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Medical TestsThe following excerpt is taken from Chapter Five of Non-Hodgkin's Lymphomas: Making Sense of Diagnosis, Treatment, and Options by Lorraine Johnston, copyright 1999 by O'Reilly & Associates, Inc. For book orders/information, call 1-800-998-9938. Permission is granted to print and distribute this excerpt for noncommercial use as long as the above source is included. The information in this article is meant to educate and should not be used as an alternative for professional medical care. The description that follows lists tests and procedures alphabetically, states whether they are inpatient or outpatient, describes what the tests and procedures accomplish, tells how to prepare for these tests, details how they are administered, relays how most people rank them regarding pain, discusses recovery issues, and outlines risks.
Abdominal surgery (laparotomy)Laparotomy is the medical name for any incision into the abdomen. While laparotomies are no longer routinely performed for diagnosing lymphoma, it may be necessary if your only evidence of disease is within the abdomen. The only way to get a sound diagnosis is by removing and examining lymph nodes or other suspicious tissue. Imaging tools such as CT scans cannot depict tumors in enough detail for your doctor to use the results as a basis for planning effective treatment, and fine-needle biopsies sometimes fail to retrieve enough tissue for a diagnosis.Use of the laparoscope (a camera-guided surgical tool containing a microscope) for this surgery is still uncommon, but is becoming more common in some major cancer centers. When a laparoscope is used, the procedure is called laparoscopy instead of laparotomy, the incision is smaller, and healing time is shorter. Some disadvantages of laparoscopy are the relative inability of the surgeon to have a clear view of entire internal abdomen, and the possibility that tumorous tissue will break apart and remain within while the surgeon is trying to remove it using only camera-guided instruments. Laparotomy is an inpatient procedure; laparoscopy can be either an inpatient or outpatient procedure. PreparationPrior to scheduling this surgery, you may need to submit in writing to your insurance company evidence of the necessity of surgery. You should verify with your insurance company how long a hospital stay they will approve and whether home aftercare is provided. You should consider filling out a durable power of attorney so that your loved ones can make decisions for you while you are recovering. Pre-operative tests such as a chest x-ray, electrocardiogram, or blood testing may be necessary.You will be asked to fast for twelve to eighteen hours before surgery. You may be instructed to use enemas or laxatives beforehand. The risks associated with this surgery will be explained to you, and you will be asked to sign a consent form. If in the past anesthesia has made you nauseous during recovery, tell the anesthesiologist. She will give you antinausea medication. MethodA local anesthetic is injected in the skin near the vein that will be used for the general anesthetic, and an intravenous line (IV) is inserted once the area is numbed. An oxygen mask may be fitted over your face while you are still awake. A general anesthetic to make you fall asleep will be injected into the IV line; afterward, you may be kept asleep with either gas anesthesia or an IV sedative.While you are asleep, the surgeon, in coordination with the pathologist, will remove a few lymph nodes, as well as small pieces of other tissue if they look suspicious, for examination in the pathology laboratory. The surgeon will carefully examine all surrounding tissue for signs of cancer. The incision is then closed layer by layer. Surgical staples or stitches will be used to close both internal and external layers of tissue. Dissolving synthetic fabric layers may be used internally to prevent a form of internal scarring called adhesion. RecoveryWhen you wake, you will still have the IV line, now supplying you with saline, nutrients, and pain killer. As you become less sleepy, you may notice that additional equipment was added during your surgery: you may, for example, have a temporary catheter in the urethra to collect urine, a temporary tube in your nose that passes to your stomach to keep it empty, or a respirator to help you breathe. These temporary assists are removed when the nurses become aware that you can function without them. In general, the sooner you are able to rise from bed and walk, the sooner you will regain full function of all body organs, as movement aids the healing process.Hospitalization times vary based on the patient's condition and the type of insurance in effect. If you feel you need to stay longer in the hospital, but your insurance policy limits your stay unless the doctor requests otherwise, be sure to make your needs known to your doctor and the nursing staff. When you are discharged, you may be restricted from driving for several weeks, depending on the location of your incision. Certain activities such as climbing stairs may also be restricted. Full recovery may take as long as six weeks and may include pronounced fatigue. PainDirectly after surgery, you will be given by IV a pain medication that most likely will be morphine. Sometimes the hospital staff looks for signs that you have awakened from general anesthesia before administering pain medication which will once again make you sleepy. This precaution is taken to ensure that you are not overdosed. Be sure to make clear your need for pain medication as soon as you are awake and are experiencing pain, as excessive pain can interfere with healing. Most patients report pain at the incision site, perhaps a sore throat from the breathing tube that was inserted and removed while they were asleep, and perhaps hip pain if a bone marrow biopsy was performed. A few report pain at the IV site.Additional pain medication beyond day one will be given freely if you ask. Many hospitals now use patient-controlled infusion (PCI) pumps for morphine dosing, as they yield a more even dose--about twenty microdoses per hour--than pain medication given by tablet or IV. PCI pumps also will yield a limited amount of additional morphine if the patient pushes a button on the pump for this purpose. The minicomputer within the pump counts the number of patient pushes so that the staff will have a good idea of your need for pain medication. Most patients find they need a minimum of three days of morphine for abdominal surgery. When you are discharged, you will be given a prescription for oral pain medicine. Many patients report a lingering dull ache in the area beneath the incision for months afterward. RisksThere are varying risks associated with surgery done under general anesthesia, including excessive bleeding from the incision site and a very small risk from the anesthesia itself. Your doctor and the hospital staff will explain fully the risks that apply most closely to your surgery.
Barium enemaSee "X-ray studies."
