2.2 Assessments by the general practitioner

2.2 Assessments by the general practitioner

Patients suspected to have lymphoma, based on the clinical assessment during the initial general practitioner visit, should be immediately referred to a specialist for diagnosis.

For patients where there is a lower index of suspicion, further examinations/investigations by the general practitioner should include (but are not limited to):

  • a thorough history and physical examination of the skin, all lymph node groups, oral examination for enlarged Waldeyer’s ring, abdominal examination and cardiorespiratory examination
  • blood tests to assess organ dysfunction including: full blood count, urea, electrolytes, creatinine, liver function tests, lactate dehydrogenase (LDH); other tests may include beta-2 microglobulin (no laboratory test can exclude these lymphomas)
  • imaging of the affected area including ultrasound, chest radiography and computed tomography (CT) scan as appropriate
  • biopsy as appropriate, depending on local access (referral to a specialist prior to biopsy may be appropriate where there is a high clinical suspicion for lymphoma)
  • fine-needle aspiration (FNA) is generally considered inadequate for diagnosing low-grade lymphomas but in some instances may be an appropriate initial investigation (e.g. in evaluating an enlarged lymph node when a non-haemopoietic neoplasm is strongly suspected (such as head and neck cancer).

Indicators of concern that should lead to prompt referral to a specialist include:

  • symptoms or results indicating organ dysfunction and low blood counts
  • symptoms that suggest neurological involvement
  • markedly elevated LDH
  • marked B symptoms (weight loss > 10 per cent, persistent fevers > 38°C, or persistent drenching night sweats).

For patients who do not need a prompt referral to a specialist, all investigations should be completed, and a path of action decided, within four weeks of first presentation.