Lymphoma is a type of cancer that affects the lymphatic system, which is part of the body's immune system. Lymphoma is grouped into two main types: Hodgkin lymphoma (previously called Hodgkin’s disease) and non-Hodgkin lymphoma (NHL). Both types are divided into stages, from stage 1 to stage 4, based on how much the cancer has spread. Stage 1 means the cancer is in its early stages, while stage 4 means it is more advanced. (Stages are sometimes rendered with Roman numerals, e.g., “stage III” instead of “stage 3.”)

Staging is an important part of diagnosing lymphoma, as it helps doctors determine the extent of the disease and guide treatment decisions. In this article, we’ll explore the different stages of lymphoma, how they are determined, and how they differ from one another.

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 and non-Hodgkin lymphoma. Doctors commonly use imaging tests, blood tests, and bone marrow biopsies to determine lymphoma stages.

Imaging Tests

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

Computed Tomography

Computed tomography (CT) scans help doctors assess areas where lymph nodes and other organs may be affected by lymphoma. A CT scan may also be used to look for cancer in the lungs and liver.

Positron Emission Tomography-Computed Tomography

Positron emission tomography (PET)-CT scans produce highly detailed images that provide more information about the location of cancerous cells. These scans are considered the most sensitive imaging tests currently available. PET-CT scans are sometimes used to identify biopsy sites and can also help monitor treatment response in certain lymphomas.

Other Imaging Tests

Chest X-rays were used in the past to stage Hodgkin lymphoma but mostly have been replaced by CT scans. Magnetic resonance imaging (MRI) is sometimes used to see if Hodgkin lymphoma has spread to the brain or spinal cord. MRI may occasionally be used to stage NHL.

Blood Tests

Blood tests may reveal abnormal cells 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 coming up with a treatment plan.

One common test is a complete blood count (CBC), which is used for both Hodgkin lymphoma and NHL. A CBC test can identify anemia (low red blood cell count) and thrombocytopenia (low platelet count). It can also indicate if cancer cells are present in the blood or bone marrow.

Bone Marrow Biopsy

Bone marrow biopsies, which can be used to stage Hodgkin and non-Hodgkin lymphoma, help determine if cancer cells have spread to the bone marrow. The results will likely influence treatment decisions. Bone marrow biopsies aren’t usually used in early stages for Hodgkin lymphoma but may be for NHL, depending on the subtype.

Staging Systems

Staging classification systems describe how advanced, or widespread, a cancer is in the body. There are multiple staging systems used for lymphoma, with the choice of system often depending on the type of lymphoma and other factors like whether the cancer affects the lymph nodes, organs, or bone marrow.

Lugano Classification

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

Stage 1

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

Stage 2

Stage 2 is slightly more widespread, affecting two or more lymph nodes on the same side of the diaphragm. 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. At this stage, lymphoma cells have spread to organs outside the lymphatic system.

Additional Stage Descriptors

Other designations may be added to the stage number to further describe Hodgkin and non-Hodgkin lymphoma. These descriptors indicate the presence of symptoms, spread of disease, or size of tumors.

Some terms are used for both Hodgkin lymphoma and NHL:

• The letter X indicates bulky or bulky disease, or the presence of a tumor of a certain size. The size threshold for bulky disease differs 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.
• The letter E for “extranodal” means lymphoma cells have spread to organs outside the lymphatic system — for example, stage 2E. This descriptor is added only to stages 1 and 2.

Including X and E is known as the Cotswolds modification of the original Ann Arbor staging system.

The following letters are used only for Hodgkin lymphoma:

• A — No B symptoms (fever, night sweats, unexplained weight loss) are present.
• B — B symptoms are present, which may mean that more aggressive Hodgkin lymphoma treatment is needed.

The presence of B symptoms in people with Hodgkin lymphoma can influence treatment in early stages. Although B symptoms can be present in non-Hodgkin lymphoma, they don’t guide NHL treatment decisions.

These letters further describe non-Hodgkin lymphoma under the Ann Arbor system and may still be used by some doctors:

• S — Cancer cells are present in the spleen.
• X — A mass is 10 centimeters or larger. This can be called bulky disease.

Other Staging Systems

Chronic lymphocytic leukemia/small 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 the presence of anemia or thrombocytopenia. The stages are A, B, and C.

Staging and Prognosis

Lymphoma stage influences prognosis (outlook). Generally, earlier-stage disease has a better prognosis than later-stage disease. However, disease stage isn’t the only factor influencing prognosis. In the case of Hodgkin lymphoma, age, sex, blood cell counts, and other blood features also affect prognosis.

The International Prognostic Index, which is used to assess outlook in NHL, considers five prognostic factors:

• Cancer stage
• The person’s age
• The person’s ability to perform daily activities
• Presence of lymphoma outside the lymphatic system
• Blood test results

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.

Talk With Others Who Understand

MyLymphomaTeam is the social network for people with lymphoma and their loved ones. On MyLymphomaTeam, more than 19,000 members come together to ask questions, give advice, and share their stories with others who understand life with Hodgkin lymphoma.

Are you or someone you care for living with Hodgkin lymphoma? What was the process of staging like? Share your experience in the comments below, or start a conversation by posting on your Activities page.