Blood product transfusionThis outpatient procedure is a means of replenishing your red blood cell and platelet blood supply if chemotherapy or radiation therapy have significantly lowered them, or have limited your bone marrow's ability to produce new blood cells.PreparationYou should check the blood product brought to you for infusion to be sure it matches your blood type. Platelet matching may also become necessary after many platelet transfusions, as the body gradually becomes sensitized to and attacks donated platelets.Be sure to tell the nursing staff if you have ever before had an allergic reaction to donor platelets. MethodAn intravenous (IV) line is inserted into a vein in your forearm or into your central catheter if you have one that can be used for transfusions. The blood product to be transfused is hung from an IV pole and is dripped into you over a period of about four hours.If you have chills, fever, or difficulty breathing during a transfusion, notify the nursing staff immediately. This may be the beginning of an allergic reaction. PainIf you have no catheter and an IV line is inserted into your vein, you may feel mild pain during its insertion.RecoveryThere are no recovery issues following transfusion. On the contrary, you can expect to feel much less tired almost immediately after red blood cells are infused.RisksThere is a risk of serious allergic reaction if donated blood products are not properly matched to yours. There is a slight risk of infection at the site of IV insertion.
Blood testsVarious blood tests detect various conditions. Each blood test's purpose is discussed following the name of the test. All are outpatient procedures.PreparationMost blood tests require no preparation; however, some may require an overnight fasting diet or the cessation of certain medications for a few days. Always tell your doctor and the staff administering the test of any drugs you are taking, prescription or over-the-counter. Zantac (Ranitidine), for example, can suppress platelet production and could cause an inaccurate result in a complete blood count.MethodMost blood tests are performed by drawing blood into a syringe from the vein just inside the elbow. If your veins have been damaged by chemotherapy, if they are hard to find, or if they roll--more common in muscular people--the technician (phlebotomist) may use a vein on the back of the hand or on the back of the lower forearm. Some implanted catheters can be used for blood draws.You can make your veins easier to access as follows:
PainMost people report minor pain or no pain during a blood draw. If, however, you are afraid of needles, of the pain of needles, or of the sight of blood, you are not alone. A policeman describes his fear of needles:When a piece of metal lodged in my eye, my eye doctor called in a surgeon from Baltimore. It turned out that the metal was already gone, but they had to remove the rust that was still in the fluid part of my eye. The surgery was done in a dark room while I was awake and lying on a table. It didn't hurt, and everything was okay until I realized they were using a needle. I thought they were going to use a laser! They finished what they had to do, but I was not happy about the needle. Good thing I was already lying down!Here are a few tips for reducing fear and pain during a blood draw:
RecoveryMost blood draws entail no recovery, but you may have slight, painless bruising at the injection site the following day. Stretching the skin to make the blood draw less painful may increase this chance of bruising. Steady pressure on the injection site for sixty seconds or more directly after the needle is withdrawn facilitates clotting and can reduce the chance of bruising.RisksUnless you have blood that won't clot normally, there are only minor risks associated with a blood draw, such as the possibility of painless bruising.Specific blood testsBlood tests are listed alphabetically.
Bone marrow aspiration/biopsyBy examining the liquid marrow or the solid core of marrow/bone structure under a microscope, a pathologist can determine if lymphoma has spread into the marrow or if chemotherapy or radiation therapy have affected the marrow's ability to function. Bone marrow aspiration involves drawing a small amount of liquid bone marrow into a narrow needle; bone marrow biopsy involves drawing a piece of bone and its attached marrow into a larger needle called a trephine. Although in most people all bones are capable of producing marrow, for these tests the large bone of the hip is usually used. Bone marrow aspiration and biopsy is usually, but not always, an outpatient procedure.PreparationA sedative and/or an amnesiac may be given to you in advance. Bring a heating pad with you, and ask the staff if you can place it over the hip area for ten minutes or so beforehand, as some patients report this reduces pain afterward. If you have had biopsies in the past and prefer the technique of a particular staff member, try to obtain an appointment that matches his or her schedule. Be sure your sedative or local anesthetic has become fully effective before allowing the staff to proceed.MethodA local anesthetic is injected over the back of the hipbone and a very small incision is made. Into this incision the needle or trephine, or each in turn if both aspiration and biopsy are being done, is inserted to penetrate the bone. For a marrow aspiration, the liquid marrow is drawn into the needle and the needle is removed. For a biopsy, the trephine is pushed through the bone to collect a core of bone and its attached marrow, and is removed. If not enough marrow can be obtained, a second insertion through the same incision but into a different area of bone will be tried. Pressure is applied over the insertion point for a few minutes to stop bleeding. A small bandage is applied.PainMany patients report moderate to severe pain during this procedure. Be sure to ask for a sedative or an amnesiac such as Versed if you know from past experience that you prefer being very much unaware of pain. You may feel unpleasant pressure as the needle is pushed through the bone, especially if your bones are very dense. You may feel a unique unpleasant sensation as the marrow is drawn into the needle. You may feel pain if the needle slips across the bone surface as it is being inserted.RecoveryUnlike a bone marrow harvest for transplantation, for aspiration or biopsy very little marrow is removed, so subsequent lightheadedness and fatigue are rare. Afterward, your hip may feel sore for a few days. This can usually be relieved with Tylenol-type medications.RisksThere is a slight risk of infection at the incision site.
Bone marrow harvestA bone marrow harvest usually is an inpatient procedure with specific preparation and recovery.
