Diagnostic Approach for Suspected Lymphoma

Rationale for Excisional Biopsy

• The European Society for Medical Oncology recommends surgical excisional biopsy as the optimal method for diagnosis of lymphoma, providing adequate tissue for complete histopathological assessment, immunophenotyping, and molecular studies 1
• Core needle biopsies should be reserved only for patients where surgical approach is impractical or would entail excessive risk, as per the European Society for Medical Oncology guidelines 1
• Fine-needle aspiration should never be used as the sole basis for lymphoma diagnosis, according to the European Society for Medical Oncology 1

Imaging Findings and Their Significance

• The PET/CT findings of FDG-avid cervical lymph nodes are highly suspicious for malignancy/lymphoma, with a Deauville score of 5 indicating uptake markedly higher than liver, which is concerning for aggressive disease, as reported in the Journal of Clinical Oncology 2, 3
• Additional findings of FDG-avid hilar/subcarinal nodes and mild uptake in inguinal nodes suggest possible widespread disease, according to the Journal of Clinical Oncology 2

Diagnostic Approach

• Tissue diagnosis is mandatory before initiating any treatment, and the American Society of Clinical Oncology recommends a complete diagnostic workup after biopsy, including immunophenotypic investigations and assessment of MYC and BCL2 rearrangements using FISH 1, 2
• Complete blood count, LDH, uric acid, and other routine chemistry should be performed as part of the baseline assessments after diagnosis, as recommended by the European Society for Medical Oncology 1, 5

Staging Considerations

• The current PET/CT already provides valuable staging information, showing involvement of cervical and thoracic nodes, and after histological confirmation, staging will be completed according to the Ann Arbor classification system, as per the European Society for Medical Oncology guidelines 1, 2, 6
• For suspected high-grade lymphomas, assessment for CNS involvement may be needed (lumbar puncture) in high-risk patients, according to the European Society for Medical Oncology 1

Common Pitfalls to Avoid

• Starting treatment without definitive histological diagnosis and proper classification of lymphoma subtype is a common pitfall to avoid, as emphasized by the European Society for Medical Oncology 1
• Overlooking the need for specialized hematopathology expertise in interpreting lymphoma specimens is another common pitfall to avoid, as highlighted by the European Society for Medical Oncology 1