Because this type of lymphoma affects the skin, it is often noticed fairly quickly. But the actual diagnosis of skin lymphoma might be delayed because the symptoms often resemble other, more common skin problems. The diagnosis of skin lymphoma can only be confirmed with tests such as biopsies (described below).
1. Biopsy
A biopsy is a procedure in which a doctor removes a sample of body tissue for viewing under a microscope or other lab tests. A biopsy is needed to diagnose lymphoma of the skin.
1.a. Lymph Node Biopsies
Skin lymphomas often spread to lymph nodes, so your doctor may recommend a lymph node biopsy to help confirm the diagnosis or to help determine how widespread the lymphoma is. This is more likely to be done if the doctor detects enlarged lymph nodes, either during a physical exam or with imaging tests (such as a CT scan).
Fine needle aspiration (FNA) biopsy: In an FNA biopsy, the doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a tumor. If an enlarged node is near the surface of the body, the doctor can aim the needle while feeling it. If the enlarged node is deep inside the body, the doctor can guide the needle while viewing it with ultrasound or a CT scan (see “Imaging tests”). An FNA does not require surgery, but in some cases it cannot remove enough tissue to make a definite diagnosis of lymphoma. But advances in lab tests (discussed later in this section) and the growing experience of many doctors with FNA have improved the accuracy of this procedure. Some doctors will use FNA in patients already diagnosed with lymphoma of the skin to confirm that an enlarged lymph node also contains lymphoma.
Excisional or incisional lymph node biopsy: This is the most common type of lymph node biopsy. In this procedure, a surgeon cuts through the skin to remove either the entire lymph node (excisional biopsy) or a small part of a large tumor (incisional biopsy). If the node is near the skin surface, this is a simple operation that can often be done with local anesthesia. But if the node is inside the chest or abdomen, the patient will be asleep or deeply sedated during the biopsy. Removing a lymph node almost always provides enough tissue to diagnose the exact type of lymphoma. This type of biopsy is preferred by most doctors, if it can be done without too much discomfort to the patient.
1.b. Skin Biopsies
There are several types of skin biopsies, and the doctor’s choice is based on each person’s situation. Usually a skin biopsy is done by a dermatologist.
Incisional and excisional skin biopsies: For these types of biopsies, a surgical knife is used to cut through the full thickness of skin. An incisional biopsy removes only part of the tumor, while an excisional biopsy removes the entire tumor. The piece of skin is removed for testing, and the edges of the wound are sewn together. These biopsies are usually done using a local anesthetic (numbing medicine).
Punch biopsy: For a punch biopsy, the doctor uses a tool that looks like a tiny round cookie cutter (usually a little more than 1/8 inch across). Once the skin is numbed with a local anesthetic, the doctor rotates the punch biopsy tool on the surface of the skin until it cuts through all the layers of the skin. Often the biopsy site is closed with a stitch.
1.c. Other Types of Biopsies
These procedures may sometimes be done to confirm a diagnosis of lymphoma, but they are more often done to help stage (determine the extent of) a lymphoma that has already been diagnosed.
Lumbar puncture (spinal tap): This test looks for lymphoma cells in the cerebrospinal fluid (CSF), which is the liquid that bathes the brain and spinal cord. Most people with skin lymphoma will not need this test. But doctors may order it if a person has symptoms that suggest the lymphoma may have reached the brain.
Bone marrow aspiration and biopsy: These procedures are sometimes done after lymphoma has been diagnosed to help determine if it has reached the bone marrow. The two tests are often done at the same time. The samples are usually taken from the back of the pelvic (hip) bone, but in some cases they may be taken from the sternum (breast bone) or other bones.
In bone marrow aspiration, you lie on a table (either on your side or on your belly). The doctor cleans the skin over the hip and then numbs the area and the surface of the bone with local anesthetic. This may cause a brief stinging or burning sensation. A thin, hollow needle is then inserted into the bone and a syringe is used to suck out a small amount of liquid bone marrow (about 1 teaspoon). Even with the anesthetic, most patients still have some brief pain when the marrow is removed.
A bone marrow biopsy is usually done just after the aspiration. A small piece of bone and marrow is removed with a slightly larger needle that is twisted as it is pushed down into the bone. The biopsy may also cause some brief pain. Once the biopsy is done, pressure will be applied to the site to help stop any bleeding.
2. Blood Tests
Blood tests are used to measure the amounts of certain types of cells and chemicals in the blood. They are not used to diagnose lymphoma, but they can sometimes help determine how advanced the lymphoma is. They may also be done during certain types of treatment (such as chemotherapy) to monitor how well the bone marrow and other organs are functioning.
Blood chemistry tests: These tests look at how well the kidneys and liver are working. Results of another blood test that measures levels of lactate dehydrogenase (LDH) will often be abnormally high in the blood of patients with widespread lymphoma. The level goes up when larger amounts of lymphoma are present.
Complete blood count (CBC): This test measures the levels of different cells in the blood, such as the red blood cells, the white blood cells, and the platelets. The CBC is often done with a differential (or “diff”) which counts the numbers of different types of white blood cells. If a person’s blood counts are low, it might mean that the lymphoma is growing in the bone marrow and crowding out normal blood cell production.
3. Imaging Tests
For skin lymphomas, imaging tests are not always needed for patients with only a few skin lesions, but they are often done in patients with a lot of skin involvement or if lymphoma cells are found in the lymph nodes or blood.
Chest x-ray: An x-ray of the chest may be done to look for enlarged lymph nodes in this area.
