When you’re first diagnosed, your specialist will carry out tests to allow them to stage, grade and ‘risk score’ the lymphoma.
Your doctors will want to know the stage of your lymphoma. Staging describes how far the lymphoma has spread and the nature of the lymphoma.
The stage of your lymphoma will affect your doctor’s recommendation about whether you should start treatment immediately and which treatment is right for you.
There’s a standard system which all doctors use to stage low-grade NHL. It’s mainly based on how many areas of your body are affected by the lymphoma. The staging groups are shown in the table below:
Staging is also based on which symptoms you have when you’re diagnosed. This is shown by a letter ‘A’ or ‘B’ – any letter can apply to any of the numbered stages.
The most important distinction in staging is between disease that hasn’t spread, called early disease (stage I or II disease with no B symptoms), and advanced disease (all other cases). This distinction is important because there are different treatment options for early stage and advanced stage disease.
Grading is a specific term that's only used to describe follicular lymphoma. Follicular lymphoma is always classed as a low-grade lymphoma, and given a stage accordingly. However, as well as staging, follicular lymphoma is also given a grade from 1 to 3 (with an A or B, as described in the table above).
Grading of follicular lymphoma looks at types of cells called centroblasts (a type of B cell). Grading looks at the affected node, and the proportion of centroblast cells compared with other cells.
These grades can sometimes help doctors see how fast the lymphoma is growing. Groups 1, 2 and 3A are classed as follicular lymphoma.
If you have grade 3B follicular lymphoma, your condition is likely to be treated as a high-grade lymphoma.
Risk scoring helps your doctor predict how your condition will respond to treatment.
There are a number of guidelines your doctor will use to predict how you’re likely to respond to treatment. These are called the follicular lymphoma indices. They look at several different aspects of your disease, including but not limited to:
- your age,
- which lymph nodes are involved,
- your haemoglobin levels (the levels of iron in your red blood cells),
- your LDH levels (the levels of a biochemical called lactate dehydrogenase in your blood), and
- the size of the largest mass of cancer cells (swollen node/s).
You’ll have a series of tests that will help your doctors to find out the stage of the low-grade NHL. These tests will also help doctors predict how you’ll respond to treatment. You’ll have heard of some of these tests, but others might be less familiar. You can always talk to your healthcare team if you have any questions.
Bone marrow aspirate and trephine
You may have a bone marrow biopsy (sample) taken soon after diagnosis, to see whether the bone marrow is affected by lymphoma. This may give doctors another opportunity to confirm your diagnosis and gain extra information about the disease.
During the procedure, a small amount of bone marrow is sucked from the hip bone using a fine needle (an aspirate).
Your doctors will then look at the bone marrow sample under a microscope. You don’t need to stay overnight in hospital for a bone marrow biopsy; you can have it as an outpatient using local anaesthetic or entonox (gas and air). It’s usually quite quick but will be uncomfortable while the sample is being taken from your marrow; you can take painkillers if you need to.
You’ll also have a bone marrow trephine. This is taken at the same time as the bone marrow aspirate, and a slightly larger piece of bone marrow is taken from the same site.
You might experience some discomfort around the area where your bone marrow sample was taken. If you’d like, you can take some paracetamol to help with the pain. Any discomfort is usually gone after 24–36 hours.
Doctors will use scans to help with your diagnosis and staging. These often use a form of radiation, but your healthcare team will always make sure that you’re not exposed to more radiation than is absolutely necessary. It may take a few weeks to get the results of all these tests, which can be a worrying time for many people. It’s really important that doctors take the time to get an accurate diagnosis and stage the lymphoma correctly, as this will determine what treatment you have.
X-rays provide good images of the denser tissues in your body, such as bone.
You might have more X-rays during your treatment, to find out how your body is responding and to check for chest infections.
CT scans look at your soft tissues (the non-bony parts of your body).
It’s likely that you’ll have a full body CT scan, which gives a detailed picture of your internal organs.
The scan isn’t painful. You’ll lie on a table that moves into a cylindrical tunnel while the pictures are taken. Your body is never completely enclosed and you’ll be able to talk to the person who takes and assesses the images (the radiographer) all the time.
You might need to have a dye injected into one of your veins, to help get a better image. If you’re feeling anxious about this procedure, you may be given a sedative to take beforehand.
Fluorodeoxyglucose positron emission tomography (FDG-PET scan, PET scan or PET/CT scan)
You’ll almost always have a PET scan (or sometimes a combination scan called a PET/CT scan) to help stage the cancer.
PET scans are often combined with CT scans. For this scan, you’ll have an injection that contains radioactive sugar. This small amount of radioactivity is completely safe. Like with CT scans, you’ll lie on a table as you move through a cylindrical tunnel. The scan can take up to three hours, including preparation time.
You’ll get more information and advice about this scan from your hospital.
As the cancerous cells take up more of the radioactive sugar than non-cancerous cells, doctors will be able to measure how much lymphoma is in your body.
You may have this scan again halfway through or at the end of your treatment to see if it’s been successful.
Magnetic resonance imaging (MRI)
An MRI uses the effect of a strong magnet on your body to produce very detailed images of soft tissues, which are then analysed on a computer.
During the test, you’ll lie on a table which will move you through the scanner. To help the computer create a better picture, you might need to have some fluid injected into a vein using a needle.
It’ll take around an hour to carry out the scan. It’s not painful, but the MRI machine is noisy – you might be given headphones so you can listen to music during the scan.
Ultrasound scans can be used to give more information on your condition. For example, it could be used to measure the size of your spleen, which is often enlarged in lymphoma patients.
Your doctors will also do several other tests on your blood and/or bone marrow samples. These will help predict how the low-grade NHL might respond to treatment. These are known as prognostic markers.
Serum β2- microglobulin (Sβ2-M)
You’ll have a test that looks at the level of a protein called serum β2-microglobulin (Sβ2- M) in your body. Some patients with NHL will have higher amounts of Sβ2-M than is normal, and this can tell doctors how advanced the low-grade NHL might be.
Lactate dehydrogenase (LDH)
When cells break down, they release a chemical called lactate dehydrogenase (LDH). If you have low-grade NHL, you’ll normally have more LDH in your body because more cells are being produced and more cells are dying. This test can tell doctors how advanced the low-grade NHL might be.