Laboratory Workup of Lymphoma in Adults

Guideline From the American Society for Clinical Pathology and the College of American Pathologists

Steven H. Kroft, MD; Cordelia E. Sever, MD; Adam Bagg, MD; Brooke Billman, MLIS, AHIP; Catherine Diefenbach, MD; David M. Dorfman, MD, PhD; William G. Finn, MD; Dita A. Gratzinger, MD, PhD; Patricia A. Gregg, MD; John P. Leonard, MD; Sonali Smith, MD; Lesley Souter, PhD; Ronald L. Weiss, MD, MBA; Christina B. Ventura, MPH, MT(ASCP); Matthew C. Cheung, MD

Disclosures

Am J Clin Pathol. 2021;155(1):12-37.

Abstract and Introduction

Abstract

Objectives: The diagnostic workup of lymphoma continues to evolve rapidly as experience and discovery lead 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. The aim of this review is to develop an evidence-based guideline for the preanalytic phase of testing, focusing on specimen requirements for the diagnostic evaluation of lymphoma.

Methods: 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 the literature to address key questions. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, recommendations were derived based on the available evidence, the strength of that evidence, and key judgments as defined in the GRADE 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 about specimen suitability, diagnostic capabilities, and correct utilization 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.

Introduction

The diagnosis and classification of lymphoma has evolved into a complex, multimodality process that requires rigorous attention to and quality assurance of numerous preanalytical, analytical, and postanalytical details. After exclusion of purely leukemic disorders and plasma cell neoplasms, the 2016 revised fourth edition of the World Health Organization's (WHO) WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues^[1] details more than 60 distinct mature lymphoid neoplasms. Although accurate prediction of outcome has long been a primary goal of lymphoma classification, direction of management was a secondary goal in some respects—historically, because of limited available therapeutic options. This has changed dramatically in recent years given the proliferation of disease-specific regimens and the explosion of novel agents that show targeted activity in distinct subtypes of lymphoma.

Consequently, accurate diagnosis and classification have become more important than ever. Yet, even as the diagnostic process for lymphoma has grown more complex and requires application of an ever-growing array of ancillary diagnostic techniques, clinical practice has shifted progressively toward less invasive procedures. Effectively, pathologists are being asked to do more with less. Given these trends, it is logical to suspect that a tipping point will eventually be reached at which the quality of the diagnostic process will begin to degrade. Overlaid is the increasing need to act as responsible stewards of limited health care resources. Yet, little guidance exists regarding appropriate procurement techniques, specimen requirements, triage processes, and algorithms for deployment of specialized ancillary studies in the diagnosis of lymphomas. Perhaps as a consequence of this lack of guidance, practice patterns vary considerably from center to center. Understanding the limitations and advantages demonstrated by the available evidence will help health care teams and patients choose a diagnostic testing strategy that is best suited to their goals and resources.

To address the uncertainty related to the workup of suspected lymphomas, the American Society for Clinical Pathology (ASCP), the College of American Pathologists (CAP), and the American Society of Hematology (ASH) convened a joint workgroup to develop an evidence-based guideline to address appropriate evaluative processes. The primary goal of this guideline was to develop recommendations for the preanalytic phase of testing, with a focus on specimen requirements. An overarching key question drove the activity of this expert panel (EP): What are the specimen requirements for an accurate diagnosis in all adult patients with clinical features raising consideration of lymphoma?

To address this question, the EP derived a set of key questions, as detailed in the Objectives section. These questions were crafted to query issues related to the relative effectiveness of various procedures, the specimen requirements for effective and accurate diagnosis, the process of triaging tissue for ancillary techniques, and the performance characteristics of those ancillary techniques.

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Table 1. Strength of Evidence
Designation	Description
High	There is high confidence that available evidence reflects true effect. Further research is very unlikely to change the confidence in the estimate of effect. Included studies will be of high or intermediate quality.
Moderate	There is moderate confidence that available evidence reflects true effect. Further research is likely to have an important impact on the confidence in estimate of effect and may change the estimate. Included studies will be of intermediate or low quality.
Low	There is limited confidence in the estimate of effect. The true effect may be substantially different from the estimate of the effect. Included studies will be of low quality.
Very low	There is very little confidence in the estimate of effect. The true effect is likely to be substantially different from the estimate of effect. Any estimate of effect is very uncertain. Included studies will be of low or very low quality.

