urgent referral for suspected non Hodgkin's lymphoma (NHL)

Last reviewed 07/2021

Haematological cancers

NICE guidance regarding referral criteria for urgent referral for possible haematological cancer (1) has been updated. The updated guidance is less specific in terms of particular symptoms e.g. generalised lymphadenopathy is used in current guidance whereas in previous guidance there were specific criteria mentioned (such as a duration of six weeks or more, increasing in size) before it was considered significant.

Leukaemia in adults

• consider a very urgent full blood count (within 48 hours) to assess for leukaemia in adults with any of the following:
  • pallor
  • persistent fatigue
  • unexplained fever
  • unexplained persistent or recurrent infection
  • generalised lymphadenopathy
  • unexplained bruising
  • unexplained bleeding
  • unexplained petechiae
  • hepatosplenomegaly

Leukaemia in children and young people

• refer children and young people for immediate specialist assessment for leukaemia if they have unexplained petechiae or hepatosplenomegaly
  
  
• offer a very urgent full blood count (within 48 hours) to assess for leukaemia in children and young people with any of the following:
  • pallor
  • persistent fatigue
  • unexplained fever
  • unexplained persistent infection
  • generalised lymphadenopathy
  • persistent or unexplained bone pain
  • unexplained bruising
  • unexplained bleeding

Myeloma

• offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate to assess for myeloma in people aged 60 and over with persistent bone pain, particularly back pain, or unexplained fracture
  
  
• offer very urgent protein electrophoresis and a Bence-Jones protein urine test (within 48 hours) to assess for myeloma in people aged 60 and over with hypercalcaemia or leukopenia and a presentation that is consistent with possible myeloma
  
  
• consider very urgent protein electrophoresis and a Bence-Jones protein urine test (within 48 hours) to assess for myeloma if the plasma viscosity or erythrocyte sedimentation rate and presentation are consistent with possible myeloma
  
  
• refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) if the results of protein electrophoresis or a Bence-Jones protein urine test suggest myeloma

Non-Hodgkin's lymphoma in adults

• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for non-Hodgkin's lymphoma in adults presenting with unexplained lymphadenopathy or splenomegaly. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss

Non-Hodgkin's lymphoma in children and young people

• consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for non-Hodgkin's lymphoma in children and young people presenting with unexplained lymphadenopathy or splenomegaly. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss

Hodgkin's lymphoma in adults

• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for Hodgkin's lymphoma in adults presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcohol-induced lymph node pain

Hodgkin's lymphoma in children and young people

• consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for Hodgkin's lymphoma in children and young people presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss

From previous guidance (2):

Refer immediately patients:

• with a blood count/film reported as acute leukaemia
• with spinal cord compression or renal failure suspected of being caused by myeloma

Refer urgently patients with persistent unexplained splenomegaly.

Investigations:

In patients with:

• persistent unexplained fatigue carry out a full blood count, blood film and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy). Repeat at least once if the patient's condition remains unexplained and does not improve
• unexplained lymphadenopathy carry out a full blood count, blood film and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy)
• any of the following additional features of lymphadenopathy then investigate further and/or refer :
  • persistence for 6 weeks or more
  • lymph nodes increasing in size
  • lymph nodes greater than 2 cm in size
  • widespread nature
  • associated splenomegaly, night sweats or weight loss
• unexplained bruising, bleeding and purpura or symptoms suggesting anaemia, carry out a full blood count, blood film, clotting screen and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy)
• persistent and unexplained bone pain, carry out a full blood count and X-ray, urea and electrolytes, liver and bone profile, PSA test (in males) and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy)

Reference:

• NICE (June 2015). Suspected cancer: recognition and referral
• NICE (June 2005). Referral Guidelines for Suspected Cancer