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Most people with non-Hodgkin lymphoma (NHL) see their doctor because they have felt a lump that hasn’t gone away, they develop some of the other symptoms of NHL, or they just don’t feel well and go in for a check-up.
If you have signs or symptoms that suggest you might have lymphoma, exams and tests will be done to find out for sure and, if so, to determine the exact type of lymphoma.
Your doctor will want to get a complete medical history, including information about your symptoms, possible risk factors, and other medical conditions.
Next, the doctor will examine you, paying special attention to the lymph nodes and other areas of the body that might be affected, including the spleen and liver. Because infections are the most common cause of enlarged lymph nodes, the doctor will look for an infection near the swollen lymph nodes.
The doctor also might order blood tests to look for signs of infection or other problems. Blood tests aren't used to diagnose lymphoma, though. If the doctor suspects that lymphoma might be causing your symptoms, they might recommend a biopsy of a swollen lymph node or other affected area.
For a biopsy, a small piece of a lymph node or, more often, an entire lymph node is removed for testing in a lab.
A biopsy is the only way to confirm a person has NHL. But it's not always done right away because many symptoms of NHL can also be caused by other problems, like an infection, or by other kinds of cancer. For example, enlarged lymph nodes are more often caused by infections than by lymphoma. Because of this, doctors often prescribe antibiotics and wait a few weeks to see if the lymph nodes shrink. If the nodes stay the same or continue to grow, the doctor might order a biopsy.
A biopsy might be needed right away if the size, texture, or location of a lymph node or the presence of other symptoms strongly suggests lymphoma.
There are several types of biopsies. Doctors choose which one to use based on each person’s situation.
Excisional or incisional biopsy: This is the preferred and most common type of biopsy if lymphoma is suspected, because it almost always provides enough of a sample to diagnose the exact type of NHL.
In this procedure, a surgeon cuts through the skin to remove the lymph node.
If the enlarged node is just under the skin, this is a fairly simple operation that can often be done with local anesthesia (numbing medicine). But if the node is inside the chest or abdomen, you will be sedated (given drugs to make you drowsy and relaxed) or given general anesthesia (drugs to put you into a deep sleep).
Needle biopsy: Needle biopsies are less invasive than excisional or incisional biopsies, but the drawback is that they might not remove enough of a sample to diagnose lymphoma (or to determine which type it is). Most doctors do not use needle biopsies to diagnose lymphoma. But if the doctor suspects that your lymph node is enlarged because of an infection or by the spread of cancer from another organ (such as the breast, lungs, or thyroid), a needle biopsy may be the first type of biopsy done. An excisional biopsy might still be needed even after a needle biopsy has been done, to diagnose and classify lymphoma.
There are 2 main types of needle biopsies:
To biopsy an enlarged node just under the skin, the doctor can aim the needle while feeling the node. If the node or tumor is deep inside the body, the doctor can guide the needle using a computed tomography (CT) scan or ultrasound (see descriptions of imaging tests later in this section).
If lymphoma has already been diagnosed, needle biopsies are sometimes used to check abnormal areas in other parts of the body that might be from the lymphoma spreading or coming back after treatment.
These procedures are not normally done to diagnose lymphoma, but they might be used to help determine the stage (extent) of a lymphoma that has already been diagnosed.
Bone marrow aspiration and biopsy: These procedures are often done after lymphoma has been diagnosed to help determine if it has reached the bone marrow. The 2 tests are often done at the same time. The samples are usually taken from the back of the pelvic (hip) bone, although in some cases they may be taken from other bones.
For a bone marrow aspiration, you lie on a table (either on your side or on your belly). After cleaning the skin over the hip, the doctor numbs the area and the surface of the bone with local anesthetic, which can cause a brief stinging or burning sensation. A thin, hollow needle is then inserted into the bone and a syringe is used to suck out a small amount of liquid bone marrow. Even with the anesthetic, most people still have some brief pain when the marrow is removed.
A bone marrow biopsy is usually done just after the aspiration. A small piece of bone and marrow is removed with a slightly larger needle that is pushed into the bone. The biopsy can also cause some brief pain.
Lumbar puncture (spinal tap): This test looks for lymphoma cells in the cerebrospinal fluid (CSF), which is the liquid that bathes the brain and spinal cord. Most people with lymphoma will not need this test. But doctors may order it for certain types of lymphoma or if a person has symptoms that suggest the lymphoma may have reached the brain.
For this test, you may lie on your side or sit up. The doctor first numbs an area in the lower part of your back over the spine. A small, hollow needle is then placed between the bones of the spine to withdraw some of the fluid.
Pleural or peritoneal fluid sampling: Lymphoma that has spread to the chest or abdomen can cause fluid to build up. Pleural fluid (inside the chest) or peritoneal fluid (inside the abdomen) can be removed by placing a hollow needle through the skin into the chest or abdomen.
