⚠ DIAGNOSTIC PHASE — TREATMENT PLAN NOT YET APPLICABLEDIAGNOSTIC PHASE — TREATMENT PLAN NOT YET APPLICABLE. Histology required before any therapy discussion (CHARTER §15.2 C7).
Patient
PZ-DIAG-LAD-001 · suspicion lineage: lymphadenopathy_workup
Tissues: lymph_node · Hypotheses: DIS-CHL, DIS-DLBCL-NOS, DIS-FL, reactive_lymphadenopathy
35F nurse presents with persistent palpable_lymph_node bilateral cervical chains (left 1.8 cm, right 2.2 cm) + right axillary node 1.5 cm × 7 weeks. No tenderness. No B-symptoms (no fevers, night sweats <1 episode/wk only, weight stable). No recent infections, no animal/tick exposures, no foreign travel. CBC normal, ESR mildly elevated 38, LDH normal. Mono spot negative, EBV / CMV serologies pending. CT neck/chest/abd: bilateral cervical + right axillary lymphadenopathy + small mediastinal nodes 8-10 mm. No splenomegaly. No primary malignancy identified on imaging. Lymphadenitis vs reactive vs early lymphoma vs metastatic carcinoma — needs excisional biopsy of largest cervical node for histology before further workup.
Matched workup: WORKUP-LYMPHADENOPATHY-NONSPECIFIC · Очікуваний термін: ~21 дnoв
Workup steps (16)
- 1lab Complete Blood Count with Differential
Baseline cytopenia assessment and ongoing monitoring of myelosuppression.
- 2lab Peripheral Blood Smear (manual review)
Морфологія еритроцитів, лейкоцитів, тромбоцитів — детекція бластів, dysplasia, schistocytes, abnormal lymphoid forms; обов'язково при будь-якій незрозумілій цитопеnoї або leukocytosis.
- 3lab Comprehensive Metabolic Panel
Електроліти (Na, K, Cl, HCO3), креатиnoн + BUN (renal function), глюкоза, кальцій, альбумін, total protein. Базова метаболічна оцінка перед будь-якою терапією + основа TLS risk + dosing adjustments.
- 4lab Liver Function Tests
Assess hepatic function — baseline + during BR cycles + DAA therapy + HBV reactivation monitoring.
- 5lab Lactate Dehydrogenase
Tumor burden surrogate; rising LDH suggests transformation or progression in indolent lymphoma.
- 6lab ESR + C-Reactive Protein
Markers of systemic inflammation. У гематологічному workup: differential diagnosis запальних vs neoplastic причин лімфаденопатії; ESR > 100 mm/h при myeloma / advanced lymphoma.
- 7lab HIV Serology (HIV-1/2 Ab + p24)
Mandatory baseline для будь-якого пацієнта з лімфомою (HIV-associated lymphomas — DLBCL, Burkitt, primary CNS), цитопеnoями неknownго генезу. Впливає на treatment intensity + ART continuation.
- 8lab Hepatitis B Serology Panel
Mandatory before any anti-CD20 therapy or rituximab-containing regimen — identify HBV reactivation risk.
- 9lab HCV Antibody (Anti-HCV)
Скриnoнг на HCV. Якщо позитивний → confirm з HCV RNA quantitative (TEST-HCV-RNA). Mandatory для лімфомного workup (HCV-associated MZL, B-cell lymphomas) і перед anti-CD20.
- 10lab CMV Serology (IgG + IgM)
Baseline CMV status — критично перед alloHSCT planning, важливо для immunocompromised patient management. У standard hematology workup — recommended перед CD20-depleting therapy.
- 11lab EBV Serology (VCA IgG/IgM, EBNA, EA)
EBV-driven lymphomas (Burkitt, classical Hodgkin, post-transplant LPD); yesож relevant перед alloHSCT. EBER-ISH on tissue — окремий test.
- 12imaging Contrast-Enhanced CT Chest/Abdomen/Pelvis
Initial staging imaging для більшості hematologic malignancies — лімфаденопатія mapping, organomegaly, extranodal involvement. Часто replaced by PET-CT для definitive lymphoma staging, але CECT доступnoша для початкового workup.
- 13histology Excisional Lymph Node Biopsy
Preferred biopsy для будь-якого suspect lymphoma — preserves nodal architecture (critical для subtyping per WHO Classification). Provides material для histology + IHC + flow + cytogenetics + molecular.
- 14histology Flow Cytometry (Immunophenotyping)
Immunophenotypic characterization of leukocytes — discriminates lymphoid vs myeloid lineage, B vs T vs NK, mature vs immature, monoclonal vs reactive. Mandatory у acute leukemia + lymphoma + MDS + MPN workup.
- 15histology CD20 Immunohistochemistry
Confirm B-cell lineage and rituximab/obinutuzumab eligibility.
