If the biopsy of the enlarged lymph node shows that you have non-Hodgkin lymphoma, you may have further tests to find out whether the cancer has spread to other areas of your body. This is called staging.
Below we describe tests that are commonly used to help stage non-Hodgkin lymphoma. You may not need to have all these tests – most people will have blood tests and at least one imaging test. Some tests may be repeated to check how well the treatment is working.
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Blood tests
Your doctor will take a blood sample to see how well your kidneys and liver are working, and to check the number of blood cells (a full blood count). Low blood counts before treatment may suggest that the cancer has spread to the bone marrow. You will also have regular blood tests to check the effects of treatment on your total number of red blood cells, white blood cells and platelets.
Imaging tests
You will usually have at least one of the tests described below:
Chest x-ray
Before an excision biopsy, you may have an x-ray of the chest area to see if the lymphoma has spread to the lymph nodes in your chest or lungs. An x-ray is painless and takes only a few minutes.
PET-CT scan
This specialised test combines a positron emission tomography (PET) scan with a non-contrast CT scan (see below) to produce a three-dimensional colour image.
For the PET scan, you will be injected in the arm with a glucose (sugar) solution containing a small amount of radioactive material. You will be asked to sit quietly for 30–90 minutes while the solution moves around your body, then the scan itself will take about 30 minutes. Cancer cells take up more of the solution than normal cells and light up on the scan.
Clinic staff will tell you how to prepare for the scan, particularly if you have diabetes. You will be encouraged to drink plenty of water to help the glucose solution leave your body.
The CT scan (see below) is used to help work out the precise location of any areas of concern shown on the PET scan.
CT scan
A CT (computerised tomography) scan uses x-ray beams to create a detailed three-dimensional picture of an area inside the body. Your chest, abdomen and pelvis will be scanned to check whether the cancer has spread.
Before the scan, you may be asked to drink a liquid or have a special dye called contrast injected into a vein. This helps ensure that anything unusual can be seen more clearly. The dye may cause you to feel hot all over, give you a strange taste in your mouth and you could feel as if you need to pass urine (pee). These reactions usually go away in a few minutes, but tell the team if you feel unwell.
The CT scanner is large and round like a doughnut. You will lie on a table that moves in and out of the scanner. The scan is painless. While it can take 30–45 minutes to prepare for the scan, the scan itself takes only a few minutes. Most people can go home as soon as the scan is over.
Before having scans, tell the doctor if you have any allergies or have had a reaction to iodine or contrast during previous scans. You should also let them know if you have diabetes or kidney disease, or are pregnant or breastfeeding.
Ultrasound
An ultrasound uses soundwaves to create a picture of the internal organs. This test is most commonly used to guide the needle to the correct lymph node during a core biopsy.
An ultrasound is painless and takes only a few minutes.
MRI scan
MRI (magnetic resonance imaging) scans are not commonly used for people with non-Hodgkin lymphoma, but may be used to check the brain and spinal cord. The MRI scan uses a combination of a powerful magnet and radio waves to create detailed pictures of areas inside the body. You will lie on a treatment table that slides into a metal cylinder. The test is painless, but some people find lying in the cylinder noisy and confined. An MRI scan takes 30–60 minutes. People with some pacemakers or other metallic objects cannot have an MRI.
Bone marrow biopsy
You may need to have a bone marrow biopsy to check whether lymphoma cells have spread to the bone marrow. A bone marrow biopsy is done in 2 steps:
| Bone marrow aspiration | The doctor inserts a needle into the bone at the back of your hip (pelvic bone) to remove a small sample of fluid (aspirate) from the bone marrow. |
| Bone marrow trephine | A second needle is used to take a matchstick-wide sample of both bone and bone marrow tissue. You will lie still while a local anaesthetic is injected into your pelvis (hip) to numb the area. To help you feel relaxed, you may be offered light sedation or medicine that you breathe in through an inhaler. |
A bone marrow biopsy takes about 30 minutes. It is usually done as an outpatient procedure and you don’t need to stay in hospital overnight.
You may feel some pressure or discomfort during the biopsy. If you feel uncomfortable afterwards, ask a member of your health care team about pain medicine. You will need to lie flat in bed for another 30 minutes after the biopsy to make sure there is no bleeding.
The bone marrow sample is examined under a microscope to see if it contains any lymphoma cells. Results are usually available in 2–7 days. Waiting for the results can be a stressful time. It may help to call Cancer Council 13 11 20.
Lumbar puncture (spinal tap)
A lumbar puncture is a procedure used to collect a sample of the fluid that surrounds the brain and spinal cord (cerebrospinal fluid). The sample is then tested for lymphoma cells.
Doctors usually diagnose non-Hodgkin lymphoma with other tests, so most people will not need to have a lumbar puncture. Sometimes a lumbar puncture may be used to deliver chemotherapy.
If you do have a lumbar puncture, you will be placed in a curled or sitting position and given an injection of local anaesthetic. A thin needle will then be inserted between 2 bones in your lower back to remove some cerebrospinal fluid. You may feel some discomfort. Tell your doctor if you feel any pain, as they may be able to give you some more anaesthetic.
After the procedure, you may have to lie on your back for a short time to help prevent a headache. If you do get a headache, it will usually get better on its own. Check with your doctor whether you can take pain medicine. A lumbar puncture can also cause nausea, but this will usually ease within a few hours.
→ READ MORE: Staging and grading for non-Hodgkin lymphoma
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More resources
Dr Puja Bhattacharyya, Haematology Staff Specialist, Western Sydney Local Health District, Blacktown Hospital; A/Prof Christina Brown, Haematologist, Royal Prince Alfred Hospital and The University of Sydney; Dr Susan Carroll, Senior Staff Specialist, Radiation Oncology, Royal North Shore Hospital and The University of Sydney; Jo Cryer, Clinical Nurse Consultant, Haematology, St George Hospital; Marie Marr, Consumer; Katelin Mayer, Clinical Nurse Consultant, Cancer Outreach Team, Nelune Comprehensive Cancer Centre, Sydney; Vanessa Saunders, 13 11 20 Consultant, Cancer Council NSW; Elise Toyer, Haematology Clinical Nurse Consultant, Blacktown Hospital.
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