Table 2. Strength of Recommendations
Designation	Recommendation	Evidence-to-Decision Judgment
Strong recommendation	Recommend for or against a particular practice (can include "must" or "should")	Supported by assessment with the GRADE EtD framework showing EP consensus of judgments directed to the far right or far left poles of the framework
Conditional recommendation	Recommend for or against a particular practice (can include "should" or "may")	Supported by assessment with the GRADE EtD framework showing EP consensus of judgments directed toward the center of the framework or with a dispersed pattern

EtD, Evidence-to-Decision framework, EP, expert panel; GRADE, Grading of Recommendations Assessment, Development, and Evaluation.

Table 3. Summary of Guideline Statements
Guideline Statement	Strength of Recommendation
1. Clinical care providers should use surgical biopsy when feasible in a clinical setting where Hodgkin lymphoma is highly suspected.	Strong recommendation
2. Clinical care providers should obtain excisional or core needle biopsy (CNB) specimens in patients with high suspicion of lymphoma.	Strong recommendation
3. Clinical care providers should not use fine needle aspiration (FNA) cytomorphology alone without ancillary testing to achieve a definitive diagnosis of lymphoma. Note: Cytomorphology alone without ancillary studies has low sensitivity and low predictive value. Note: A defined subset of lymphoma requires architectural assessment and cannot be reliably diagnosed and subclassified by FNA.	Strong recommendation
4. Clinical care providers should follow up with patients with "negative" results for persistent signs and symptoms of lymphoma and pursue larger volume biopsy when clinical suspicion for lymphoma persists.	Strong recommendation
5. Clinical care providers may use positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose (FDG-PET) to identify sites for biopsy in patients with suspected transformed/aggressive-histology lymphoma. As feasible, biopsies should be directed to the site of greatest FDG avidity.	Conditional recommendation
6. Clinical care providers may obtain bone marrow biopsies for the primary diagnosis in select patients with suspected lymphomas. Note: For certain lymphoma types (eg, splenic low-grade lymphomas, lymphoplasmacytic lymphomas) bone marrow biopsy may be preferred over more invasive surgical methods.	Conditional recommendation
7. Clinical care providers may use cerebrospinal fluid (CSF) for the evaluation of primary or secondary central nervous system (CNS) lymphoma in select patients.	Conditional recommendation
8. Clinical care providers should use a combined morphologic and flow cytometric evaluation of cerebrospinal fluid (CSF) in the investigation of possible primary or secondary CNS lymphoma in select patients.	Strong recommendation
9. Based on low negative predictive values, clinical care providers should follow up with patients with "negative" results for persistent signs and symptoms of CNS lymphoma and pursue repeat CSF examination or biopsy when clinical suspicion for lymphoma persists.	Strong recommendation
10. Clinical care providers should use immunophenotyping by flow cytometry and/or immunohistochemistry in addition to morphology for the evaluation of specimens for the diagnosis and subclassification of lymphomas.	Strong recommendation
11. Clinical care providers may use fluorescence in situ hybridization (FISH) analysis when evaluating specimens in patients with suspected or confirmed lymphoma, or in the subclassification of lymphoma. FISH analysis is feasible on specimens obtained by FNA and may increase diagnostic yield. Note: Demonstration of the appropriate rearrangements is required for a diagnosis of high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements.	Conditional recommendation
12. Clinical care providers should not routinely use up-front polymerase chain reaction-based clonality studies of antigen receptor genes (ie, T-cell receptor and immunoglobulin) in the initial investigation of lymphoma. There may be a confirmatory role in certain settings for these studies.	Conditional recommendation
13. Clinical care providers may use molecular tests to aid in classification of lymphomas. For example, pathologists may use MYD88 L265P to aid in the classification of indolent B-cell lymphoma. Note: This recommendation statement refers to non-FISH molecular tests.	Conditional recommendation

Table 4. Good Practice Statements
1. For the diagnosis of difficult-to-classify lymphomas, laboratories should have a robust peer review process. Peer review may include a second review by a more experienced pathologist or a consensus review by a group of pathologists.
2. Pathologists should use clinical information in the workup and classification of lymphoma and lymphoma subtypes.
3. Laboratorians should include specimen handling elements in the final pathology report.
4. Laboratories should provide appropriate turnaround times for lymphoma test results to inform clinical decision-making.
5. Laboratories should establish policies to ensure efficient allocation and utilization of tissue for lymphoma testing.
6. Laboratories that send out tests for lymphoma diagnosis should have a process in place to ensure that specimens are sent and reviewed by outside reference laboratories in a timely manner.