The doctor uses a local anesthetic to numb the skin before inserting the needle. The fluid is then taken out and checked in the lab for lymphoma cells.
All biopsy samples and fluids are looked at in the lab by a pathologist (a doctor specially trained to recognize cancer cells). The size and shape of the cells and how they are arranged may show not only if the person has a lymphoma, but also what type of lymphoma it is. But usually other types of lab tests are needed as well.
Flow cytometry and immunohistochemistry: For both flow cytometry and immunohistochemistry, the biopsy samples are treated with antibodies that stick to certain proteins on cells. The cells are then looked at in the lab (immunohistochemistry) or with a special machine (for flow cytometry), to see if the antibodies attached to them.
These tests can help determine whether a lymph node is swollen because of lymphoma, some other cancer, or a non-cancerous disease. The tests can also be used for immunophenotyping – determining which type of lymphoma a person has, based on certain proteins in or on the cells. Different types of lymphocytes have different proteins on their surface, which correspond to the type of lymphocyte and how mature it is.
Chromosome tests: Normal human cells have 23 pairs of chromosomes (strands of DNA), each of which is a certain size and looks a certain way in the lab. But in some types of lymphoma, the cells have changes in their chromosomes, such as having too many, too few, or abnormal chromosomes. These changes can often help identify the type of lymphoma.
For more information, see Testing Biopsy and Cytology Specimens for Cancer.
Imaging tests use x-rays, sound waves, magnetic fields, or radioactive particles to produce pictures of the inside of the body. These tests might be done for a number of reasons, including:
The chest might be x-rayed to look for enlarged lymph nodes in this area.
A CT scan combines many x-rays to make detailed, cross-sectional images of your body. This scan can help tell if any lymph nodes or organs in your body are enlarged. CT scans are useful for looking for lymphoma in the abdomen, pelvis, chest, head, and neck.
CT-guided needle biopsy: A CT can also be used to guide a biopsy needle into a suspicious area. For this procedure, you lie on the CT scanning table while the doctor moves a biopsy needle through the skin and toward the area. CT scans are repeated until the needle is in the right place. A biopsy sample is then removed to be looked at in the lab.
Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. This test is not used as often as CT scans for lymphoma, but if your doctor is concerned about spread to the spinal cord or brain, MRI is very useful for looking at these areas.
Ultrasound uses sound waves and their echoes to create pictures of internal organs or masses. In the most common type of ultrasound, a small, microphone-like instrument called a transducer is placed on the skin (which is first lubricated with a gel). It gives off sound waves and picks up the echoes as they bounce off the organs. The echoes are converted by a computer into an image on a computer screen.
Ultrasound can be used to look at lymph nodes near the surface of the body or to look inside your abdomen for enlarged lymph nodes or organs such as the liver and spleen. It can also detect kidneys that have become swollen because the outflow of urine has been blocked by enlarged lymph nodes.
For a PET scan, you are injected with a slightly radioactive form of sugar, which collects mainly in cancer cells. A special camera is then used to create a picture of areas of radioactivity in the body. The picture is not detailed like a CT or MRI scan, but it can provide helpful information about your whole body.
If you have lymphoma, a PET scan might be done to:
PET/CT scan: Some machines can do both a PET scan and a CT scan at the same time. This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT scan. PET/CT scans can often help pinpoint the areas of lymphoma better than a CT scan alone.
This test is usually done if a person is having bone pain or has lab results that suggest the lymphoma may have reached the bones.
For bone scans, a radioactive substance called technetium is injected into a vein. It travels to damaged areas of bone, and a special camera can then detect the radioactivity. Lymphoma often causes bone damage, which may be seen on a bone scan. But bone scans can’t show the difference between cancers and non-cancerous problems, such as arthritis and fractures, so further tests might be needed.
Blood tests are not used to diagnose lymphoma, but they can sometimes help determine how advanced the lymphoma is.
These tests are not used to diagnose lymphoma, but they might be done if you are going to get certain chemotherapy drugs commonly used to treat lymphoma that could affect the heart or the lungs.
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Freedman AS, Jacobson CA, Mauch P, Aster JC. Chapter 103: Non-Hodgkin’s lymphoma. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015.
National Cancer Institute. Physician Data Query (PDQ). Adult Non-Hodgkin Lymphoma Treatment. 2018. Accessed at https://www.cancer.gov/types/lymphoma/hp/adult-nhl-treatment-pdq on May 1, 2018.
National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: B-cell Lymphomas. Version 3.2018. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/b-cell.pdf on April 30, 2018.
Roschewski MJ, Wilson WH. Chapter 106: Non-Hodgkin Lymphoma. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 5th ed. Philadelphia, Pa: Elsevier; 2014.
Last Revised: August 1, 2018