Bone scan (scintigraphy)This outpatient test exploits the fact that some bone irregularities will absorb more of a substance than will healthy bone tissue. Your doctor will choose a scintigraphic agent that works best with the type of tumor you have and its location.PreparationFor a bone density scan, no contrast agent is injected. For imaging of suspected tumors, a mild radioactive agent, usually Technetium-99, will be injected and you will be asked to return later, perhaps in three hours, for scanning. You will be encouraged to drink copious amounts of water to spread the agent from soft tissue into bone. Get comfortable after lying down on the table for the scan, because you must hold this position for up to an hour.MethodScanning is done by having the fully clothed patient lie on a table that has, above and below it, a camera that is sensitive to the energy emitted by the agent injected. It is important to hold still for duration of the film exposure. The table is fully open, not enclosed like an MRI machine, and you'll see the arm of the camera passing over your body starting with your head and going toward your feet. The arm is about six inches wide and about as long as the table is wide. It moves slowly; a whole-body scan can take thirty or forty minutes.PainA slight sting may be felt when the scintigraphic agent is injected.RecoveryThere are no recovery issues associated with this test.RisksAs with other imaging techniques, there are risks of false-positive and false-negative readings.
BronchoscopySee "Endoscopy."
Catheter insertion (central catheter, central line)This procedure can be inpatient or outpatient. A central catheter or line is a flexible tube that is threaded into a very large vein near your heart. Its presence in a large vein dilutes chemotherapy drugs amidst a large volume of blood and thus makes chemotherapy safer. Moreover, depositing chemotherapy drugs near your heart will distribute them more quickly and more evenly to all parts of your body than is possible when chemotherapy is infused directly into an arm vein. Using a central catheter can eliminate damage to arm veins during chemotherapy, and can eliminate somewhat painful penetration of arm veins for blood testing and for administering other drugs.PreparationYou need to decide whether a catheter is the right choice for you. You will also need to decide whether to get an external catheter (with tubing emerging from the skin) or a subcutaneous catheter (under the skin). Your oncologist may have very strong opinions on this topic.Some advantages of catheter use are:
Some drawbacks of catheter use are:
See "Abdominal surgery" for a description of preparation for general anesthesia. See "Node biopsy" for a description of preparation for local anesthesia. You will be asked to dress in a hospital gown and will be taken to a surgical suite. After the anesthetic has taken effect, two areas, both on the chest, or one on the chest and one on the neck, will be cleansed and two incisions will be made. The surgeon will access the large vein near the heart through one of these incisions. The central line will be threaded through the large vein until it rests near your heart. The other end will be threaded beneath your skin and, for an internal port, secured there. For an external port, it will be threaded through the surface of the skin with an anchor just below the surface. RecoveryYou will be taught how to clean and flush your port if you have chosen an external catheter. Redness, swelling, or bleeding that persists at the incision site should be reported to your doctor.PainSome who have had a central line implanted report pain when moving their arms or when lying in a certain position. This pain may continue for several weeks following implantation. Some who elect local anesthesia report feeling deep pain during the procedure:I had a Groshong catheter implanted in anticipation of many different needs for vascular access. That was a tough thing to accommodate without feeling like an alien. The same surgeon who had done such a good job removing the malignant node seemed to turn into Conan the Barbarian for this procedure. I had no general anesthetic to relax me, nor was I aware I could ask for one. He inserted a needle several times into my chest to administer a local, and I quietly wept both from shock and pain. A nurse stroked my head and patted my shoulder, whispering that it would not last long. RisksIn addition, surgery entails risks such as accidental penetration of a major vein, uncontrolled bleeding, and slight risks associated with anesthesia.
ColonoscopySee "Endoscopy."
CT scan (computed tomography, "CAT" scan)An outpatient procedure, computed tomography is a series of many very narrow x-rays taken at many varying depths of tissue and from different angles around your body. These x-ray images are then analyzed and reassembled by a computer into an image of your internal organs. CT scans differ from traditional x-ray imaging in that x-ray imaging can't readily distinguish organs that are lying behind other organs. Imagine looking at several veils hanging one behind the other, each painted with a different design. You can imagine how difficult it might be to discern the design on the farthest veil. CT scans, on the other hand, are able to delineate even those organs that are obscured by other tissue.PreparationYou may be asked to fast overnight, to use a laxative, or to purchase and drink a contrast agent if a CT scan of your abdomen and/or pelvis is planned.Your studies may require an iodine-based contrast agent. Be sure to tell your doctor and the staff doing the test if you have thyroid disease or are allergic to iodine in seafood or other sources. A non-ionizing version of the contrast agent can be substituted. Because the iodine contrast agent used may cause a sensation of heat, skin flushing, or rapid heartbeat, be sure to tell the technician if you have heart disease, high blood pressure, or any other health concerns in addition to being a lymphoma survivor. If you have internal staples from a previous surgery or pieces of metal embedded in your body from a previous injury, tell the technician. They represent no danger to you during the scan, but may appear on the film as unexplained phenomena. CT scanners are open, doughnut-shaped machines that generally do not cause patients to feel claustrophobic. MethodCT scans are performed while you are lying in a carefully chosen position that has been aligned with the machine. It is important to maintain the position that was chosen until the technician says you can relax. Most CT scan sessions include a fast, initial pass with no contrast agent, followed by a second, slower scan with a contrast agent. The first scan images the entire body to use as a frame of reference for the rest of the scanning. During the first scan, you'll feel the table you're lying on move smoothly through the doughnut-hole of the machine, without stopping and starting.While the second, slower scan is underway, you may be asked to hold your breath briefly over and over. Some scanning machines take ten to twenty minutes to scan, depending how much of the body is being scanned. During this time, the contrast agent is slowly dripped into your vein. The part of you being scanned is positioned inside the doughnut-hole, which is about twelve inches thick. You'll feel the table you're lying on move slowly through the machine a few centimeters at a time, stopping and starting. Some people enjoy taking a nap at this point. Newer scanners can do the entire scan very quickly, in about twenty seconds. For these machines, you may have to hold your breath for the entire twenty seconds, and if a contrast agent is injected, it will be pushed rapidly into your vein instead of slowly dripped. This quick administration of the contrast agent may cause stronger feelings of heat and faster heartbeat, sensations that are not considered an allergic reaction. You will feel the table you're lying on move smoothly through the doughnut-hole of the machine without stopping and starting. For some studies of the stomach or bowels, you may be required to drink a contrast agent just before the scan is taken. PainCT scans are painless. However, when a contrast agent is used, it is injected into a vein, perhaps causing minor discomfort. As mentioned under "Preparation," the iodine contrast agent used may cause a sensation of heat, skin flushing, or rapid heartbeat.RecoveryIf you have had a study that required drinking a contrast agent, you may experience gas, diarrhea, or constipation for one to three days afterward. Drinking large amounts of water will hasten the removal of the contrast agent from the digestive tract. If you have had a contrast agent injected, you may have a harmless and temporary discoloration of the urine or skin for several days afterward. If you are sensitive to iodine or have a thyroid condition, you may feel fatigue for several days after receiving an iodine-based contrast agent.RisksA CT scan, if repeated over and over for many years, may deliver enough radiation to body tissue to cause health problems later in life, such as lung, thyroid, or breast cancers. However, as CT scanning technology has improved, the amount of radiation delivered has lowered.
