Once Hodgkin disease is diagnosed, tests will be done to determine the stage (extent of spread) of the disease. The treatment and prognosis (outlook) for a person with Hodgkin disease depend to some extent on both the type and the stage of the disease.
Hodgkin disease generally starts in one set of lymph nodes and spreads directly to another set nearby without skipping areas, at least until late in the disease. Invasion (growth) into nearby organs can sometimes occur as well. Rarely, Hodgkin disease will grow into just one organ other than lymph nodes, such as the lung. The current staging system is based on these facts.
Staging is based on:
- Your medical history (if you have certain symptoms)
- The physical exam
- Biopsies
- Imaging tests, which typically include a chest x-ray, CT scan of the chest/abdomen/pelvis, and PET scan
- Blood tests
- Bone marrow aspiration and biopsy (sometimes but not always done)
The medical history/physical exam and biopsies are discussed in the section, "How is Hodgkin disease diagnosed?"
Imaging tests used to stage Hodgkin disease
Imaging tests use x-rays, sound waves, magnetic fields, or radioactive particles to produce pictures of the inside of the body. Imaging tests may be done for a number of reasons after a diagnosis is made, including:
- To help determine the stage of the lymphoma
- To help determine if treatment has been effective
- To look for possible signs of cancer recurrence after treatment
Chest x-ray
Hodgkin disease often causes enlargement of lymph nodes in the chest, which can usually be seen on a plain chest x-ray.
Computed tomography (CT) scan
The CT scan is an x-ray test that produces detailed cross-sectional images of the body. Unlike a regular x-ray, CT scans can show the detail in soft tissues (such as internal organs). This scan can help tell if any lymph nodes or organs in your body are enlarged. CT scans are useful for looking for Hodgkin disease in the chest, abdomen, pelvis, and neck.
Instead of taking one picture like an x-ray, a CT scanner takes many pictures as it rotates around the patient. A computer combines these pictures into detailed images of the part of the body that is being studied.
Before the scan, the patient may be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye to better outline abnormal areas in the body. The patient may need an IV line through which the contrast dye is injected. The injection can cause some flushing (a feeling of warmth, especially in the face). Some people are allergic to the dye and get hives or a flushed feeling or, rarely, have more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you or your child has any allergies or has ever had a reaction to any contrast material used for x-rays.
CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. During the test, the table slides in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring when the pictures are being taken. Doctors may advise medicine for some children to help keep them calm or even asleep during the test. Many medical centers now use spiral CT (also known as helical CT), which completes the scan more quickly and also yields more detailed pictures.
In some cases, a CT can be used to guide a biopsy needle precisely into a suspicious area. For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table while a radiologist moves a biopsy needle through the skin and toward the location of the mass. CT scans are repeated until the needle is within the mass. A biopsy sample is then removed and looked at under a microscope.
Magnetic resonance imaging (MRI) scan
This test is rarely used in Hodgkin disease, but if your doctor is concerned about spread to the spinal cord or brain, MRI is very useful for looking at these areas.
Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material called gadolinium is often injected into a vein before the scan to produce better details. This contrast material usually does not cause allergic reactions.
MRI scans take longer than CT scans, often up to an hour. You may have to lie inside a narrow tube, which is confining and can be distressing to some people. Some children may need sedation. Newer, more open MRI machines may be another option. The MRI machine makes loud buzzing and clicking noises that you might find disturbing. Some places give you headphones or earplugs to help block this noise out.
Positron emission tomography (PET) scan
For a PET scan, a form of radioactive sugar (known as fluorodeoxyglucose or FDG) is injected into the blood. Because cancer cells in the body are growing quickly, they absorb large amounts of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body.
PET scans can help tell if an enlarged lymph node contains Hodgkin disease or is benign. It can also help spot small areas that might be lymphoma, even if the area looks normal on a CT scan.
PET scans are often used to tell if Hodgkin disease is responding to treatment. Some doctors will repeat the PET scan after 2 or 3 courses of chemotherapy. If it is working, the lymph nodes will no longer take up the radioactive sugar. PET scans can also be used after treatment in helping decide whether an enlarged lymph node still contains cancer or is just scar tissue.
In looking at patients with Hodgkin disease, a machine that combines the PET scan with a CT scan is often used. This allows the doctor to compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT. PET/CT scans often can help pinpoint the areas involved with lymphoma better than a CT alone.
Gallium scan
During this test, a small dose of radioactive gallium is injected into a vein. It is attracted to lymph tissue in the body. A few days later a special camera is used to detect the radioactivity, showing the location of the gallium. This test can find tumors that might be Hodgkin disease in lymph nodes and other organs.
Gallium scans are not used as much now as in the past, because most doctors do a PET scan instead. This test can still sometimes be useful in finding areas of lymphoma that the PET scan might miss. It can also help distinguish infections from lymphomas when the diagnosis is not clear.
Bone scan
A different radioactive substance (technetium) is used for bone scans. After it is injected into a vein, it travels to damaged areas of the bone. A special camera can then detect the radioactivity. Hodgkin disease sometimes causes bone damage, which may be picked up on a bone scan. But bone scans can't show the difference between cancers and non-cancerous problems, which means further tests might be needed.
This test is not usually done unless a person is having bone pain or has lab test results that suggest the Hodgkin disease may have reached the bones.
