Non-Hodgkin lymphoma diagnostic study of choice

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]; Associate Editor(s)-in-Chief:  Preeti Singh, M.B.B.S.[3]

## Overview[edit | edit source]

The diagnostic study of choice for non-Hodgkin lymphoma is excisional lymph node biopsy. A bone marrow biopsy is an alternative to a lymph node biopsy. According to the Ann Arbor system with Cotswald modifications, there are four stages of non-Hodgkin lymphoma based on the number of nodes and extra nodal involvement.

## Diagnostic study of choice[edit | edit source]

* The diagnostic study of choice for non-Hodgkin's lymphoma is excisional lymph node biopsy.[1]
* An excisional biopsy is needed because it preserves the architecture of the lymph node and allows for precise determination of the type of lymphoma.
* Fine needle aspiration biopsy is usually insufficient.[2]
* In addition to light microscopy evaluation of the excisional biopsy samples, the immunophenotypic analysis with immunohistochemistry helps to determine non-Hodgkin's lymphoma subtypes and distinguish non-Hodgkin's lymphoma from T cell rich large B cell lymphoma and anaplastic large cell lymphoma.[2]
* The presence of CD20 positive clonal B cells defines non-Hodgkin lymphoma.[3]
* In about 40% of adult patients with non Hodgkin lymphoma, the extranodal sites are the primary presenting sites with the most common site being the Gastrointestinal tract.[3]
* A bone marrow (BM) biopsy can also be done to diagnose non-Hodgkin lymphoma if there is sufficient evidence of marrow involvement such as presence of cytopenias.[3]
* Non-Hodgkin lymphoma cells originate in the bone marrow, which is the site of B cell production and maturation.
* Bilateral BM biopsy has been recommended with trephine biopsy being preferred to marrow aspiration for detecting marrow infiltration.[4][5]
* BM biopsies, performed under local anesthesia, were obtained using the conventional technique with a Jamshidi needle from the posterior superior iliac spines, fixed in 10% formalin solution and decalcified using 10% formal - formic acid for 4 - 6 h followed by routine processing and paraffin embedding.[6]

## Staging[edit | edit source]

According to the Ann Arbor staging system with Cotswald modifications, there are four stages of non-Hodgkin lymphoma based on the number of nodes and extra nodal involvement. Staging for non-Hodgkin lymphoma is provided in the following table:[7][8]

Ann Arbor staging system Stage  | Involvement

|

stage I
I  | One nodal group or lymphoid organ (e.g. spleen or thymus)
IE  | One extra nodal site
stage II
II  | Two or more nodal groups, same side of diaphragm
II E  | Localized extra nodal site with stage II criteria, both on the same side of the diaphragm
stage III
III  | Nodal groups on both sides of the diaphragm
III S (1)  | With splenic involvement
III E (2)  | With localized extra nodal site
III SE  | Both
stage IV
IV  | Disseminated involvement of one or more extra lymphatic organ (e.g. lung, bone) +/- any nodal involvement
Additional staging variables
X  | Bulky nodal disease: largest tumor is 10 cm or larger
A  | Asymptomatic
B  | Presence of B symptoms (fever, night sweats and weight loss)
E  | Extra nodal: other than the lymph nodes or spread to tissues beyond, but nearby, the lymphatic tissues
S  | Spleen
Limited disease  |

* Stage I or II

* No B symptoms

* Non-bulky tumor

Advanced disease  |

* Stage III or IV

* B symptoms

* Bulky tumor

## References[edit | edit source]

1. ↑ Jiang M, Bennani NN, Feldman AL (2017). "Lymphoma classification update: B-cell non-Hodgkin lymphomas". Expert Rev Hematol. 10 (5): 405–415. doi:10.1080/17474086.2017.1318053. PMID 28395545.CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 Intragumtornchai T, Bunworasate U, Wudhikarn K, Lekhakula A, Julamanee J, Chansung K; et al. (2018). "Non-Hodgkin lymphoma in South East Asia: An analysis of the histopathology, clinical features, and survival from Thailand". Hematol Oncol. 36 (1): 28–36. doi:10.1002/hon.2392. PMID 28332735.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 3.2 Casulo C, Burack WR, Friedberg JW (2015). "Transformed follicular non-Hodgkin lymphoma". Blood. 125 (1): 40–7. doi:10.1182/blood-2014-04-516815. PMID 25499449.CS1 maint: Multiple names: authors list (link)
4. ↑ Bartl R, Frisch B, Burkhardt R, Jδger K, Pappenberger R, Hoffmann-Fezer G. Lymphoproliferations in bone marrow: i0 dentification and evaluation, classification and staging. J Clin Pathol 1984;37:233-54.
5. ↑ Bain BJ, Clark DM, Lampert IA, Wilkins BS, editors. Bone marrow pathology. 3 rd ed. UK: Blackwell Science Ltd; 2001.
6. ↑ Culling CF, Allison RT, Barr WT. Connective tissue. In: Cellular Pathology Techniques. 4 th ed. London: Butterworth and Co. ltd; 1985. p. 172-3.
7. ↑ Bligh MP, Borgaonkar JN, Burrell SC, MacDonald DA, Manos D (2017). "Spectrum of CT Findings in Thoracic Extranodal Non-Hodgkin Lymphoma". Radiographics. 37 (2): 439–461. doi:10.1148/rg.2017160077. PMID 28287948.CS1 maint: Multiple names: authors list (link)
8. ↑ Thacker N, Bakhshi S, Chinnaswamy G, Vora T, Prasad M, Bansal D; et al. (2017). "Management of Non-Hodgkin Lymphoma: ICMR Consensus Document". Indian J Pediatr. 84 (5): 382–392. doi:10.1007/s12098-017-2318-0. PMID 28378140.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)