- 16histology Tissue biopsy + IHC panel + ancillary molecular
Більшість локалізованої лімфаденопатії — реактивна (особливо cervical у young patients). Biopsy criteria: size > 1.5 cm, persistence > 4-6 weeks, atypical location (supraclavicular, mediastinal, generalized), B-симптоми, abnormal CBC/LDH. Modern triage для cervical / supraclavicular nodes коли differential включає carcinoma metastasis — FNA-first з WHO-LNSC categorization (5-tier: Inadequate / Benign / Atypical / Suspicious / Malignant); категорія drives next-step decision. Якщо lymphoma вже leading hypothesis (B-symptoms + atypical lab profile + axillary/inguinal/ generalized LAD) — excisional залишається preferred (architectural pattern + adequate IHC + FISH material).
Biopsy preferred: Excisional biopsy if LN persistent > 4-6 weeks AND size > 1.5 cm AND lymphoma is leading hypothesis (atypical location, B-symptoms, abnormal CBC/LDH)
Питання що мають бути закриті (7)
- Реактивна vs неоплазма?
- Якщо неоплазма — лімфома vs metastatic carcinoma vs інше?
- Якщо проводилась FNA — WHO-LNSC категорія (Inadequate / Benign / Atypical / Suspicious / Malignant)? Category визначає escalation.
- Якщо лімфома — escalate до WORKUP-SUSPECTED-LYMPHOMA з повним staging?
- Інфекційна causes виключена (TB, syphilis, brucellosis, toxoplasmosis якщо географічно relevant)?
- Drug-induced lymphadenopathy виключена (phenytoin, allopurinol, etc.)?
- Autoimmune / connective tissue disease виключена (ANA, etc. якщо clinical features)?
MDT brief
Discussion questions (1, 0 blocking)
DQ-DIFFERENTIAL
What is the differential diagnosis plan between hypotheses: DIS-CHL, DIS-DLBCL-NOS, DIS-FL, reactive_lymphadenopathy? Which molecular / IHC tests differentiate them?
Multiple hypotheses — must be differentiated before treatment discussion.
→ pathologist
MDT talk tree (2 steps)
| # | Owner | Topic | Action |
|---|
| 1 | pathologist | Pathology confirmation | What is the differential diagnosis plan between hypotheses: DIS-CHL, DIS-DLBCL-NOS, DIS-FL, reactive_lymphadenopathy? Which molecular / IHC tests differentiate them? |
| 2 | radiologist | Specialist review | Stage / restaging imaging + biopsy guidance — radiologist. |
Skills (required) — mandatory virtual specialists (2)
- Pathologist (general) required
Any suspicion requires biopsy — pathologist plans site selection, IHC panel, ancillary tests.
Owns: DQ-DIFFERENTIAL
- Radiologist required
Stage / restaging imaging + biopsy guidance — radiologist.
Technical MDT skill metadata (2/16 activated in this plan)
All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).
| Specialist | skill_id | Version | Last reviewed | Sign-offs | Domain |
|---|
| Cellular therapy specialist (CAR-T) | cellular_therapy_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
| Clinical pharmacist | clinical_pharmacist | v0.1.0 | 2026-04-25 | 0 | clinical_pharmacy |
| Hematologist / oncohematologist | hematologist | v0.1.0 | 2026-04-25 | 0 | hematology_oncology |
| Hematopathologist (lymphoma / leukemia / myeloma) | hematopathologist | v0.1.0 | 2026-04-25 | 0 | hematopathology |
| Infectious disease / hepatology | infectious_disease_hepatology | v0.1.0 | 2026-04-25 | 0 | infectious_diseases |
| Medical oncologist (solid-tumor chemotherapist) | medical_oncologist | v0.1.0 | 2026-04-25 | 0 | solid_oncology |
| Molecular geneticist / molecular oncologist | molecular_geneticist | v0.1.0 | 2026-04-25 | 0 | molecular_oncology |
| Palliative care | palliative_care | v0.1.0 | 2026-04-25 | 0 | palliative_care |
| Pathologist (general) | pathologist | v0.1.0 | 2026-04-25 | 0 | pathology |
| Primary care / family physician | primary_care | v0.1.0 | 2026-04-25 | 0 | primary_care |
| Psycho-oncologist | psychologist | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Radiation oncologist | radiation_oncologist | v0.1.0 | 2026-04-25 | 0 | radiation_oncology |
| Radiologist | radiologist | v0.1.0 | 2026-04-25 | 0 | diagnostic_imaging |
| Social worker / case manager | social_worker_case_manager | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Surgical oncologist | surgical_oncologist | v0.1.0 | 2026-04-25 | 0 | surgical_oncology |
| Transplant specialist (BMT) | transplant_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |