The rapid proliferation of complex and expensive ancillary tests useful in the diagnosis and management of hematopoietic malignancies presents a formidable challenge to clinicians and pathologists alike, especially those pathologists who are not subspecialty trained in hematopathology. There are opportunities for improved utilization, enhanced outcomes, and reduced costs by using an integrated, disease management team approach as has recently been described in the evaluation of bone marrow biopsy specimens by pathologists at Vanderbilt University1; similar opportunities are expected with samples from other sites and disease entities.
The diagnostic workup of malignant lymphoma continues to evolve rapidly as experience and discovery lead to the addition of new clinicopathologic entities to the WHO 2008 classification scheme, and of 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. Anecdotal practice experience suggests that there is relatively wide variation in practice in both settings. Most pathologists have had the experience of receiving tissue in formalin with no prior indication that the clinical differential diagnosis includes a hematolymphoid neoplasia, in which case fresh tissue submission is highly desirable for diagnostic optimization.
A primary goal of this guideline would be evidence-based recommendations for the pre-analytic phase of testing with a focus on specimen requirements. Given the rapid evolution of the testing and classification algorithms, the expert panel believes that the most important message for the interdisciplinary team to address is that "rule out lymphoma" specimens require special handling, and that these handling decisions are best made when planned in advance in consultation with the pathologist or as institutional protocols agreed upon by surgery, interventional radiology, pathology, and other involved departments. Addressing the adequacy and role of limited specimens such as fine needle aspirations and needle biopsies would be in scope.
A secondary goal would be to provide evidence-based guidance on which ancillary testing and clinical parameters ensure a level of diagnostic certainty to provide actionable results.
Overarching Question: What are the specimen requirements for accurate diagnosis in all adult patients with clinical features raising consideration of lymphoma?
1a. To what degree do specimen types allow for accurate primary diagnosis of indolent, aggressive, and Hodgkin lymphoma?
1b. For each specimen type, what are the optimum and minimum requirements for accurate primary diagnosis or exclusion of lymphoma?
1c. What are the appropriate analytical triage processes by which fresh tissue can be distributed for indolent, aggressive, and Hodgkin lymphoma?
2. What are the diagnostic test characteristics of the available additional assays and how does additional testing of the primary specimen influence the diagnostic accuracy to enable actionable therapy for indolent, aggressive, and Hodgkin lymphoma
- American Society for Clinical Pathology
- American Society of Hematology
- Steven Howard Kroft, MD, ASCP Co-chair
- Cordelia E. Sever, MD, FCAP, CAP Co-chair
- Matthew Cheung, MD, ASH Co-chair
- Adam Bagg, MD
- Catherine Diefenbach, MD
- David M. Dorfman, MD, PhD, FCAP
- William G. Finn, MD, FCAP
- Dita A. Gratzinger, MD, PhD, FCAP
- Patricia A. Gregg, MD, FCAP
- John P. Leonard, MD
- Sonali Smith, MD
- Ronald L. Weiss, MD, MBA, FCAP
- Brooke Billman, MLIS, AHIP
- Jennifer J. Clark, SCT(ASCP)cmMBcm
- Lesley Souter, PhD
- Christina Ventura, MPH, MT(ASCP)
Review more upcoming CAP evidence-based guidelines by the Pathology and Laboratory Quality Center.
- Seegmiller AC, Kim AS, Mosse CA, et al. Optimizing Personalized Bone Marrow Testing Using an Evidence-Based, Interdisciplinary Team Approach. Am J Clin Pathol. 2013;140(5):643-650. doi:10.1309/AJCP8CKE9NEINQFL.