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  • This manual is not a substitute for consultation with an appropriate specialist.
  • The contents of this manual have been developed through consensus of a Provincial Tumour Group. Please note the various update dates for each section as some of the content of the manual may not be up to date.

Appendix I

​Updated 10 March 2009

Technical Suggestions for Biopsies of Lymph Node and related Hematopoietic Organs 

The single greatest obstacle of accurate diagnosis and hence to appropriate treatment of lymphoid and related hematopoietic malignancies is unsuitable handling of specimens at the time of surgery. Ideally, the surgeon should consult the hospital pathologist prior to biopsy as input from both sources is necessary for the satisfactory handling of lymph nodes.

1. Lymph Node Biopsy 

The surgeon should excise the largest node in a group of nodes whenever possible. The entire node should be removed intact with a minimal amount of crushing or handling. The specimen should be exposed to drying for the shortest time possible. If any time must elapse prior to processing the specimen in the pathology department, it should be wrapped in gauze soaked in normal saline and placed in the fridge at 4°C. During grossing in of the lymph node, a fresh cut surface can be used to prepare imprint preparations. These should be stained with the same procedure as that used for marrow aspirates. The preferred fixative is buffered formalin and the tissue should be fixed for appropriate lengths of time depending on the size of the tissue. B-Plus is a reasonable alternative fixative, but should only be used as a secondary fixative when sufficient tissue is available. B5 is not recommended for use due to its harmful effects on the environment. A representative portion of the lymph node should be sent as quickly as possible to the Immunology Laboratory of the BCCA, Vancouver Cancer Centre for flow cytometric analysis. The tissue should be sent at 4°C using wet ice or an ice pack in a sterile container with saline. Although a frozen section may be requested during surgery as a guide, definitive diagnosis of lymphoma by frozen section is virtually impossible. In addition, if the node is small, frozen section should be avoided at all cost, as it will interfere with the subsequent quality of the permanent sections and immunohistochemistry. If sufficient material is available, a portion of the lymph node should be snap-frozen in liquid nitrogen. This resource is invaluable should complex molecular genetic testing or gene expression profiling be required.

For all lymph nodes submitted fresh to the BCCA a cell suspension is prepared from the lymph node and processed for immunophenotypic analysis by flow cytometry, cytogenetics, gene rearrangement studies using fluorescence in situ hybridization (FISH), molecular genetic testing and other related studies. Importantly, cytogenetics and flow can only be performed using fresh material. The dedicated Lymphoma Pathology Program at the BCCA will routinely perform some or all of these tests as required to reach a definitive diagnosis. If the original slides, a copy of the pathology report and a representative paraffin block(s) are also submitted when it becomes available with a request for consultation, these results are then integrated into a final consultative report. This process is typically very expeditious. The Hematopathology Program at the BCCA has an extensive test menu for lymphoid malignancies, including many tests and reagents that are not commercially available. There is no charge for these and any related tests if cases are submitted for consultation.

2. Bone Marrow 

Both a satisfactory aspirate and biopsy are required for the proper evaluation of patients with lymphoma. The aspirate is most useful in the diagnosis of leukemias and plasma cell disorders such as myeloma. Spread films, in addition to squash preparations, should always be made because these facilitate individual cell identification. A satisfactory trephine biopsy is essential for the diagnosis and staging of lymphoma as the location and shape of any lymphoid infiltrate is of major diagnostic importance.

3. Fine Needle Aspiration and Core Needle Biopsies 

If at all possible an entire involved lymph node should be biopsied. This will provide a definitive diagnosis and proper subtyping which are essential for treatment planning. Fine needle aspiration biopsy or core needle biopsy may be quite useful in the re-staging and follow-up of patients with an established diagnosis of Hodgkin lymphoma or malignant lymphoma; however, a fine needle aspiration biopsy or needle core biopsy is not sufficient to establish the original diagnosis. If an involved lymph node cannot be completely excised, an incisional biopsy from involved tissue may be quite useful.

It is especially important not to place reliance on a negative fine needle aspiration biopsy or needle core biopsy in a patient with no established diagnosis. This often leads to delay in proper diagnosis.

Appendix II

Protein Testing in Lymphoproliferative Disorders
Serum protein electrophoresis with or without certain additional tests is required on all new patients with multiple myeloma or other plasma cell disorders, malignant lymphoma and all patients with chronic B or T lymphoid leukemias. These tests are not required in new patients with a diagnosis of Hodgkin's disease. The terminology of protein testing and recommendations for specific tests are as follows:

1. Serum Protein Electrophoresis (SPE) 
SPE is performed by cellulose acetate or high resolution agarose gel electrophoresis. The latter technique is very sensitive and useful for the detection of small monoclonal paraprotein bands. In the majority of patients with myeloma, SPE is useful for diagnosis usually demonstrating a monoclonal protein, associated hypogammaglobulinemia or both. For long-term monitoring of patients with clinically significant monoclonal proteins, quantitation of the paraprotein by SPE is preferred to other available tests. It more accurately estimates the actual amount of protein present than quantitative immunoglobulin studies. 

