Diagnosis of childhood Hodgkin lymphoma

Diagnosis is the process of finding out the cause of a health problem. Diagnosing childhood Hodgkin lymphoma (HL) usually begins with a visit to your child’s doctor. The doctor will ask about any symptoms your child has and do a physical exam. Based on this information, your doctor may refer your child to a specialist or order tests to check for lymphoma or other health problems.

It’s important for the healthcare team to rule out other reasons for a health problem before making a diagnosis of childhood HL. If the doctor suspects childhood HL, your child’s care will be managed by a healthcare team that specializes in caring for children with cancer.

The following tests are usually used to rule out or diagnose childhood HL. Many of the same tests used to diagnose cancer are used to find out the stage (how far the cancer has spread). Your child’s doctor may also order other tests to check your child’s general health and to help plan their treatment.

Your child’s health history is a record of their symptoms, risk factors and past medical events and problems. The doctor will ask questions about your child’s personal or family history of certain genetic or medical conditions such as:

• HL
• Epstein-Barr virus (EBV) infection
• weakened immune system
• HIV or AIDS
• ataxia-telangiectasia (AT)
• Wiskott-Aldrich syndrome

A physical exam allows the doctor to look for any signs of childhood HL. During a physical exam, the doctor may:

• check if any lymph nodes are larger than normal (enlarged)
• feel the abdomen to see if the liver or spleen is larger than normal
• listen to the lungs for any breathing problems
• look for signs of a mediastinal mass in the chest, such as shortness of breath
• check the tonsils to see if they are swollen or if there are growths on them
• look for signs of superior vena cava syndrome (SVCS), such as swelling of the face and neck

Find out more about physical exams.

A complete blood count (CBC) measures the number and types of white blood cells, red blood cells and platelets. A CBC is done to check for low red blood cell counts (called anemia), which may be more common in children with HL. Doctors also use the results of a CBC as a baseline that they can check against during treatment.

Find out more about a complete blood count.

Doctors may order a blood test to measure the erythrocyte sedimentation rate (ESR). The ESR is a measure of how quickly red blood cells (also called erythrocytes) fall to the bottom of a test tube. It is a general marker of inflammation. The ESR may be higher than normal with HL.

Blood chemistry tests measure certain chemicals in the blood. They show how well certain organs are working and can help find abnormalities. Blood chemistry tests that may be done to diagnose HL include the following.

Kidney function tests, such as blood urea nitrogen (BUN) and creatinine, may be done to show how well the kidneys are working. Higher levels of these substances may mean that the kidneys are not functioning well, which may be because of cancer.

Liver function tests, such as alanine transaminase (ALT), alkaline phosphatase (ALP), bilirubin and albumin, may be done to show how well the liver is working. Albumin levels are often lower in children with HL. The level of albumin at diagnosis may be useful in prognosis.

Find out more about blood chemistry tests.

An x-ray uses small doses of radiation to make an image of parts of the body on film. A chest x-ray may be used to check for:

• larger than normal lymph nodes in the chest
• a mass in the chest (mediastinum)
• fluid around the lungs or heart

Find out more about x-rays.

A computed tomography (CT) scan uses special x-ray equipment to make 3D and cross-sectional images of organs, tissues, bones and blood vessels inside the body. A computer turns the images into detailed pictures.

A CT scan may be used to check for enlarged lymph nodes or a mass in the neck, chest, abdomen or pelvis. It also allows doctors to see if any organs or large blood vessels are being compressed and if there is any disease in the brain or near the spinal cord. A CT scan may also be used to see if the cancer has spread to any organs, such as the lungs, liver or spleen.

Sometimes a CT scan is combined with a PET scan (called a PET-CT scan) to find more information about the cancer.

Find out more about CT scans.

A positron emission tomography (PET) scan uses a type of radioactive sugar to look for changes in the metabolic activity of body tissues. A computer analyzes the radioactive patterns and makes 3D colour images of the area being scanned.

A PET scan may be used to look for HL that has spread from where it started to other areas of the body or to measure how well treatment is working. It is used instead of or in addition to a bone scan. It is typically combined with a CT scan for a more complete picture and 3D assessment of disease.

Your child will not be able to have any food or drink (other than water) on the night before a PET scan.

Find out more about PET scans.

An ultrasound uses high-frequency sound waves to make images of structures in the body. It may be used to examine the abdomen and organs that may be affected by HL, such as the kidneys, spleen or liver.

Find out more about ultrasounds.

Magnetic resonance imaging (MRI) uses powerful magnetic forces and radiofrequency waves to make cross-sectional images of organs, tissues, bones and blood vessels. A computer turns the images into 3D pictures.

MRI can be used to check for enlarged lymph nodes in the chest, abdomen or pelvis. It can also be used to see if the cancer has spread to the brain or spinal cord.

Find out more about MRIs.

During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab. The report from the lab will show whether or not cancer cells are found in the sample.

A biopsy may be done on an enlarged lymph node in the neck, under the arm or in the groin. A biopsy sample may also be taken from a tumour in the chest or abdomen. Children are usually under a general anesthetic so that the surgeon can get an adequate tissue sample.

The type of biopsy done depends on where the doctors need to collect the samples from.

Surgical excisional lymph node biopsy is usually done to collect samples from lymph nodes. The surgeon may do an excisional biopsy, which removes all of a lymph node. In some cases, doctors may use an incisional biopsy to remove part of a lymph node.

Core needle biopsy may be used for some types of tumours, such as a large tumour in the chest or a tumour in the bone. The surgeon may use a CT scan to guide the needle to the tumour during the biopsy.

Find out more about surgical biopsy and core needle biopsy.

During a bone marrow aspiration and biopsy, the doctor removes tissues or cells from the bone marrow so they can be tested in a lab. This test may be used to diagnose and stage childhood HL that may have spread to the bone marrow.

Find out more about bone marrow aspiration and biopsy.

Doctors can use the following types of cell and tissue studies to diagnose childhood HL.

Immunophenotyping is the study of proteins expressed by cells. These techniques use a very specific antigen-antibody reaction to identify proteins in tissues or cells. They use monoclonal antibodies marked with a fluorescent label or specific enzyme label that binds only to specific antigens (proteins). The fluorescent or enzyme label allows doctors to see the lymphoma cells so they can tell the type of HL.

Immunohistochemistry is a method commonly used in immunophenotyping. It uses a microscope to view the fluorescent labels. It also allows doctors to examine cells and their surroundings. Immunohistochemistry helps doctors determine the types of cells present in a sample, including if there are Hodgkin and Reed-Sternberg (HRS) cells. Immunohistochemistry can rule out HL. It can also help to diagnose non-Hodgkin lymphoma or other diseases.

To make the decisions that are right for your child, ask your healthcare team questions about a diagnosis.