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Investigation, diagnosis and staging

• Document 'B' symptoms in history.

• Document extent of nodal involvement by clinical examination.

• Confirm diagnosis by biopsy: best histology from lymph node excision biopsy; image guided needle biopsy or even laparotomy, mediastinoscopy or mediastinotomy may be necessary to obtain a tissue diagnosis.

• Clinical staging is now usual; routine staging laparotomy for 'pathological staging' abandoned; useful only if result may substantially reduce treatment.

• Clinical staging includes the initial biopsy site and all other abnormalities detected by non-invasive methods.

210 • Pathological staging requires biopsy confirmation of abnormal sites.

• FBC: may show normochromic normocytic anaemia, reactive leucocy-tosis, eosinophilia and/or a reactive mild thrombocytosis.

• ESR/plasma viscosity; U&E; LFTs; urate; LDH.

• CT chest, abdomen and pelvis to define occult nodal and extranodal involvement.

• Bone marrow trephine biopsy to exclude marrow involvement in patients with stage III/IV disease or B symptoms (not essential in stage IA/IIA disease); BM may show reactive features.

• Isotope bone scan, MRI or PET scan may be necessary.

• Biopsy of other suspicious sites may be necessary e.g. liver or bone.

• Attempt semen cryopreservation in young males with advanced disease (often unsuccessful in those with 'B' symptoms).

Ann Arbor staging classification (Cotswolds modification)

The Ann Arbor staging classification has strong prognostic value and is determined by the number of lymph node regions (not sites) involved and the presence or absence of 'B' symptoms. The Cotswolds modification reflects the use of modern imaging techniques, recognises clinical and pathological staging and clarifies differences in disease distribution and bulk.

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