2. Immunofixation (IFE) 
Once a paraprotein band is identified by SPE, the type of the paraprotein band is determined by IFE. This technique is very sensitive and has, for the most part, replaced immunoelectrophoresis. In any disorder characterized by a paraprotein, this test is usually only required at diagnosis to establish the nature of the paraprotein. If a monoclonal protein is identified in the urine (Bence-Jones protein) by urine protein electrophoresis (UPE), the identity of the paraprotein is also determined by IFE.

3. Quantitative Immunoglobulin Levels 
The specific amounts of individual immunoglobulins by class (IgG, IgM, IgA) can be determined by several methodologies. Two of the more common methods are radial immune diffuse and nephelometry. These measurements are of utility in patients with immune deficiency, however, they are of minimal value in patients with neoplastic lymphoproliferative disorders with a paraprotein. Occasionally it is useful to determine that the other classes of immunoglobulin are decreased in a patient with a paraprotein. 

4. Urine-Protein Electrophoresis (UPE) 
A 24 hour urine sample is usually required in patients with a neoplastic paraprotein. The urine sample is concentrated and then fractionated by protein electrophoresis. The amount of protein is quantitated and the pattern is examined to determine if a paraprotein band is present. If a band is detected the specific type is identified by IFE. Older qualitative tests for presence of Bence-Jones protein are no longer useful.  

Appendix III

Revised 16 November 2017

Immunizations for Patients with Lymphoma, Hodgkin Lymphoma, Myeloma and Leukemia

Patients who have a lymphoid cancer (lymphoma, Hodgkin lymphoma, myeloma, chronic lymphocytic leukemia or related conditions) should receive certain immunizations to help boost or maintain their immunity. However, immunizations using live organisms may be dangerous and should only be taken if you are specifically advised by your oncologist to do so. Keep one copy of these recommendations with your own health records and take a copy to your family physician or local Health Unit Immunization Clinic.

Patients who are currently receiving chemotherapy or radiation should wait until 12 months after treatment is finished before receiving immunizations, except for influenza vaccine, which should be taken every year, whether or not you are receiving treatment. If you have any questions about these recommendations, discuss them with your lymphoid cancer specialist. Recommendations for special revaccinations after hematopoietic stem cell transplant (bone marrow or peripheral blood stem cell transplant) are available from your Bone Marrow Transplant Program specialist.

Type of ImmunizationWho Should be Given this Immunization?When Should it be Given?
Influenza vaccine
All patients
Every year, in the autumn
Pneumococcal vaccine
All patients
At the time of diagnosis, if the pneumococcal vaccine can be given at least 2 weeks before initiation of anti- lymphoid cancer treatment. If that is not possible, delay until at least 12 months after completion of all lymphoid cancer treatment and any other immunosuppressive treatment. Repeat again once 5 years later.
All patients
Every 10 years
Meningococcal Men-C- C and, 2 weeks later, Men-P-ACYW and Haemophilus influenza type b vaccine
Patients whose spleen is removed or treated with radiation
Give all 3 at least 2 weeks before removal of the spleen (splenectomy), if possible, or, if spleen already removed, give as soon as possible after splenectomy. Repeat Men-P- ACYW every 5 years. (Note: these vaccines are given free of charge at the local Health Unit Immunization Clinic for patients who have splenectomy)
Polio vaccine-inactivated
Polio vaccine is not necessary for lymphoid cancer patients unless specifically instructed by their lymphoid cancer specialist or Bone Marrow Transplant Program specialist
Measles (live virus) Mumps (live virus) Rubella (live virus)
Yellow fever (live virus)

No patients, unless specifically instructed to do so by your lymphoid cancer specialist or Bone Marrow Transplant Program specialist.

Shingrix® (Zoster Vaccine Recombinant, Adjuvanted)
All patients
Shingrix ® should be delayed until at least 12 months after completion of all lymphoid cancer treatment and any other immunosuppressive treatment including corticosteroids (prednisone, dexamethasone).
Hepatitis viruses A or B
All patients
Safe to be given at any time; however, most effective if given at least 12 months after completion of all lymphoid cancer treatment and any other immunosuppressive treatment including corticosteroids (prednisone, dexamethasone).

SOURCE: Appendices ( )
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