting and should be arranged for outpatient follow-up, according to the National Comprehensive Cancer Network 2

Excisional or incisional lymph node biopsy is the gold standard for diagnosis of lymphoma, as recommended by the American Society of Clinical Oncology 9
Core needle biopsy should only be considered for patients with difficult-to-access lymph nodes (e.g., retroperitoneal), according to the European Society for Medical Oncology 2
Adequate tissue should be obtained for comprehensive pathologic evaluation including morphology, immunohistochemistry, flow cytometry, and molecular studies, as suggested by the College of American Pathologists 3

Consultation with hematology/oncology is necessary for all patients with strong suspicion of lymphoma, as recommended by the American Society of Clinical Oncology 1
Admission is considered for patients with significant B symptoms affecting functional status, bulky disease causing airway compromise or organ dysfunction, tumor lysis syndrome, or superior vena cava syndrome, according to the National Comprehensive Cancer Network 1