The disease is diagnosed by the medical specialists in haematology, oncology or surgery, following a careful history, physical examination, a blood test, if any, and X-ray examinations, on the basis of the biopsy of a swollen lymph node or other tissue examined under a microscope. The biopsy is essential to diagnose the disease and (above all) to determine the exact type of lymphoma at issue.
The diagnostic procedure includes the following steps:
History and physical examination
It is the collection of the clinical history and subjective symptoms. The doctor will evaluate the lymph nodes of the neck, armpits and groin, and will verify whether the spleen and liver are enlarged.
Methods of radiological diagnostics
Chest X-ray: it is a simple X-ray to obtain a basal chest evaluation. Sometimes it is the first examination leading to the suspected diagnosis. It is often during the course of therapy for assessing potential infectious complications
Ultrasound: it allows for both superficial lymph nodes to be properly defined and measured, and abdominal lymph nodes and the spleen to be assessed. Although it has some limits, it has the advantage of not exposing patients to radiations or to side effects as well as being very economical.
CT (computerised tomography): CT (or CAT scan) is a radiological examination that allows for internal organs to be assessed more precisely compared to regular X-rays and permits to view all body areas. It is an eminently suitable instrument to detect changes both in the abdomen and chest and to accurately measure their size. In general it is carried out with a contrast medium injected into the patient’s arm vein. It’s a fast, easily accessible, repeatable and comparable examination.
MRI (Magnetic Resonance Imaging): in clinical practice it is not considered a cross-sectional methodology and is not recommended for use in routine staging of lymphomas. It has however specific indications, for example when it is essential to explore the central nervous system or a bone. It does not expose patients to ionizing radiation and can therefore be used with children or pregnant women. With this technique too it may be useful to inject a contrast medium.
PET (Positron Emission Tomography)/TC: PET/TC is a hybrid device that combines positron emission tomography (PET) and TC. The PET examination consists in the preliminary intravenous administration of a small amount of sugar (glucose) labelled with a radioactive isotope. The labelled sugar accumulates where the lymphomatous tissue is. After a certain timeframe, the examination, which is very similar to a simple TC, is performed on the patient. While the patient is lying on the table the device called “CT-PET scanner” detects the radiation emitted by the body and shows the accumulations in areas where the lymphoma is. It is very useful in lymphomas particularly “avid” of sugars such as Hodgkin’s or large B-cell lymphomas. It is also useful to determine whether residues of lymph nodes highlighted by the simple CT scan performed after treatment are inactive (scars that do not pick up the sugar) or are still active (avid).
Visit also the page of the FIL Scientific Commission Imaging.
Lymph node biopsy
Lymph node biopsy consists in the partial or full removal of a lymph node in order to analyse the tissue under the microscope and determine the presence and type of lymphoma cells, if any. It is a simple intervention that is mostly carried out by the surgeon under local anaesthesia and usually does not require hospitalisation. Should the biopsy show the presence of a lymphoma, further examinations will then be required in order to obtain information on the extension of lymphoma in the body (staging procedures). Given the complexity and the therapeutic implications of the correct identification of the subtype of lymphoma, it is always advisable that the diagnosis be performed by an Anatomic Pathology with suitable equipment and good experience in the diagnostic industry.
Visit also the page of the FIL Scientific Commission Pathology.
Bone marrow aspiration and biopsy
Bone marrow examination allows evaluating whether a lymphomatous infiltration of bone marrow is present. The bone marrow examination can be carried out via 2 slightly different types of collection in correspondence with the rear part of the pelvis bone. These marrow collections are concurrently carried out on an outpatient basis under local anaesthesia and with an execution time not exceeding 15-20 minutes. It is not necessary to be fasting. The patient is positioned prone on an examination table; the sample collection is performed with specific needles from the posterior higher iliac spine (the most protruding part of the hip bone near the sacral bone).
Bone marrow aspirate: following local anaesthesia, the physician introduces a needle that penetrates into the bone and aspires 5-10 cc of bone marrow blood through a syringe. Samples collected are sent to the laboratory for analysis. The patient may feel a slight discomfort/pain during the execution of the procedure, particularly in the short phase of the bone marrow blood suction. Patients may go back to performing their regular activities within the same day.
Bone marrow biopsy: The procedure is essentially identical to the foregoing; a slightly bigger needle is introduced to extract a small portion of bone of cylindrical shape (the so-called frustum), which is sent to the anatomo-pathologists to be analysed.
Blood test: is the simple collection of venous blood to run a series of laboratory tests with a view to obtaining a complete blood count (function of the kidneys, liver, lymphoma activity markers etc.).