Go back



    Hematological / Oncological

    Last Updated Jan 19, 2022
    Read Disclaimer
    By Nicholas Sparrow, Ramandeep Ubhi



    • Lymphoma is a malignancy of the lymphatic system.
    • Categorized into Hodgkin Lymphoma and non-Hodgkin lymphoma.
    • Include a wide variety of hematologic malignancies with varying clinical presentations.
    • Some patients will present with symptoms secondary to extra-nodal involvement, which can include many common ED complaints such as GI complaints, headache, back pain etc.

    Initial Presentation – Signs and Symptoms

    Hodgkin Lymphoma – generally slow progression:

    • Non-tender, firm lymph node (cervical/mediastinal more common).
    • Constitutional symptoms: fever, night sweats, or unintended weight loss.
    • Other symptoms: Pruritus, fatigue, alcohol-associated pain, splenomegaly, hepatomegaly.
    • Incidental findings: Mediastinal Mass on CXR, Hypercalcemia, Anemia, Eosinophilia.

    Non-Hodgkin Lymphoma – progression to extra nodal involvement can be rapid, wide variety of initial presentations:

    • Most commonly: lymphadenopathy and constitutional symptoms similar to Hodgkin lymphoma.
    • GI involvement: Abdominal mass/organomegaly, vomiting, early satiety, obstruction.
    • CNS: headache, focal deficits, seizures, meningitis, back pain, cord compression.
    • Tumor Lysis Syndrome: hyperkalemia, hyperphosphatemia, and hypocalcemia and associated symptoms.
    • Other: Airway obstruction, pericardial tamponade, SVC syndrome.

    Diagnostic Process


    • CBC with differential
    • CRP, ESR
    • Extended electrolytes: Na, K, P, Mg, Ca
    • LFTs & Kidney function
    • LDH, uric acid
    • HIV, Hep B & C


    • CXR/Chest CT
    • Further imaging depending on clinical presentation (eg. CT head, CT abdo-pelvis)

    Ultimately patients will need lymph-node biopsy (excisional ideally), but this is not routinely done in the Emergency.

    Recommended Treatment

    Patients will need to be referred to oncology for consideration for chemotherapy +/- radiation. Protocols vary based on classification of lymphoma.

    Chemotherapy protocols and PPOs available from BC Cancer (link below).

    When to use steroids:

    • Patients with known lymphoma may present to ED with oncologic emergencies that may benefit from corticosteroids, 2 examples of this below.
    • Generally pre-biopsy steroids are avoided if other treatments promptly available.
    • Steroids can cause apoptosis in. lymphoma which has been reported in some cases to delay accurate histologic diagnosis.
    • Spinal cord compression:
      • when signs and symptoms of cord compression (back pain, neurologic deficits) are present the entire spine should be evaluated with MRI ideally (CT if MRI not available).
      • Urgent neurosurgery/radiation oncology/medical oncology consultation.
      • If corticosteroids pursued, Dexamethasone (eg. 10-16mg IV, subsequently 16mg PO daily until definitive management).
    • Hypercalcemia:
      • Hypercalcemia in most Hodgkin and up to a third of Non-Hodgkin lymphoma is due to increased calcitriol.
      • Hypercalcemia in these cases may respond well to corticosteroid treatment (eg. 20-40mg PO prednisone daily).
      • Symptomatic or severe hypercalcemia is also treated with IV hydration and calcitonin (4-8 IU/kg SC or IM q6-12 hrs) for acute management.
      • IV bisphosphonates (Zoledronic acid 4mg IV) and Denosumab (120mg SC) will reduce calcium over next few days. Generally, do not repeat dose within one week.

    Complications secondary to treatment:

    • Tumor lysis syndrome:
      • tumor lysis can release large amounts of potassium, phosphate, and uric acid.
      • Can be life threatening and can lead to AKI, arrhythmias, or seizures.
      • Cardiac monitoring and ICU admission likely needed.
      • Treatment involves IV fluids to maintain good urine output, treatment of hyperkalemia, phosphate binders can be considered to treat hyperphosphatemia, Rasburicase for hyperuricemia (0.2 mg/kg/day), and lastly calcium replacement once phosphate is corrected or if symptomatic (tetany/arrhythmias).
      • Dialysis is indicated if these measures do not fix above electrolyte abnormalities, or there is fluid overload/renal deterioration.
    • Febrile neutropenia:
      • Treatment of febrile neutropenia involves recognition of fever or SIRS response in context of neutropenia and early initiation of empiric antibiotics.
      • Empiric treatment guidelines can be found at BC Cancer (link below).

    Quality Of Evidence?


    When lymphoma is highly suspected, avoid pre-biopsy steroids unless alternative treatment is not urgently available.

    Low Grade Recommendation: NICE guidelines recommend avoiding pre-biopsy steroids even in metastatic spinal cord compression but this recommendation is based on low quality observational studies.


    Other Resources

    Related Information

    Reference List


    COMMENTS (0)

    Add public comment…