PassFinals
Haematology & Oncology

Lymphoma

A heterogeneous group of clonal lymphoid malignancies that may present with persistent lymphadenopathy, splenomegaly, extranodal disease or systemic symptoms; tissue classification and subtype-specific staging determine urgency and treatment.

In a nutshell

Lymphoma is a heterogeneous lymphoid malignancy that usually presents with persistent painless lymphadenopathy or splenomegaly, with or without B symptoms. Diagnosis needs adequate tissue for architecture and immunophenotyping; PET-CT and subtype-specific risk assessment then guide specialist treatment.

Classic presentation

Persistent painless cervical, axillary or groin lymphadenopathy with or without unexplained fever, drenching night sweats, weight loss, pruritus, splenomegaly or extranodal symptoms.

Key points

  • Use the suspected-cancer pathway for unexplained lymphadenopathy or splenomegaly; associated fever, night sweats, breathlessness, pruritus and weight loss increase concern.
  • Obtain adequate tissue: excision is preferred for suspected non-Hodgkin lymphoma when feasible, and a non-diagnostic core should lead to excision rather than another small core.
  • Classify the subtype with histology, immunophenotyping, flow cytometry and selected molecular or FISH testing before choosing treatment.
  • Stage with PET-CT or contrast CT and use subtype-specific systems; PET-CT usually removes the need for routine marrow biopsy in classical Hodgkin lymphoma.
  • Indolent asymptomatic lymphoma may be observed, while aggressive lymphoma needs prompt specialist treatment; do not use a generic lymphoma regimen.
  • Prevent tumour lysis syndrome before treatment in high-risk disease and escalate airway, spinal, sepsis and electrolyte emergencies immediately.

First-line investigation

Excision or adequately planned core biopsy of the most accessible abnormal tissue, with lymphoma pathology, after urgent referral when lymphoma is suspected.

Management

Refer and identify emergencies

  • Use the suspected-cancer pathway for unexplained lymphadenopathy or splenomegaly, and escalate airway, mediastinal, spinal, sepsis, cytopenia or tumour-lysis emergencies immediately.4,6,12

Obtain diagnostic tissue

  • Arrange an excision or adequately planned core biopsy with lymphoma pathology; avoid routine corticosteroids before biopsy when clinically safe.1,9

Stage and treat the subtype

  • Use PET-CT or contrast CT, pathology and risk scores to choose PET-adapted Hodgkin treatment, aggressive-lymphoma immunochemotherapy or active monitoring for selected asymptomatic indolent disease.1,5,7,2

Prevent treatment toxicity

  • Risk-assess tumour lysis syndrome, use protocol-led hydration and urate-lowering prophylaxis, and monitor electrolytes, urate, renal function and fluid balance closely.11,12,10

Escalate high-risk biology and compression

  • Seek specialist advice for high-grade B-cell molecular findings, CNS or extranodal high-risk disease, bulky mediastinal disease, spinal cord compression or suspected infection during treatment.1,9,7

Plan relapse and survivorship care

  • Monitor symptoms and treatment late effects, and refer early for subtype-specific salvage, cellular or stem-cell therapy when relapse or refractory disease is suspected.5,7,2,3

Exam traps

  • Fine-needle aspiration alone is not adequate to classify most lymphomas because architecture is needed.
  • B symptoms are fever, drenching night sweats and more than 10% unintentional weight loss over 6 months; fatigue alone is not a B symptom.
  • Do not give pre-biopsy corticosteroids routinely because they can impair tissue diagnosis; life-threatening compression requires specialist-led rescue treatment.
  • Indolent lymphoma is not automatically treated immediately; watch and wait may be appropriate when asymptomatic.
  • Tumour lysis risk is determined by tumour biology, bulk, LDH, renal function and treatment, not by lymphoma diagnosis alone.

Illustrations

Reed-Sternberg cellPhotomicrograph of a lymph node biopsy showing binucleate Reed-Sternberg cells in a reactive background.Unknown authorUnknown author, Wikimedia Commons · Public domain
Ann Arbor stagingDiagram of Ann Arbor staging showing nodal regions above and below the diaphragm and extranodal extension.PassFinals · original

Key sources

  1. NICE, Non-Hodgkin lymphoma: diagnosis and management (NG52)
  2. NHS, Treatment for non-Hodgkin lymphoma
  3. NHS, Treatment for Hodgkin lymphoma
  4. NICE, Suspected cancer: recognition and referral (NG12)
  5. British Society for Haematology, Guideline for the first-line management of Classical Hodgkin Lymphoma
  6. NHS, Symptoms of non-Hodgkin lymphoma
  7. British Society for Haematology, The management of newly diagnosed large B-cell lymphoma
  8. NHS, What is Hodgkin lymphoma?
  9. NICE, Spinal metastases and metastatic spinal cord compression (NG234)
  10. British National Formulary, online prescribing information
  11. British Society for Haematology, Updated guidelines for the diagnosis and management of tumour lysis syndrome in adults and children
  12. NHS England, Harm from delayed administration of rasburicase for tumour lysis syndrome

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.