Table 5. Secondary Reviews for Different Lymphomas
Highly Reproducible Lymphoma Types^a	Lymphoma Types for Which Secondary Review Is Suggested
Nodular sclerosis classic HL	Rare HL subtypes
DLBCL	DLBCL with suspicion for Burkitt lymphoma
CLL/SLL^b	High-grade B-cell lymphoma
MCL	FL with suspicion for transformation
Low-grade FL	All T-cell and NK-cell lymphomas
	CLL with suspicion for Richter transformation
	Marginal zone lymphoma

CLL, chronic lymphocytic leukemia; DLBCL, diffuse large B-cell lymphoma; FL, follicular lymphoma; HL, Hodgkin lymphoma, MCL, mantle cell lymphoma; NK, natural killer; SLL, small lymphocytic lymphoma.
^aHighly reproducible lymphoma types are defined as lymphoma types with high interobserver agreement between reviewing pathologists.^{81–84,87–89}
^bCLL/SLL was considered out of scope for this guideline.

Table 6. Routine TAT Targets for Lymphoma Tests ^a
Test	TAT (Business Days)
FISH for unique translocations	5–7
Flow cytometric analysis	1–2
Immunohistochemistry	1–2
Morphologic assessment	1–2
PCR for antigen receptor gene rearrangements	5–7

FISH, fluorescence in situ hybridization; PCR, polymerase chain reaction; TAT, turnaround time.
^aData derived from practice survey sent out to pathologists and hematologists.

Appendix. Disclosed Interests and Activities From November 2017 to May 2020 ^a
Author	Activity	Sponsor
Adam Bagg, MD	Consulting Lecture fees (honoraria)	Amgen Cornell University American Society for Clinical Pathology College of American Pathologists Loma Linda University American Registry of Pathology City of Hope Cancer Center International Society for Laboratory Hematology West Penn Allegheny Health System United States and Canadian Academy of Pathology Brigham and Women's University Yale University
	Position of influence	Associate Editor, Journal of Molecular Diagnostics, American Society for Investigative Pathology American Medical Foundation
	Research funding	Novartis-Penn Alliance
	Advisory board	Beckman Coulter Targeted Oncology Jazz Pharmaceuticals Blueprint Pharmaceuticals Acceleron Pharmaceuticals
Matthew C. Cheung, MD	Research funding	Gilead Immunovaccine GlaxoSmithKline Celgene Jannsen Allos Acerta Abbvie Hoffman-LaRoche IMV and Merck
Catherine Diefenbach, MD	Stock options/bonds	Gilead
	Advisory board	Genentech Seattle Genetics Bristol Myers Squibb Merck Celgene Janssen MorphoSys
	Research funding	Genentech Seattle Genetics Bristol Myers Squibb Incyte Millennium Merck Lymphangioleiomyomatosis (LAM) Therapeutics MEI Pharma
David Dorfman, MD, PhD	Royalties	Genentech
William Finn, MD	Stock options/bonds	Laboratory Associates of Michigan
William Finn, MD	Patent	US Patent 7,853,432
Dita Gratzinger, MD, PhD	Research funding	KaloBios
Patricia Gregg, MD	Consulting fees	NeoGenomics
Steven H. Kroft, MD	Position of influence	Editor-in-chief, American Journal of Clinical Pathology
John P. Leonard, MD	Consulting fees	Hospira Bayer Juno Therapeutics Teva Celgene Kite Pharma Genmab Nanostring Regeneron AbbVie Sutro Biopharma Sunesis Genentech Biotest Bristol Meyers Squibb Gilead
John P. Leonard, MD	Research funding	Genentech Celgene Abbvie Gilead Pharmacyclics Regeneron Karyopharm Bristol Meyers Squibb National Institutes of Health Leukemia and Lymphoma Society Leukemia Research Foundation
Cordelia Sever, MD	Research funding	Horiba Sight Diagnostics Techcyte Inc
Sonali Smith, MD	Consulting fees	Gilead Juno Pharmacyclics TG Therapeutics Genentech Nanostring Portola AbbVie Celgene
	Research funding	Celgene TG Therapeutics Acerta Pharmacyclics Janssen National Cancer Institute/Southwest Oncology Group (SWOG)
	Position of influence	Lymphoma Research Foundation
	Lecture fees (honoraria)	Genentech Kite
Ronald Weiss, MD, MBA	Stock options/bonds	AvanSciBio

^aThe following individuals have reported no relevant disclosures: Brooke Billman, MLIS, AHIP; Lesley Souter, PhD; Christina B. Ventura, MPH, MT(ASCP).

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Laboratory Workup of Lymphoma in Adults

Guideline From the American Society for Clinical Pathology and the College of American Pathologists

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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