Endoscopy (colonoscopy, bronchoscopy, gastroscopy, sigmoidoscopy)This outpatient test uses a microscope and light source on a narrow flexible tube to examine and sample parts of the body that would otherwise require open surgery to access. For the non-Hodgkin's lymphomas, the organs most often examined are the larynx, bronchial tubes and lungs, stomach, complete colon, or sigmoid (lower) colon.PreparationDepending on the part of the body being examined, you may be asked to restrict your diet, to use a laxative or an enema, or to forego certain medications such as aspirin for a day or more. You may be asked to bring someone with you to drive afterward. If a colonoscopy is planned, discuss sedation with your doctor, as some but not all patients report pain with this procedure.MethodFirst, a sedative may be injected into a vein of your forearm to relax you. It may be administered with a syringe or by an IV that will remain in place until you are ready to go home. A self-inflating blood pressure cuff may be used on your upper arm, and a rubber thimble for monitoring oxygen levels may be placed on your finger.Once the sedative has taken effect, the endoscope will be inserted and a painless, quick examination will ensue. Very small pieces of tissue may be collected painlessly and sent to the pathology lab for testing. While the scope is being used, you may be asleep or you may be vaguely aware that the procedure is underway. You may retch if the scope's tube is inserted in your throat, but the sedative will make you feel as if it is happening to someone else. RecoveryIf a sedative was used, it may take about a half hour to awaken. For several hours after having a sedative, it is unwise to drive, even if you feel able to do so.PainSome patients report pain during colonoscopy. Some report a panicked feeling of being unable to breathe during bronchoscopy.RisksThere are a few low risks associated with endoscopy, such as the risk of puncture of the esophagus or intestine. There is a very small risk of the sedative injection site becoming infected.
FISH (fluorescence in situ hybridization)See "Blood tests."
Flow cytometrySee "Blood tests."
Gallium scan (scintigraphy, gallium scintigram)This outpatient test exploits the fact that some lymphoma tumors will absorb more of a substance than will surrounding tissue or healthy lymphatic tissue. Your doctor will choose a scintigraphic agent that works best for the type of tumor you have and its location. Circumstances when different scintigraphic agents may be used include:
Sometimes this procedure is repeated using a camera that is sensitive to the emission of a single positron (a positron is a piece of an atom). This is called a SPECT or SPET scan, and works on a similar principle, that is, the gallium makes your tissue more visible to the camera. The gamma camera, if it is used, is not a doughnut-shaped solid thing like a CT scanner. It's more like a shield that moves back and forth in half circles starting at the top of the body and working down. It moves close to the body, but does not touch it. PreparationAn enema or laxative may be necessary the day before the test. After lying down on the camera table, get comfortable because you must hold this position for about one hour.MethodAn injection of gallium-67 is made into a vein in the forearm and the needle is withdrawn. Depending on the agent used, the patient may be scanned repeatedly in two, four, twenty-four, forty-eight, or seventy-two hours, or a combination of these times. For the repeated tests, the patient must return to the hospital. No second injection is required before the second scan. Scanning is done by having the fully clothed patient lie on a camera table that is sensitive to the energy emitted by the agent injected. It is important to hold still for the duration of the film exposure. Some patients are embarrassed to note that, although they are fully clothed, the computer-assembled image on the screen is of the naked body.PainA slight sting may be felt when the scintigraphic agent is injected. You won't have to stay away from others later to avoid exposing them to radioactivity, as is necessary after receiving injections of some other isotopes. Allergic reactions are extremely rare.RecoveryThere are no recovery issues associated with this test.RisksAs with other imaging techniques, there are risks of false-positive and false-negative readings with gallium.
GI seriesSee "X-rays."
Intravenous pyelogramSee "X-rays."
LaparotomySee "Abdominal surgery."
Lumbar punctureSee "Spinal tap."
