Guidelines on the investigation and management of lymphoid diseases
1. The diagnosis of lymphoma should be made based on an assessment of the patient’s clinical features, imaging, and by histological and immunohistochemical assessment of a tissue biopsy. Biopsy types will include lymph node excision and needle core biopsies and surgical or needle core biopsies of extranodal sites. Lymphoma should not usually be diagnosed on the basis of fine needle aspiration specimens alone.Further confirmatory tests contributing to the diagnosis may include some or all of:
- Radiological imaging results
- Peripheral blood morphology
- Bone marrow morphology
- Histological examination of bone marrow trephines
- Immunophenotyping of peripheral blood and bone marrow samples
- Immunohistochemical analysis of bone marrow trephines
- Karyotype and fluorescent in situ hybridisation (FISH) analysis of peripheral blood, bone marrow, lymph node or extranodal tissue specimens.
- Molecular biological analysis of appropriate genetic markers in samples obtained from peripheral blood, bone marrow, lymph nodes or extranodal tissue.
- Other specialist and ‘send-away’ tests where considered appropriate
- Obtaining specialist pathological review at recognised national centres of expertise where considered appropriate
2. Lymphoma staging should include data obtained from clinical examination, radiological assessment and (usually) bone marrow trephine biopsy. The standard radiological staging assessment for lymphoma comprises a computed tomography (CT) scan of the thorax, abdomen and pelvis. Other areas may require additional CT imaging as directed by clinical and radiological assessment. Other imaging modalities which may be used to contribute to lymphoma staging include:
- CT-Positron Emission Tomography (PET) scanning
- Ultrasound imaging
- Magnetic Resonance Imaging (MRI)
3. A management plan should be formulated by consultation between the members of the MDT and taking into account the following factors:
- The lymphoma diagnosis(and subtype, where relevant)
- The disease stage
- The patient’s performance status
- The patient’s expressed wishes regarding treatment
- Current NICE guidance where available
- Current BCSH guidelines (currently available for follicular lymphoma, mantle cell lymphoma, CNS prophylaxis, post-transplant lymphoproliferative disorder and mature T and NK cell neoplasms).
- The results of well-conducted clinical trials and other recent evidence from the peer-reviewed medical literature
4. Where possible the patient should be offered treatment in a current clinical trial if the patient is eligible and such a trial is available.
5. Where measurable disease is apparent by radiological examination at initial diagnosis, re-staging of the disease following treatment should be performed using the same imaging modality. In addition any further imaging modalities the MDT consider appropriate and likely to add information which may influence management may be used in re-staging.
6. Re-staging should routinely be performed at the end of a planned course of treatment in order to assess disease response. In addition, in most patients receiving cyclical chemotherapy regimens, interim re-staging (typically after half the planned course of chemotherapy has been delivered) should be performed and reviewed at the MDT. The results of interim re-staging should be used to aid the decision as to whether to continue the current proposed course of treatment to its planned conclusion, whether to alter or stop treatment and to determine the total extent of further treatment.
7. Once patients have completed a planned course of treatment they may be re-referred to the MDT for re-discussion and reassessment of staging and other investigations at any of the following time points:
- Following clinical suspicion of relapse or re-progression of disease
- Following planned interim re-staging following a period of observation
- Following clinical suspicion of transformation of the original disease or the development of secondary phenomena