Diagnosis of Hodgkin lymphoma

Diagnosis is the process of finding out the cause of a health problem. Diagnosing cancer often means first ruling out other heath conditions that share similar symptoms with cancer. It can be a very worrying time for you and your loved ones. Sometimes this process is quick. Sometimes it can feel long and frustrating. But it's important for doctors to get all the information they need before making a diagnosis of cancer.

Diagnosing Hodgkin lymphoma (HL) usually begins with a visit to your family doctor. Your doctor will ask you about any symptoms you have and may do a physical exam. Based on this information, your doctor may refer you to a specialist or order tests to check for HL or other health problems.

The following tests are usually used to rule out or diagnose HL. Many of the tests that are used to diagnose cancer are also used to find out the stage (how far the cancer has spread). Your doctor may also order other tests to check your general health, help plan your treatment and see how well treatment is working.

Your health history is a record of your symptoms and risks and all the medical events and problems you have had in the past. Your doctor will ask questions about your history of:

• symptoms that suggest HL
• Epstein-Barr virus (EBV) infection
• HIV or AIDS

Your doctor may also ask about a family history of HL.

A physical exam allows your doctor to look for any signs of HL. During a physical exam, your doctor may:

• check if any lymph nodes are larger than normal (enlarged)
• feel the abdomen to see if the liver or spleen is larger than normal
• listen to the lungs for any breathing problems

Find out more about a physical exam.

A computed tomography (CT) scan uses special x-ray equipment to make 3D and cross-sectional images of organs, tissues, bones and blood vessels inside the body. A computer turns the images into detailed pictures.

A CT scan is one of the main imaging tests used to diagnose HL. It may be used to check for enlarged lymph nodes or a mass in the neck, chest, abdomen or pelvis. It also allows your healthcare team to see if:

• a tumour is pressing on any organs or large blood vessels
• there is any disease in the brain or near the spinal cord
• the cancer has spread to any organs, such as the lungs, liver or spleen

A CT scan may also be used to measure how well treatment for HL is working.

Find out more about CT scans.

A positron emission tomography (PET) scan uses a type of radioactive sugar to look for changes in the metabolic activity of body tissues. A computer analyzes the radioactive patterns and makes 3D colour images of the area being scanned. The type of radioactive sugar most often used in PET scans to diagnose HL is fluorodeoxyglucose (FDG). This is why the test is sometimes called an FDG-PET scan.

A PET scan is one of the main imaging tests used to diagnose and find out where HL has spread in the body. It is also used to measure how well treatment for HL is working.

Find out more about PET scans.

An x-ray uses small doses of radiation to make an image of parts of the body on film. A chest x-ray is used to check for larger than normal lymph nodes in the chest. It is also used to see if HL has spread to the lungs.

Find out more about x-rays.

An ultrasound uses high-frequency sound waves to make images of parts of the body. It may be used to examine the abdomen and organs that may be affected by HL, such as the kidneys, spleen or liver.

Find out more about ultrasounds.

During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab. The report from the lab will show whether or not cancer cells are found in the sample.

A biopsy may be done on an enlarged lymph node in the neck, under the arm or in the groin. A biopsy sample may also be taken from a tumour in the chest or abdomen.

The type of biopsy done depends on where the doctors need to collect the samples from.

A surgical lymph node biopsy is usually done to collect samples from lymph nodes. The surgeon may remove all of a lymph node (called an excisional biopsy). In some cases, doctors may remove only part of a lymph node (called an incisional biopsy). Find out more about a surgical biopsy.

A core biopsy guided by a CT scan may be used for some types of tumours, such as a large tumour in the chest or a tumour in the bone. Find out more about a core biopsy.

Cells and tissues are analyzed in the lab to look for cancer. A report from a pathologist will show whether or not cancer cells are found in the sample and what type of cancer has been found.

Special lab techniques are used to prepare the samples so that very small details in the cells and tissues can be seen under a microscope.

Immunophenotyping is the study of proteins (antigens) expressed by cells. It uses fluorescent monoclonal antibodies that will glow under a special light. Each monoclonal antibody will only attach to a certain antigen if it is in or on the cells.