Lymphangiogram (bipedal lymphangiography, lymphography)This outpatient test, which is rarely used these days because better tests exist, allows the oncology team to view lymph nodes within the lower body. The nodes will absorb an iodine dye that causes them to be visible on x-ray film. Cancerous nodes sometimes will be different in appearance from normal nodes and other body parts. This test does not always illuminate all cancerous nodes in the lower body, especially if the spread of lymphoma blocks a lymphatic vessel or destroys the structure of a lymph node, but this is also true of other imaging tests that use contrast agents such as dye.PreparationThis is an outpatient procedure. You may be asked to restrict your diet to clear liquids for one day prior to the test. Because this procedure can be a painful one, you should determine several days in advance how experienced the technician is. Ask your oncologist if the procedure can be done elsewhere if the technician does not do lymphangiograms more than five times a year.Tell the technician if you are allergic to iodine, have ever had trouble breathing or an outbreak of hives after eating shellfish, have thyroid disease, or are pregnant. Empty your bladder before the test, because its timing ranges from ninety minutes to six hours. MethodA small amount of blue-green dye is injected into the top of the foot between the toes in order to highlight the lymphatic vessels. When one or more lymphatic channels becomes visible, a local anesthetic is injected and a small incision is made above the vessel. Into each incision a very small needle is placed to inject iodine dye that will trace through the lower lymphatic system. Sometimes the needle must be repositioned in order to enter the lymphatic vessel. The dye is injected slowly via automatic pump over an hour or more. While the dye is being injected, a fluoroscope, which is a type of x-ray machine, is used to trace the progress of the dye through the lymphatic system.While the dye is being injected, the patient must sit or lie quietly, so be sure you are warm and comfortable at the outset of this lengthy procedure. Pay particular attention to the position and relaxation of your feet, as they must stay in this position for several hours, so an awkward position quickly will become a weary one. After the dye has been injected, the incisions are stitched and the patient is x-rayed. The dye will remain in the body for up to a month and repeated imaging can be done. Most likely you will have x-ray sessions scheduled over two or more days to capture increasingly fine detail as the dye travels well into the nodes. PainThis procedure ranges from minor to severe with respect to pain. Some patients report severe pain if needles must be repositioned to find a lymphatic vessel, because the procedure can stretch from the normal ninety minutes to five or more hours. Discuss in advance the possibility that the local anesthetic may wear off if lymphatic vessels are not found on the first try, and ask what they will do to keep you pain-free. Others report that the pain of recovery lasts a week owing to the incisions that must heal, and report that walking is difficult and that wearing shoes is impossible. The iodine dye can cause a mild warmth, burning, or pressure sensation as it travels through the lower body, especially in the feet, behind the knees, or in the groin.RecoveryRecovery lasts from three days to one week while incisions heal. Urine, feces, skin, and vision may have a blue-green discoloration for a few days. Stitches must be kept dry, and a return visit to remove stitches is necessary.RisksThere is some discussion in the medical literature whether thyroid dysfunction may occur in those who have had both lymphangiogram and radiation therapy. Infection at the incision site is possible. Some people, especially those who are allergic to iodine, have an allergic reaction to the dye, such as difficulty breathing. Some people develop a fever and swollen lymph nodes from the dye.
Mammogram (mammography, breast x-ray)An x-ray of the breast is called a mammogram. Certain lymphomas can lodge in the breast and must be distinguished from benign cysts and other cancers of the breast. If you are a male or female survivor of NHL and notice a lump in the breast, contact your doctor immediately.PreparationIf you are female and are still having menstrual periods, schedule your mammogram for the ten days following the first day of your period. This will lessen the chance that your breasts will be tender and will give a more accurate x-ray result. Avoid caffeine, chocolate, and other foods that may contribute to breast tenderness for several days prior to your mammogram.Request an appointment that includes a patient/doctor consultation directly following the x-ray session, so that you can discuss immediately with the doctor any unusual results, and have repeat x-rays or ultrasound if warranted. Otherwise, if the results are questionable, you may have to wait several highly stressful days, or even longer, for the staff to find an opening in their schedule for repeat testing or for the doctor's availability. Tell the technicians and the radiologist that you are a non-Hodgkin's lymphoma survivor. Before the mammogram, remove all aluminum-based antiperspirants and all metallic jewelry. Be sure the technician is aware of moles, scars, or other skin characteristics that may appear questionable on the films. You will be asked to remove all clothing from the waist up and to replace them with a gown. While the mammograms are being performed, however, the gown must be partially removed to facilitate placing the breast above the photographic plate. MethodMammography is usually done while the woman is standing with the breast resting against a warmed, flat surface that contains a photographic plate. The technician will measure the density of the breast tissue and slowly lower a matching plate from above until the breast is somewhat compressed. While you are holding that position carefully, she will step behind a radiation shield and activate the x-ray machine for about three seconds.Usually, two x-rays of each breast are taken, each from a different angle, to maximize the amount and location of tissue imaged. It is particularly important to capture the tissue high against the chest wall, approaching the collarbone, because in fact breast tissue extends beyond what we traditionally refer to as the breast. Using equipment commonly available today, tissue compression remains necessary to ensure good visualization of all breast tissue. You will be asked to wait, wearing the gown, until the films are developed to ensure that films of high clarity were obtained. If unclear, the studies must be repeated. If unusual features are present on one of the films, the x-ray may be redone using a small compression paddle to highlight a particular area of breast tissue. Alternately, ultrasound may be used to re-image the breast in an attempt to distinguish benign fluid-filled cysts from other lesions. If the radiologist should ask to immediately aspirate a suspicious cyst or to immediately biopsy a suspicious lump, decline such on-the-spot procedures unless your oncologist has told you that this radiologist is experienced with handling lymphoma biopsies. It is, of course, wisest to do an assessment of the radiologist's capabilities before making your mammography appointment so that no extra delays are encountered if you do need an aspiration or biopsy. PainMany women report discomfort, minor pain, or moderate pain during breast compression. Some women report a great deal of pain. If you have had previous breast surgery or breast implants, you may experience pain that is qualitatively or quantitatively different from that experienced by other women.RecoveryMany women report a bruise-like pain or a discharge from the nipple for a day or two. Report these after-effects to your oncologist and your primary care doctor.RisksSome researchers believe that the accumulated dose of radiation delivered to breast tissue over a lifetime may increase a woman's risk of getting breast cancer. This, of course, must be weighed against the risk of failing to detect a breast cancer or breast MALT lymphoma. The risk associated with bruising or discharge from the nipple is thought to be minor or absent.
