Hodgkin lymphoma (HL) can occur in different locations within the body. It often develops within lymph nodes — small glands that filter out foreign substances like germs. As the lymphoma becomes more advanced, it may spread to other organs or to other sets of lymph nodes. Doctors describe how far the lymphoma cells have spread by assigning a stage. The stage is used to recommend treatments and estimate outlook.

Measuring Hodgkin Lymphoma Stages

Doctors use a variety of tests when determining a person’s lymphoma stage. Among the most important are imaging tests, such as positron emission tomography (PET) scans and computed tomography (CT) scans. These tests can help doctors find cancer cells located in other parts of the body and identify enlarged lymph nodes, allowing them to see where lymphoma has spread.

Doctors consider other information when staging HL, including a person’s symptoms. Gathering this information entails using other diagnostic tests, such as:

• Physical exams
• Lymph node biopsy (removal of a small piece of tissue)
• Bone marrow aspiration (removal of fluid from the bone marrow)
• Bone marrow biopsy (removal of bone and cells from the bone marrow)

Staging for Hodgkin Lymphoma

Doctors use staging systems to assign lymphoma stages. Originally, doctors used the Ann Arbor staging system, developed in 1971. Now, many doctors have switched to the Lugano classification system, which was adapted from the Ann Arbor system. Lugano classification is also used to stage non-Hodgkin lymphoma.

There are four Hodgkin lymphoma stages. The stage describes which parts of the lymphatic system are affected. The lymphatic system is a part of the immune system and includes lymph nodes, lymph vessels, and several different organs. The system helps the body fight infection and get rid of waste. The higher a lymphoma’s stage, the further the disease has spread to different parts of the lymphatic system or to other tissues outside the system.

Stage 1 Hodgkin Lymphoma

Stage 1 lymphoma (also written as stage I) is diagnosed when cancer cells are only found in one area of the body. Lymphoma cells may be found in:

• One lymph node
• Multiple nodes within one group of lymph nodes
• One lymphatic system organ, such as the thymus
• One small area within one organ or tissue outside of the lymphatic system

Stage 2 Hodgkin Lymphoma

People with stage 2 (stage II) HL have lymphoma cells in multiple nearby locations. In many cases, people with stage 2 disease have cancer in two or more groups of lymph nodes on the same side of the body. The body is divided by a thin muscle called the diaphragm that sits underneath the lungs. Stage 2 Hodgkin lymphoma may affect multiple lymph node regions on the top half of the body, such as in the chest or neck. Alternatively, people are diagnosed with stage 2 disease if they have cancer in multiple groups of lymph nodes in the lower part of the abdomen.

Doctors will also diagnose stage 2 HL if they find lymphoma cells in a group of lymph nodes and in a nearby organ. Both the nodes and the organ are on the same side of the diaphragm.

Stage 3 Hodgkin Lymphoma

In stage 3 (stage III) Hodgkin lymphoma, cancer cells have spread further within the body. They are found in multiple lymph node areas on both sides of the diaphragm. A person may also be diagnosed with stage 3 disease if they have cancer in lymph nodes above the diaphragm and in the spleen.

Stage 4 Hodgkin Lymphoma

Stage 4 (stage IV) Hodgkin lymphoma has spread outside of the lymphatic system. People who have stage 4 lymphoma have cancer cells found throughout one or more organs like the bone marrow, lungs, or liver.

Other Ways of Describing Hodgkin Lymphoma Stage

Sometimes, doctors may add a letter to the end of the disease stage (e.g., stage 2E). Each of these letters has a different meaning that further describes the instance of cancer:

• B — The person has a set of symptoms called B symptoms, which includes fever, night sweats, and weight loss.
• A — The person does not have any B symptoms.
• E — The lymphoma is extranodal, meaning that it can be found in tissues or organs outside of the lymphatic system.
• S — There are lymphoma cells in the spleen.
• X — The person has “bulky” disease. This means they have tumors in the chest at least a third as large as the chest, or that they have tumors in other locations that are larger than 10 centimeters (about 4 inches).

How Does Staging Affect Treatment Options?

Doctors use a person’s lymphoma stage as one factor in making treatment decisions. Doctors will also consider the type of lymphoma a person has, as well as their age, general health, personal preferences, and signs and symptoms.

Treating Early-Stage Hodgkin Lymphoma

Doctors consider stage 1 and stage 2 HL to be early-stage disease. Different treatment decisions may be made depending on whether the lymphoma is “favorable” or “unfavorable.” Favorable Hodgkin lymphoma is unlikely to relapse (come back after being treated). Unfavorable lymphoma, on the other hand, has a higher chance of relapsing.

Doctors use several factors to determine whether or not an instance of lymphoma is favorable. Factors that increase the chances lymphoma will return include:

• Bulky disease
• Lymphoma cells in three or more groups of lymph nodes
• B symptoms
• Lymphoma cells outside of the lymph nodes, in other organs
• High sedimentation rate (red blood cells quickly sink to the bottom of a test tube), which can be a sign of inflammation

Early-stage, favorable Hodgkin lymphoma can be managed with less aggressive treatments. People in this group typically undergo chemotherapy, radiation therapy, or both. Those who have early-stage, unfavorable HL often receive more intense treatments, such as stronger chemotherapy drugs or additional rounds of chemotherapy. People also often receive radiation treatments.

If a person’s lymphoma is resistant to treatment, they may choose other options, such as stronger chemotherapy drugs, immunotherapy, or a stem cell transplant.

Treating Advanced-Stage Hodgkin Lymphoma

Doctors use a different set of risk factors to determine the likelihood that stage 3 or stage 4 Hodgkin lymphoma will return. These factors include:

• Being male
• Being at least 45 years old
• Having low levels of albumin protein in the blood
• Having low levels of hemoglobin in the blood
• Having high white blood cell levels
• Having low levels of lymphocytes (a type of white blood cell)

Doctors typically recommend a more aggressive treatment plan for stage 3 and stage 4 Hodgkin lymphoma. Most people with advanced-stage Hodgkin lymphoma receive several rounds of intense chemotherapy. Radiation therapy is often used to treat larger tumors. As is the case with early-stage tumors, lymphoma that is resistant to therapy may be treated with immunotherapy drugs or with a stem cell transplant.

How Does Staging Affect Prognosis?

In general, people with early-stage disease have a better prognosis (outlook) than those with advanced lymphoma. However, even stage 4 Hodgkin lymphoma can be cured — treatments may help the lymphoma go away and not come back.

The prognosis for people with Hodgkin lymphoma is measured using a five year relative survival rate. This number is a comparison between people with and without a particular cancer. The overall five year relative survival for everyone with HL is 88.3 percent. This means that those with Hodgkin lymphoma are about 88.3 percent as likely to live for five years or more after diagnosis compared to people without Hodgkin lymphoma. This survival rate changes by stage:

• Stage 1 — 92.2 percent
• Stage 2 — 94.3 percent
• Stage 3 — 85.5 percent
• Stage 4 — 78.5 percent

These numbers were calculated using information from people who were diagnosed between 2011 and 2017. Survival rates are constantly improving, so people diagnosed with Hodgkin lymphoma today may have an even better outlook.

Talk With Others Who Understand

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