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How We Diagnose Hodgkin Lymphoma

  • Margaret Shipp, MD, and Philippe Armand, MD, PhD


    Lymphoma Program leaders Margaret Shipp, MD, and Philippe Armand, MD, PhD

  • Accurate diagnosis of your lymphoma sub-type is crucial in determining the proper course of treatment. This makes it important to be seen at — or consult with — a large lymphoma treatment center like ours, which diagnoses and cares for many patients with all forms of this kind of cancer.

    Data from our program shows that in 10 to 15 percent of cases, a second opinion from our team renders a different diagnosis from what was given by a referring doctor. Our hematopathologists and radiologists conduct these diagnostic tests and study the results on a daily basis, which gives us deep experience in this area.

    Correctly identifying the sub-type of lymphoma is particularly important in determining:

    • How many cycles of chemotherapy are necessary.
    • Whether to integrate radiation into the treatment plan.

    Initial Diagnosis

    Biopsy

    A biopsy of involved tissue or lymph nodes is essential in order to make a diagnosis. Our surgeons have expertise in performing lymph node biopsies that ensure adequate tissue is gathered to make a precise diagnosis. Generally, the removal of all or a big part of a lymph node is the preferred method in order to ensure an adequate sample. A pathologist then examines the lymph node tissue to look for the malignant B cells.

    Immunophenotyping may be done on tissue that was removed to study the protein expressed by cells. This is used to diagnose the specific type of lymphoma by comparing the cancer cells to normal cells.

    Radiographic Studies

    Your doctor may conduct imaging studies (see below), such as CT scans, X-rays, and PET scans, of the chest, abdomen, and pelvis. Radiologists look for an enlarged spleen or lymph nodes, or abnormal retinal veins.

    PET scanning can identify patients who are candidates for chemotherapy treatment alone. This spares them from exposure to any unnecessary risks of radiotherapy, which can include cardiac disease and secondary malignancies.

    Genetic and Molecular Analysis

    You can have a precise "tumor profile" created that gives us information that may reveal genetic or chromosomal abnormalities. We have unique expertise in interpreting molecular and genomic tests and translating the data into an action plan.

    Even within the same diagnosis, the specific mutation "profile" of a cancer can predict very different outcomes. Knowing the particular combination of mutations driving a patient's disease can help physicians decide whether to recommend a regimen of certain approved drugs, a stem cell transplant, or enrollment in a clinical trial.

    Blood Tests

    Your doctor may decide to run blood tests, including a blood chemistry study. This is a procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.

    Your doctor may check for erythrocyte sedimentation rate. During a sedimentation rate procedure, a sample of blood is checked for the rate at which the red blood cells settle to the bottom of the test tube.

    Flow Cytometry

    This blood test measures:

    • The number of cells in a sample
    • The percentage of live cells in a sample
    • Certain characteristics of cells, such as size, shape, and the presence of tumor markers on the cell surface

    The cells are stained with a light-sensitive dye, placed in a fluid, and passed in a stream before a laser or other type of light. The measurements are based on how the light-sensitive dye reacts to the light.

    FISH (Fluorescence In Situ Hybridization)

    This test looks at genes or chromosomes in cells and tissues. It is used to detect certain chromosomal abnormalities.

    Prognosis

    The prognosis (chance of recovery) and treatment options depend on the following:

    • The signs and symptoms
    • The stage of the cancer
    • The type of Hodgkin lymphoma
    • Blood test results
    • Age, gender, and general health
    • Whether the cancer is recurrent or progressive

    Staging

    The process used to find out if cancer has spread within the lymph system or to other parts of the body is called staging. Hodgkin lymphoma stages range from stage I (in which only one lymph node region or structure is involved) to stage IV (in which the cancer has spread beyond the lymphatic system).

    The following tests and procedures may be used in the staging process:

    CT scan (CAT scan): A procedure that produces a series of detailed pictures of areas inside the body, taken from different angles. The pictures are taken by a computer linked to an X-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For adult Hodgkin lymphoma, CT scans of the neck, chest, abdomen, and pelvis are taken.

    PET scan: A procedure to find tumor cells. First, a small amount of radioactive substance is injected into a vein. The PET scanner then rotates around the body and creates a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

    PET-CT scan: A procedure that combines the pictures from a positron emission tomography (PET) scan and a computed tomography (CT) scan. The PET and CT scans are done at the same time, on the same machine. The pictures from both scans are combined to create a more detailed picture than either test would produce by itself.

    Bone marrow aspiration and biopsy: The removal of bone marrow, blood, and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist examines the bone marrow, blood, and bone to look for signs of cancer. This procedure is not needed for all patients. Your physician will review with you if a bone marrow biopsy is necessary.

    Stages

    Sub-classifications

    Additional criteria help to further identify subgroups within each stage, identified as A, B, E, S, and X:

    • A: The patient does not have B symptoms (fever, weight loss, or night sweats).
    • B: The patient has B symptoms.
    • E: Cancer is in an organ or tissue outside the lymph system but may be next to an affected area of the lymph system.
    • S: Cancer is in the spleen.
    • X: The cancer is bulky (over a certain size).

    Early-stage Hodgkin lymphoma is further broken down into two subsets. Experts use different criteria to classify them as either "favorable" or "unfavorable." This classification can be a useful measure of prognosis, guide the treatment plan, and define the aspects of the disease that can be evaluated to determine the effectiveness of treatment.

    Stage I

    Stage I is divided into stage I and stage IE.

    • Stage I: Cancer is found in one lymph node group.
    • Stage IE: Cancer is found outside the lymph system in one organ or area.

    Stage II

    Stage II is divided into stage II and stage IIE.

    • Stage II: Cancer is in two or more lymph node groups, either above or below the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
    • Stage IIE: Cancer is in one or more lymph node groups either above or below the diaphragm and outside the lymph nodes in a nearby organ or area.

    Stage III

    Stage III is divided into stage III, stage IIIE, stage IIIS, and stage IIIE+S.

    • Stage III: Cancer is in lymph node groups above and below the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
    • Stage IIIE: Cancer is in lymph node groups above and below the diaphragm and outside the lymph nodes in a nearby organ or area.
    • Stage IIIS: Cancer is in lymph node groups above and below the diaphragm, and in the spleen.
    • Stage IIIE+S: Cancer is in lymph node groups above and below the diaphragm, outside the lymph nodes in a nearby organ or area, and in the spleen.

    Stage IV

    In stage IV, the cancer is:

    • Outside the lymph nodes throughout one or more organs, with or without lymph node involvement.
    • In the lung, liver, bone marrow.