MRI (magnetic resonance imaging)This outpatient test uses large magnets and radio waves to cause the different atoms that make up our cells to vibrate at different speeds. The different speeds are then mapped by a computer into an image of the body part being examined. MRI is better than a CT scan for imaging soft tissue, such as cartilage or the brain.PreparationYou will be asked to lie on a table that moves in and out of the tunnel-shaped MRI machine. The body part being scanned may be positioned within a basket-like brace to help keep the position chosen by the technician.MRI machines make hammering noises because the magnets are being repositioned constantly while the images are being generated. The technician will supply you with disposable earplugs. A contrast agent may be injected for imaging certain organs. Imaging the brain, for example, is sometimes facilitated by injecting a very safe agent called gadolinium. Ask the technician about the risk associated with the agent being used, and tell her if you have any allergies or problems with blood clotting. Some people find the enclosed models of MRI machines claustrophobic. Certain MRI machines have an open gazebo-like design to reduce claustrophobia, with the magnets overhead supported on pillars. Yet others are made of clear plastic. While images from open models may be distinct enough for diagnosing knee problems, for example, they might not be detailed enough for mapping the brain. If you're claustrophobic, there are several things that will help, such as knowing that there is a speaker inside the machine so that the technician can hear you if you ask for help, and that you, in turn, can hear her. There is also a hand-held beeping summons that you can press if you feel tense. Most facilities have a sound system and will let you choose the music. You may also notice that relaxing photographs have been taped to the inside of the machine. Fans circulate fresh air into the tunnel at all times. It's also possible that, unless your head is being imaged, only part of your body will be within the machine and your head may not. Most relaxing of all may be the thought that this is seventeen million dollars of technology, and for one hour, it's all yours. Some people, on the other hand, report that the MRI experience is comforting, like a return to the womb. In fact, a friend reports that he likes to have an MRI because it's the only place where nobody can interrupt him. If you still feel that claustrophobia will be a serious problem, ask your doctor whether a sedative would interfere with the imaging process. MethodAn initial scan to set benchmarks is done rapidly using no contrast agent. A second scan for finer detail is then repeated at slower speed. If a contrast agent is to be used, it is injected into a vein in the arm before the second scan. Although sound is muted by earplugs, you will hear hammering noises that vary in speed and pitch. While being scanned, one must remain as still as possible, but breathing is not restricted as it sometimes is during a CT scan.A scan of the knee or brain, for example, takes about forty minutes. After scanning is complete, there is a five- to ten-minute wait while the computer analyzes and maps the signals generated by the magnets. The technician will check the resulting images to be sure they are readable. PainThe imaging process is painless, although you may feel a slight sting or warmth during injection if a contrast agent is used.RecoveryIf a contrast agent is used, temporary changes in the color of skin, urine, or feces are possible.RisksThere may be risks of an allergic reaction associated with specific contrast agents; ask your doctor or the technician. As always, there is a very slight risk of infection or minor, painless bruising at the injection site.
MUGA scan (multiple gated acquisition scan, gated blood pool scan, radionuclide ventriculography [RNV])This outpatient test is used following certain chemotherapies to determine if the heart has been damaged so that an assessment can be made regarding how much additional chemotherapy can be administered safely. It is done both before and after cancer treatment to assess pre- and post-chemotherapy heart function.PreparationYou may be asked to restrict food or caffeine intake for about three hours prior to the test. Wear comfortable clothing, because you may be walking on a treadmill or riding a stationary bicycle for about fifteen minutes.MethodA safe, mildly radioactive contrast agent such as technetium-99 or thallium is injected into your forearm and subsequently collects in the heart, arteries, and veins. Sometimes a binding agent for the contrast agent is injected first. Alternately, a small amount of blood may be drawn, and the contrast and binding agents mixed with this blood and reinjected. You may be resting, exercising for fifteen minutes, or both while this test is performed. The scanning camera will be placed above your chest if you are lying down or in front of your chest if you are exercising. For the resting scan you must hold quite still.An electrocardiograph machine may be used at the same time. If used, its electrodes will be attached to about six areas of your rib cage using sticky bandages. Two weeks after my first chemotherapy, I had a MUGA scan done to check the health of my heart since the Adriamycin in the CHOP can be very damaging to the heart. There was nothing to this test, but I was disappointed that they couldn't use my catheter and instead had to inject the dye in my arm. A small amount of blood was drawn from my arm and then mixed with a radioactive tracer. This sat for thirty minutes and then was reinjected into my arm for the pictures. All in all, the procedure took about sixty minutes total: thirty minutes of waiting and thirty minutes of pictures, once without the dye and then again with. PainMinimal pain is possible at the injection site. If you experience chest pain during this test, tell the technician immediately.RisksThere is a very slight risk of developing cancer associated with the very small amount of radioactive material used--more so if you have had many previous x-rays, CT scans, radiation therapy, or other procedures that use radioactive agents, as radiation dose is cumulative.There is a slight risk of infection at the injection site.
