Laboratory Workup of Lymphoma in Adults: Guideline From the American Society for Clinical Pathology and the College of American Pathologists

Abstract

Context.— The diagnostic workup of lymphoma continues to evolve rapidly as experience and discovery led to the addition of new clinicopathologic entities and techniques to differentiate them. The optimal clinically effective, efficient, and cost-effective approach to diagnosis that is safe for patients can be elusive, in both community-based and academic practice. Studies suggest that there is variation in practice in both settings. Objective.— To develop an evidence-based guideline for the preanalytic phase of testing, focusing on specimen requirements for the diagnostic evaluation of lymphoma. Design.— The American Society for Clinical Pathology, the College of American Pathologists, and the American Society of Hematology convened a panel of experts in the laboratory workup of lymphoma to develop evidence-based recommendations. The panel conducted a systematic review of literature to address key questions. Using the Grading of Recommendations Assessment, Development, and Evaluation approach, recommendations were derived based on the available evidence, strength of that evidence, and key judgements as defined in the Grading of Recommendations Assessment, Development, and Evaluation Evidence to Decision framework. Results.— Thirteen guideline statements were established to optimize specimen selection, ancillary diagnostic testing, and appropriate follow-up for safe and accurate diagnosis of indolent and aggressive lymphoma. Conclusions.— Primary diagnosis and classification of lymphoma can be achieved with a variety of specimens. Application of the recommendations can guide decisions on specimen suitability, diagnostic capabilities, and correct use of ancillary testing. Disease prevalence in patient populations, availability of ancillary testing, and diagnostic goals should be incorporated into algorithms tailored to each practice environment.

Axillary lymphadenopathy in a liver transplant recipient: Initial manifestation of disseminated cryptococcosis

“…Rarely, the initial manifestation may be lymphadenopathy alone; this presentation has been reported in both immunocompromised and immunocompetent hosts [3] , [4] . While fine needle aspiration cytology (FNAC) may be the initial diagnostic modality in some patients, excisional biopsy may be preferred if lymphoma is suspected [5] .…”

The diagnosis and management of suspected lymphoma in general practice

“…There is no “classic” presentation, standard workup, nor single test to diagnose or even definitively rule out lymphoma 4 . When symptomatic, lymphoma commonly presents with fatigue, pain, palpable lymphadenopathy, and shortness of breath/cough, 5 all of which are nonspecific findings with exceptionally broad differential diagnoses.…”

“…For all biopsy types, there is a concerningly high false negative rate for lymphoma, with a recent study noting a negative predictive value (NPV) as low as 54.3% for open surgical biopsy 81 . Providers should monitor all patients with negative biopsy results for persistent signs and symptoms of lymphoma and pursue larger‐volume biopsy if clinical suspicion for lymphoma remains high 4 . In addition, FC may not accurately pick up T‐cell clones and T‐cell rearrangement studies are often needed for diagnosis of T‐cell lymphoma, though this is typically managed by the pathologist and not the ordering provider 82 …”

“…Overall, FNA is unlikely to yield an actionable, accurate, or complete diagnosis of lymphoma, and is not recommended for a targeted workup of suspected lymphoma 4 . Subspecialty guidelines for evaluation of head and neck masses (including lymphadenopathy) do however recommend FNA as the first line sampling method 83 .…”

Leveraging fine-needle aspiration to improve HIV-associated lymphoma diagnostic capacity in resource-limited settings

“…HIV-associated lymphomas are often curable and increased capacity for diagnosis is critical to address the public health burden of HIV-associated lymphoma in South Africa. More time-consuming and expensive excisional lymph node biopsies or core biopsies are the gold-standards for diagnosis of lymphoma as FNA has varied success in making an accurate diagnosis on which treatment decisions can be made [10][11][12]. The diagnostic utility of cytologic examination of FNA material can be improved with ancillary tests, such as immunophenotyping via immunohistochemistry or flow cytometry and B and T-cell clonality via PCR molecular testing; however, the ability to evaluate nodal architecture is lost.…”