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Stages of Lymphoma

Posted on April 13, 2021
Medically reviewed by
Todd Gersten, M.D.
Article written by
Alison Channon

Lymphomas are cancers of the lymphatic system that are staged based on the spread of cancer cells. Lymphomas are split into two categories: Hodgkin lymphoma (HL, also called Hodgkin’s disease) and non-Hodgkin lymphoma (NHL). Most subtypes of HL and NHL can be assigned a stage from 1 to 4 depending on how advanced the cancer is. Stage 1 is the least advanced, while stage 4 is the most advanced. Staging is part of the diagnostic process and is important for determining the best treatment options.

Staging Tests for Hodgkin and Non-Hodgkin Lymphoma

After lymphoma is diagnosed, testing will determine the extent of the disease. Many of the same tests are used to stage Hodgkin lymphoma and non-Hodgkin lymphoma. Here are some common tests that assist doctors in determining lymphoma stages.

Imaging Tests

Imaging tests show doctors where cancer is present in the body. Imagining tests can determine how many lymph nodes or organs are affected and identify the location and size of tumors.

Computed Tomography (CT) Scan

CT scans are often performed where lymph nodes are present. A CT scan may also be used to identify any cancer in the lungs and liver.

Positron Emission Tomography-Computed Tomography (PET-CT) Scan

PET-CT scans produce highly detailed images that provide more information about the location of cancerous cells. They are considered to be the most sensitive imaging tests currently available. PET-CT scans are sometimes used to identify biopsy sites and after treatment to assess its effectiveness.

Other Tests

Chest X-rays have been used in the past to stage Hodgkin lymphoma, but they have mostly been replaced by CT scans. Magnetic resonance imaging (MRI) is sometimes used to assess if HL has spread to the brain or spinal cord. MRIs are also occasionally used to stage NHL.

Blood Tests

Blood tests can be used to determine if cancer is present in the blood. They can also be used to identify inflammation and other substances that indicate the stage of cancer. Your doctor may run several types of blood tests when staging your cancer and determining a treatment plan.

One commonly used test is a complete blood count (CBC). CBC tests are used for both HL and NHL. A CBC test can identify anemia and low numbers of platelets. A CBC may also indicate if cancer cells are present in the blood or bone marrow.

Bone Marrow Biopsy

Bone marrow biopsies can be used to stage HL and NHL. They are used to determine if cancer cells have spread to the bone marrow. The results of the biopsy will likely influence treatment decisions. Bone marrow biopsies are not usually used in early stage HL or NHL.

Staging Systems

Staging classification systems are used to describe how advanced, or widespread, a cancer is in the body. Staging numbers may sometimes appear as Roman numerals (stage I, stage II, and so on).

Lugano Classification

Hodgkin and non-Hodgkin lymphoma are often staged using the Lugano classification system. The Lugano classification was published in 2014 and provided updates to the Ann Arbor system, published in 1971. Stages 1 and 2 are considered limited stage, while stages 3 and 4 are considered advanced stage.

Stage 1

Stage 1 is localized. Lymphoma cells are only found in one lymph node region or in one organ outside the lymphatic system.

Stage 2

Stage 2 is slightly more widespread. In stage 2, two or more lymph nodes on the same side of the diaphragm are affected. Lymphomas can also be defined as stage 2 when cancer cells are found in a lymph node and a nearby organ on the same side of the diaphragm.

Stage 3

In stage 3, cancerous cells are found on both sides of the diaphragm. Lymphoma cells may be present in the spleen or an organ outside the lymphatic system.

Stage 4

Stage 4 indicates that cancer cells have spread throughout the body. In stage 4, lymphoma cells have spread to organs outside of the lymphatic system.

Other Stage Descriptors

Additional descriptors may be added to the stage number to further describe HL and NHL. These indicate the presence of symptoms, spread of disease, or size of tumors.

Some terms are used for both HL and NHL:

  • The words bulky or bulky disease can be added to a stage number to indicate the presence of a tumor of a certain size. The size threshold for bulky disease is different depending on the type of lymphoma. This designation is most important for stage 2 cancers because it may signal the need for more aggressive treatment.
  • When lymphoma cells have spread to organs outside the lymphatic system, the letter “E” for extranodal is added to the stage number — for example, stage 2E. This descriptor is only added to stages 1 and 2.

The following letters are only used for Hodgkin lymphoma:

  • “A” means no B symptoms (fever, night sweats, unexplained weight loss) are present.
  • “B” indicates that B symptoms are present. The presence of B symptoms may mean that more aggressive treatment is needed.

The presence of B symptoms in people with Hodgkin lymphoma can influence treatment in early stages. While B symptoms can also be present in non-Hodgkin lymphoma, they do not influence treatment decisions. Read more about staging Hodgkin lymphoma.

The letters listed below are used to further describe non-Hodgkin lymphoma under the Ann Arbor system. Some doctors may still use these letters to describe NHL.

  • “S” means cancer cells are present in the spleen.
  • “X” indicates the presence of a mass 10 centimeters or larger. This can be called bulky disease.

Other Staging Systems

Chronic lymphocytic leukemia/small-cell lymphocytic lymphoma (CLL/SLL), a type of non-Hodgkin lymphoma, is staged using the Rai system in the United States and the Binet system in Europe.

The Rai system divides CLL/SLL into five stages based on the presence of a certain type of lymphocyte (white blood cell) in the blood and bone marrow. The stages are numbered 0 through 4.

The Binet system stages CLL/SLL by the number of affected lymphoid tissue areas and by the presence of anemia or thrombocytopenia (too few platelets). The stages are A, B, and C.

Staging and Prognosis

Lymphoma stage influences prognosis. Generally speaking, earlier stage disease has a better prognosis than later stage disease. However, disease stage is not the only factor influencing prognosis. In the case of Hodgkin lymphoma, prognosis is also influenced by age, sex, blood cell counts, and other blood features.

The International Prognostic Index (IPI), used to assess outlook in NHL, considers five prognostic factors. In addition to cancer stage, the IPI considers age, a person’s ability to perform daily activities, whether lymphoma is present outside the lymphatic system, and blood tests.

Your oncologist can help you understand how your specific cancer type and stage, along with personal health factors and any risk factors, will influence your treatment and prognosis.

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Todd Gersten, M.D. is a hematologist-oncologist at the Florida Cancer Specialists & Research Institute in Wellington, Florida. Review provided by VeriMed Healthcare Network. Learn more about him here.
Alison Channon has nearly a decade of experience writing about chronic health conditions, mental health, and women's health. Learn more about her here.

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