Needle biopsy (fine-needle aspiration, CT-guided needle biopsy, percutaneous biopsy)This outpatient test is a means for diagnosing non-Hodgkin's lymphomas that are not contained within a lymph node or that may have affected other organs such as the liver. Biopsies of suspected lymphomas are sometimes done with a needle instead of an incision. Organs commonly examined using needle biopsy are the thyroid, kidney, liver, lung, breast, uterine cervix, pancreas, salivary gland, spinal fluid, and bone marrow. Bone marrow biopsies and spinal taps will be discussed separately.This test is not considered a good choice for identifying lymphoma within a node. The architecture of the entire lymph node contributes important information for the diagnosis; needle biopsy cannot retrieve the entire node. Indeed, at times needle biopsy retrieves no cancerous tissue. Instead, a healthy part of the cancerous node is mistakenly sampled, or no tissue at all can be sampled because malignant nodes can be dense, inaspirable tissue. This procedure can be helpful, however, to determine the recurrence of a lymphoma, and in these cases, flow cytometry and morphological studies often are done to evaluate the suspected recurrence. PreparationYou may be asked to fast for twelve hours before the procedure if a sedative or general anesthetic will be used, or if the tissue being biopsied is part of the digestive system. Prior to biopsy of the uterine cervix, you should not have sexual intercourse for twenty-four hours. Blood or urine samples may be collected prior to the biopsy. For children, ask the doctor if the procedure can be done under sedation or general anesthesia, or if EMLA cream can be applied at the site of the puncture two hours before surgery. Bring comfortable clothing to wear afterward, and plan on not being able to walk or drive alone after a sedative or general anesthetic is used.MethodYou will be lying flat on a table for most such biopsies, although lung biopsies may be done while you're either lying flat or seated. The skin will be cleaned. A local anesthetic will be injected, or a sedative or general anesthetic may be given by injection or by inhalation, or, if a fine-needle biopsy is planned, no anesthetic may be used. Directly before the biopsy, the area of interest may be imaged by CT scan or x-ray, and the skin above may be targeted with ink or dye. Depending on the organ being examined, you may be asked to regulate your breathing or to hold quite still during the biopsy. A tiny incision is made and the biopsy needle is inserted through the incision. For kidney biopsies, a guide needle may be used first. A small amount of tissue is drawn (aspirated) into the syringe. The needle is withdrawn, pressure is applied to halt bleeding, a bandage is applied--no stitches are required--and the tissue is sent to the pathology lab for analysis.For breast biopsies, stereotactic needle biopsies, which are computer-guided and very rapid, are sometimes performed. While you are lying face-down on a table equipped with an area to accommodate the breast, the tissue of interest is mapped from several angles. The automated biopsy needle enters and exits the breast within seconds. PainA slight sting from injected anesthetic or fine-needle biopsy is common. Depending on which organ is being biopsied, you may feel pressure, a brief, sharp pain, a dull, deep ache, or cramping. For liver or other digestive tract biopsies, you may feel pain in the shoulder. Tenderness or bruising may exist at the site of the biopsy and within any intervening muscle tissue for three to seven days. Some physicians prescribe Tylenol or Tylenol/codeine combinations for the aftereffects.RecoveryAfter biopsy of the uterine cervix, you may be asked to forego sexual intercourse for seven days. Following kidney biopsies, you may be asked to lie on your back for twelve to twenty-four hours, and you may note blood in your urine for twenty-four hours.RisksRisks of organ failure while under general anesthesia, of infection, of bleeding, internal or external, at the site of the puncture, or of injury to adjacent organs exist. For lung biopsies, risk of a collapsed lung exists, and any difficulty breathing should be reported immediately to your doctor. For kidney biopsies, blood in the urine may persist beyond twenty-four hours and should be reported to your doctor.
Node biopsy (excisional biopsy)This test is the best means for the diagnosis of nodal non-Hodgkin's lymphomas. It is usually, but not always, an outpatient procedure. An inpatient stay usually is necessary if the node being biopsied is in the abdomen (see "Abdominal surgery").PreparationNo physical preparations are necessary. For children, however, ask the doctor if EMLA cream can be applied at the site of the incision two hours before surgery.MethodWhile lying flat on a table, the area above the node will be cleaned and a local anesthetic will be injected. At times a general anesthetic is given by injection or by inhalation, but this is uncommon. An incision is made, the entire node is removed, and the incision is stitched. The node is sent to the pathology lab for analysis.The surgeon and the pathologist must coordinate the preparation of the node for pathology after its removal. PainA slight sting from the local anesthetic is common. Tenderness may exist at the site of the biopsy for three to seven days.RecoveryYou may be instructed to keep the incision dry until the stitches are removed. Stitches usually are removed in seven to ten days.RisksA slight risk of organ failure while under general anesthesia exists. A slight risk of infection or bleeding at the site of the incision exists.
PCR (polymerase chain reaction)See "Blood tests."
SigmoidoscopySee "Endoscopy."
Sonogram (ultrasound, sonography)An outpatient procedure, sonography creates a map of how your body structures appear when sound waves echo from them. The sonography equipment includes a wand that generates sound waves and a microphone for sensing the echoes the sound waves generate. The wave signal is passed to a computer that reformats the signals into a picture of body organs on a screen.Bone interferes with sonography, so scanning the brain with this equipment is not successful using the equipment readily available today. Color Doppler ultrasound is specialized sonography that can detect the speed and direction of blood flow within the body. The differences appear as different colors. This is useful because some tumors commandeer a large blood supply, and this excessive blood supply may be visible and meaningful using color Doppler ultrasound. A common use today is visualization of the ovaries and breasts to distinguish fluid-filled cysts from solid tumors. PreparationFor a pelvic sonogram, you may be asked to drink large quantities of water, because the bladder acts as a window for sound waves when it is very full.MethodYou will be lying on a table while the technician gently presses the wand over your body. Depending on what body part is being imaged, you may be asked to remove certain items of clothing and to wear a sheet in their place. The technician will first apply warmed gel to your skin to make the wand move smoothly. She may ask you to tilt your body and to maintain the tilt with your muscles, or she may place pillows under you.For a transvaginal ultrasound, she will apply warm gel to a special wand and ask you to insert it comfortably into your vagina. Once in place, she will guide it from side to side to visualize the uterus and ovaries. This specialized wand is quite long, which means that the technician's hands are not very close to your private body parts, and, being covered by a sheet, you probably won't feel that your body is overly exposed to a stranger. If you are having pelvic sonography along with a second sonographic scan, ask the technician to do the pelvic scan first so that you can empty your bladder. Many sonography facilities have an overhead screen so that you can see the same image the technician is seeing. PainSonography is not painful. Having to maintain a very full bladder for a pelvic sonogram is uncomfortable.RisksThere are no known risks associated with sonography.RecoveryThere are no recovery issues following sonography.SPECT or SPET (single positron emission computed tomography)See "Gallium scan."