Computed tomography (CT) scan: The CT scan is a type of x-ray test that produces detailed, cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into detailed images of the part of your body that is being studied. Unlike a regular x-ray, CT scans can show the detail in soft tissues (such as internal organs). This scan can help tell if any lymph nodes or organs in your body are enlarged.
A CT scanner has been described as a large donut, with a narrow table in the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken. Before the test, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV line through which a different kind of contrast dye (IV contrast) is injected.
The injection can cause some flushing (redness and warm feeling). A few people are allergic to the dye and get hives or, rarely, have more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays.
Magnetic resonance imaging (MRI) scan: Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material called gadolinium is often injected into a vein before the scan to better see details. The contrast material usually does not cause allergic reactions.
MRI scans are very helpful in looking at the brain and spinal cord, but they are not often used to evaluate skin lymphomas unless a CT scan can’t be done for some reason. MRI scans take longer than CT scans – often up to an hour. You may have to lie inside a narrow tube, which is confining and can be distressing to some people. Newer, more open MRI machines may be another option. The MRI machine makes loud buzzing and clicking noises that you may find disturbing. Some places provide headphones or earplugs to help block this out.
Positron emission tomography (PET) scan: For a PET scan, a radioactive substance (usually a type of sugar related to glucose, known as FDG) is injected into the blood. The amount of radioactivity used is very low. Because cancer cells in the body grow quickly, they absorb large amounts of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it can look for possible areas of lymphoma in all areas of the body at once.
PET scans can help tell if an enlarged lymph node contains lymphoma or is benign. It can also help spot small areas that might be lymphoma, even if the area looks normal on a CT scan. PET scans can also be used to tell if a lymphoma is responding to treatment. Some doctors will repeat the PET scan after 1 or 2 courses of chemotherapy. If the chemotherapy is working, the abnormal areas will no longer take up the radioactive sugar. Some newer machines are able to perform both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT.
Ultrasound: Ultrasound uses sound waves and their echoes to produce a picture of internal organs or masses. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is first lubricated with a gel). It gives off sound waves and picks up the echoes as they bounce off the organs. The echoes are converted by a computer into a black and white image that is displayed on a screen.
Ultrasound can be used to look at lymph nodes near the surface of the body or to look inside your abdomen for enlarged lymph nodes or organs such as the liver and spleen. (It can’t be used to look at organs or lymph nodes in the chest because the ribs block the sound waves.) It is sometimes used to help guide a biopsy needle into an enlarged lymph node. This is an easy test to have done, and it uses no radiation. You simply lie on a table, and a technician moves the transducer over the part of your body being looked at
4. Lab Tests of Biopsy or Blood Samples
These tests may be done on biopsy samples or, in some cases, blood samples to help diagnose lymphoma and determine what type it is. Pathologists can sometimes tell which kind of lymphoma a patient has by just looking at the cells under a microscope, but usually these other types of tests are needed to confirm the diagnosis.
Cytogenetics: This technique allows doctors to evaluate the chromosomes (long strands of DNA) in the lymphoma cells. The cells are looked at under a microscope to see if the chromosomes have any translocations (where part of one chromosome has broken off and is now attached to another chromosome), as happens in certain types of lymphoma. Some lymphoma cells may have too many chromosomes, too few chromosomes, or other chromosome abnormalities. These changes can help identify the type of lymphoma. Cytogenetic testing usually takes about 2 to 3 weeks because the lymphoma cells must be grown in lab dishes for a couple of weeks before their chromosomes can be viewed under the microscope.
Flow cytometry: For this test, a sample of cells is treated with special antibodies that stick to the cells only if certain substances are present on their surfaces. The cells are then passed in front of a laser beam. If the cells now have antibodies attached to them, the laser will cause them to give off light, which can be measured and analyzed by a computer. Groups of cells can be separated and counted by these methods.
This is the most commonly used test for immunophenotyping – classifying lymphoma cells according to the substances (antigens) on their surfaces. Different types of lymphocytes have different antigens on their surface. These antigens may also change as each cell matures. Flow cytometry can help determine whether a biopsy sample contains lymphoma, some other cancer, or a non-cancerous disease. It has also become very useful in helping doctors determine the exact type of lymphoma so that they can select the best treatment.
Immunohistochemistry: In this test, a part of the biopsy sample is treated with special antibodies (man-made versions of immune system proteins) that attach to cells only if specific molecules are on their surface or inside the cells. These antibodies cause color changes, which can be seen under a microscope. This test can be used to help diagnose lymphoma and tell what type it is.
Molecular genetic tests: In this test, a part of the biopsy sample is treated with special antibodies (man-made versions of immune system proteins) that attach to cells only if specific molecules are on their surface or inside the cells. These antibodies cause color changes, which can be seen under a microscope. This test can be used to help diagnose lymphoma and tell what type it is.
5. Medical History and Physical Exam
Usually the first step is for your doctor to take your medical history. The doctor probably will ask when the changes in your skin first appeared, whether they have changed in size or appearance, and whether they are itchy or painful. You may be asked if you have any other symptoms, like fever or weight loss. Because skin lymphomas can be hard to tell apart from allergies and other causes of rashes, you might also be asked if you have recently been exposed to something that could be causing your skin problems, such as if you are taking a new medicine or are using a new laundry detergent.
During the physical exam, your doctor will note the size, shape, color, and texture of any area(s) of skin in question. The rest of your body will be checked for other areas of skin involvement. The doctor may also feel the lymph nodes (small, bean-sized collections of immune cells) under the skin in the neck, underarm, or groin, as lymphomas can sometimes cause lymph nodes to become enlarged. If you are being seen by your primary doctor and skin lymphoma or another type of skin cancer is suspected, you may be referred to a dermatologist (a doctor who treats skin diseases), who will look at the skin more closely.