Immunohistochemistry is a method commonly used in immunophenotyping. It uses a microscope to view the fluorescent monoclonal antibodies that have attached to the cells. Since each monoclonal antibody attaches to a specific antigen, the pathologist can see which antigens are present. Knowing the antigens that are on the surface of or in cells helps pathologists make a diagnosis. It can also help them plan treatment with drugs that are designed to target that antigen.

Immunohistochemistry helps doctors determine the types of cells in a sample, including if there are any Hodgkin and Reed-Sternberg (HRS) cells or lymphocyte-predominant (LP) cells.

HRS cells have the antigens CD-30 and CD-15. If these antigens are found, it may help the pathologist diagnose the cancer as Hodgkin lymphoma.

LP cells have the antigens CD-45 and CD-20. If these antigens are found, it may help the pathologist diagnose the cancer as nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL).

Find out more about cell and tissue studies.

A complete blood count (CBC) measures the number and quality of white blood cells, red blood cells and platelets. A CBC is done to help rule out an infection. It also gives doctors a baseline to compare with blood cell counts taken during and after treatment.

Find out more about a complete blood count (CBC).

Doctors may order a blood test to measure the erythrocyte sedimentation rate (ESR). The ESR measures how quickly red blood cells (also called erythrocytes) fall to the bottom of a test tube.

Red blood cells fall faster than normal when there is inflammation in the body, so the ESR is a general marker of inflammation.. The ESR may be higher than normal in some people with HL

Blood chemistry tests measure certain chemicals in the blood. They show how well certain organs are working and can help find problems. Blood chemistry tests used to help stage HL include the following.

Lactate dehydrogenase (LDH) can be used to measure how well the liver is working, but it also shows if there is cell damage. LDH levels can be higher than normal when HL is more active and damaging cells.

Alanine aminotransferase (ALT) and aspartate transaminase (AST) may be measured to check how well the liver is working. Higher than normal levels of ALT or AST may mean that HL has spread to the liver.

Alkaline phosphatase may be measured to check how well the liver is working and to check the bones. A higher than normal level of this enzyme may mean that HL has spread to the liver or the bones.

Serum creatinine may be measured to check how well the kidneys are working. A higher than normal level of creatinine in the blood may mean that HL has damaged the kidneys.

Find out more about blood chemistry tests.

Magnetic resonance imaging (MRI) uses powerful magnetic forces and radiofrequency waves to make cross-sectional images of organs, tissues, bones and blood vessels. A computer turns the images into 3D pictures.

MRI scans are not usually needed to diagnose HL. But they may be used to see if cancer has spread to the brain, spinal cord, bone or muscle tissue.

Find out more about MRI.

Your healthcare team may order the following tests while considering or ruling out HL. These tests don’t diagnose HL, but their results may affect your treatment plan.

People who have an HIV (human immunodeficiency virus) infection are at a higher risk of developing HL. Your healthcare team may do an HIV test if they think that HL is related to an HIV infection.

An HIV test is a blood test that measures the level of HIV antibodies in the blood. A high level of these antibodies means the body is infected with HIV.

If you have an HIV infection, your healthcare team will create a treatment plan that includes treating both HL and HIV. You may have lower doses of chemotherapy drugs because your immune system may be weakened by the HIV infection.

Hepatitis B virus (HBV) and hepatitis C virus (HCV) can cause inflammation of the liver (called hepatitis). The liver removes waste products, bacteria and harmful substances from the blood. When the liver is damaged by hepatitis, it doesn’t work well.

You may be tested for these infections before you start treatment for HL. This is because the liver normally removes chemotherapy drugs from the body. But if the liver isn’t working well, certain chemotherapy drugs could build up in your bloodstream and cause other health problems. If hepatitis has already damaged your liver, some types of chemotherapy or immunotherapy may worsen that damage.

If you have hepatitis B or hepatitis C, your healthcare team will create a treatment plan to meet your needs.

If there is any chance that you are pregnant, you will have a pregnancy test. If you are pregnant when you're diagnosed, your healthcare team will talk to you about your treatment options.

To make the decisions that are right for you, ask your healthcare team questions about diagnosis.