Spinal tap (lumbar puncture)This outpatient test collects a sample of cerebrospinal fluid (CSF) that surrounds the spine and brain. For the non-Hodgkin's lymphomas, CSF usually is examined for the presence of cancer cells, but it also may be collected for many other reasons, such as identifying opportunistic organisms that may gain a foothold during chemotherapy.PreparationNo physical preparation is necessary.MethodYou will be asked to lie on your side with your knees pulled up to your chest and your chin down on your collarbone during the drawing of the fluid, which takes only a few minutes. The area around your lower spine will be cleaned and a local anesthetic will be injected. After the anesthetic has taken effect, a needle will be inserted between two bones of your backbone (lumbar vertebrae) to tap the fluid that lies under the membrane that surrounds your spinal column. Once the needle is inserted, you must hold very still in the curved position to avoid spinal damage. The spinal fluid is drawn into the syringe, the needle is removed, brief pressure is applied to stop bleeding, and a small bandage is applied.Immediately after I was admitted to the hospital for my first high-dose chemotherapy session, I underwent a spinal tap. I had never had a spinal tap before, but I recalled the procedure from my student nursing days. Without that experience, I think I would have surmised that this is just about as barbaric as the practice of medicine could get... but of course subsequent elements of my treatment would far surpass the spinal tap in that category. PainSome people report a brief, sharp pain as the needle enters the membrane. Others report pronounced pressure until the needle is properly positioned. Some people report severe headache after the procedure, especially if they were not able to lie flat afterward for the six or eight hours recommended.RecoveryYou must lie flat for six to eight hours after this procedure to allow your body to replace and redistribute spinal fluid surrounding the spine and the brain. This posture prevents headache.RisksA serious risk of spinal damage or paralysis exists if movement during the procedure displaces the needle. Slight risks of infection at the injection sites or of bleeding into the spinal column exist. Risk of headache exists, especially if the patient does not lie flat for several hours after the procedure.
Thallium scanA thallium scan for studying the heart is very similar to a MUGA scan, described in its own section. A thallium scan for locating lymphoma tumors is very similar to a gallium scan, also described in its own section.
Ultrasound (ultrasonography, sonogram)See "Sonography."
X-rays (radiographic studies)X-ray imaging may be used early in the diagnostic process to detect unusual masses and determine the extent of disease in the chest, although chest x-ray studies in the absence of a biopsied lymph node cannot positively diagnose a lymphoma. During treatment, x-rays can be used to locate intestinal blockages caused by certain chemotherapies and to detect other secondary conditions. X-ray imaging is diagnostic and is different from X-radiation therapy in that it delivers much lower doses of radiation to tissue.X-ray studies are an outpatient procedure. PreparationYou may be asked to fast overnight, to use a laxative, to purchase and drink a contrast agent, or to drink copious amounts of water if x-ray imaging studies of your colon or kidneys are planned.If your studies will require an iodine-based contrast agent, as is used for certain x-ray studies of the kidneys, be sure to tell your doctor and the staff doing the test if you have thyroid disease or are allergic to iodine in seafood or other sources. A non-ionizing version of the contrast agent can be substituted. If you have internal staples from a previous surgery or pieces of metal embedded in your body from a previous injury, tell the technician. They represent no danger to you during the x-ray session, but may appear on the film as unexplained phenomena. MethodX-rays are taken while you are sitting, standing, or lying in a carefully chosen position that has been aligned with the x-ray machine. It is important to maintain the position that was chosen and to remain very still until the technician says you can relax.For some studies of the stomach or bowels, you may be required to drink a contrast agent while the x-rays are being taken. For some bowel studies, an enema may be administered to fill the lower bowel with a contrast agent. Hospitals with the latest equipment will help you retain the fluid with an inflatable bulb that is part of the enema package and is inserted just inside the rectum and painlessly inflated when correctly positioned. If this newer equipment is not available, you will be expected to retain the contrast agent using rectal muscles alone for up to ten or fifteen minutes. While not painful, this may be uncomfortable, because in these circumstances the urge to empty the bowel is quite strong. PainX-ray studies are painless. However, if a contrast agent such as dye is needed, it may be injected into a vein, causing minor discomfort (see "Blood tests"). Some studies require positioning of the body that may be temporarily uncomfortable if, for example, you suffer from back pain. If you are having a barium enema, ask the technician to let you remove the nozzle of the enema yourself when the test is complete to reduce the chance of rectal discomfort.RecoveryIf you have had a study that required a contrast agent in the stomach, small intestine, or large intestine, you may experience gas, diarrhea, or constipation for one to three days afterward. Drinking large amounts of water will hasten the removal of the contrast agent from the digestive tract. If you have had a contrast agent injected, you may have a harmless and temporary discoloration of the urine or skin for several days afterward. If you are sensitive to iodine or have a thyroid condition, you may feel fatigue for several days after receiving an iodine-based contrast agent.RisksX-ray studies, if repeated over and over, may deliver enough radiation to body tissue to cause health problems later in life, such as lung, thyroid, or breast cancers. |
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