Other tests
Blood tests
Blood tests aren't part of the formal staging system for Hodgkin disease, but they can help your doctor get a sense of how advanced the disease is and how well you might tolerate certain treatments.
Hodgkin disease cells do not appear in the blood, but a complete blood count can sometimes reveal signs of Hodgkin disease. Anemia (not having enough red blood cells) can be a sign of more advanced Hodgkin disease. A high white blood cell count is another possible sign, although it can also be caused by infection. Another test called an erythrocyte sedimentation rate (ESR) can help measure how much inflammation is in the body.
Blood tests may also be done to check liver and kidney function and to look for signs that that cancer might have reached the bones.
Your doctor may also suggest other blood tests to look for signs of certain infections:
- HIV tests: if you have abnormal symptoms that might be related to HIV infection
- Hepatitis B virus tests: if your doctor plans on using a drug called rituximab (Rituxan) in your treatment, which could cause problems if you have this infection
Bone marrow aspiration and biopsy
If Hodgkin disease has been diagnosed, these tests may be done sometimes to tell if it is in the bone marrow. The bone marrow aspiration and biopsy are usually done at the same time. The samples are taken from the back of the pelvic (hip) bone, although in some cases they may be taken from the sternum (breast bone) or other bones.
In bone marrow aspiration, you lie on a table (either on your side or on your belly). After cleaning the skin over the hip, the doctor numbs the area and the surface of the bone by injecting a local anesthetic, which may cause a brief stinging or burning sensation. A thin, hollow needle is then inserted into the bone and a syringe is used to suck out a small amount of liquid bone marrow (about 1 teaspoon). Even with the anesthetic, most patients still have some brief pain when the marrow is removed.
A bone marrow biopsy is usually done just after the aspiration. A small piece of bone and marrow is removed with a slightly larger needle that is twisted as it is pushed down into the bone. The biopsy may also cause some brief pain. Once the biopsy is done, pressure will be applied to the site to help stop any bleeding.
Most children having a bone marrow aspiration and biopsy either receive medicine to make them drowsy or have general anesthesia so they are asleep.
The samples are then viewed under a microscope to look for signs of Hodgkin disease.
Tests of heart and lung function
These tests are not used to help stage Hodgkin disease, but they may be done if you are going to get certain chemotherapy drugs commonly used to treat Hodgkin disease that may affect the heart or the lungs.
- Your heart function may be checked with an echocardiogram (an ultrasound of the heart) or a MUGA scan.
- Your lung function may be checked with pulmonary function tests, in which you breathe into a tube connected to a machine.
Cotswold staging system
A staging system is a way for members of the cancer care team to summarize the extent of a cancer's spread. The staging system for Hodgkin disease (HD) is known as the Cotswold system, which is a modification of the older Ann Arbor system. It has 4 stages, labeled I, II, III, and IV.
If Hodgkin disease affects an organ outside of the lymph system but next to an affected lymph node, the letter "E" is added to the stage (for example, stage IE or IIE). If it involves the spleen, the letter "S" may be added.
Stage I: Either of the following means that the disease is stage I:
- HD is found in only 1 lymph node area or lymphoid organ such as the spleen (I).
- The cancer is found only in 1 area of a single organ outside the lymph system (IE).
Stage II: Either of the following means that the disease is stage II:
- HD is found in 2 or more lymph node areas on the same side of (above or below) the diaphragm — the muscle beneath the lungs that separates the chest and abdomen (II).
- The cancer extends locally from one lymph node area into a nearby organ (IIE).
Stage III: Either of the following means that the disease is stage III:
- HD is found in lymph node areas on both sides of (above and below) the diaphragm (III).
- The HD is in lymph nodes above and below the diaphragm, and has also spread to a nearby organ (IIIE), to the spleen (IIIS), or to both (IIIES).
Stage IV: HD has spread widely through 1 or more organs outside of the lymph system, such as liver, bone marrow, or lung. Cancer cells may or may not be found in nearby lymph nodes.
Other modifiers may also be used to describe the Hodgkin disease stage:
Bulky disease
This term is used to describe tumors in the chest that are at least ⅓ as wide as the chest, or tumors in other areas that are at least 10 centimeters (about 4 inches) across. It is usually designated by adding the letter "X" to the stage. Bulky disease may require more intensive treatment.
A vs. B
Each stage may also be assigned an A or B. The letter B is added (stage IIIB, for example) if any of the B symptoms listed below are present:
- Loss of more than 10% of body weight over the previous 6 months (without dieting)
- Unexplained fever of at least 101.5°F
- Drenching night sweats
These symptoms usually mean the disease is more advanced. If a person has any of these, then more intensive treatment is usually recommended. If no B symptoms are present, the letter A is added to the stage.
Resistant or recurrent Hodgkin disease
These terms are not part of the formal staging system, but doctors or nurses may use them to describe what is going on with the lymphoma in some cases.
The terms resistant or progressive disease are used when the disease does not go away or progresses (grows) while you are still being treated with initial therapy.
Recurrent or relapsed disease means that Hodgkin disease initially responded well to treatment and went away, but it has now come back. If Hodgkin disease returns, it may do so in the area of the body where it first started or in another part of the body. This may occur shortly after treatment or years later.
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