Staging for Hodgkin disease
Once Hodgkin disease is diagnosed, tests will be done to figure out the stage (extent) of the disease. The treatment and prognosis (outlook) for a person with Hodgkin disease depend somewhat on both the type and the stage of the disease. If you have any questions about the stage of your lymphoma or how it affects your treatment, be sure to ask your doctor.
Hodgkin disease most often starts in one set of lymph nodes. If it spreads, it is usually to a nearby set of lymph nodes. It can sometimes grow into nearby organs, too.
Staging is based on the results from:
- Your medical history (symptoms)
- The physical exam
- Imaging tests, which often include a chest x-ray, CT scans, and a PET scan
- Blood tests
- Bone marrow aspiration and biopsy (sometimes but not always done)
Imaging tests used to stage Hodgkin disease
Imaging tests use different methods to make pictures of the inside of the body. One or more of these tests may be used to help look for tumors or enlarged lymph nodes, to learn the extent of the Hodgkin disease, to find out how well treatment is working, or to see if the cancer has come back after treatment.
Hodgkin disease often causes swelling of lymph nodes in the chest, which can often be seen on a plain chest x-ray.
Computed tomography (CT) scan
The CT scan uses x-rays to make detailed pictures inside the body. This test gives your doctor a better look at lymph nodes in the chest, belly (abdomen), and pelvis, as well as other organs.
A CT scanner has been described as a large donut, with a narrow table that slides in the middle “hole.” You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken. Doctors give some children medicine to help keep them calm or even asleep during the test.
Before the test, you or your child might be asked to drink a liquid or get an injection of a kind of dye to help better outline places in the body. 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 has ever had a reaction to any contrast used for x-rays.
CT-guided needle biopsy: In some cases, a CT can be used to guide a biopsy needle into an area of concern. You lie on the CT scanning table while a doctor moves a biopsy needle through the skin and toward the area. A biopsy sample is then removed to be looked at in the lab.
Magnetic resonance imaging (MRI) scan
This test is rarely used for Hodgkin disease, but if your doctor is concerned about spread to the spinal cord or brain, MRI is very useful for looking at these places.
MRI scans use radio waves and strong magnets instead of x-rays to make detailed pictures. A substance is often injected into a vein before the scan to better show details. It does not usually cause allergic reactions.
MRI scans take longer than CT scans – often up to an hour. You might have to lie inside a narrow tube, which can upset those who are afraid of enclosed spaces. Some children may need medicine to make them calm and sleepy. Newer, more open MRI machines might be another option.
Positron emission tomography (PET) scan
For a PET scan, a small amount of radioactive sugar is injected into the blood. This sugar collects in the cancer cells. A special camera can then pick up the radioactivity and show the areas of cancer in the body.
PET scans can help tell whether a swollen lymph node contains Hodgkin disease. They are also used to tell how well treatment is working. In looking at people with Hodgkin disease, a machine that combines the PET scan with a CT scan (known as a PET/CT scan) is often used. These scans can help pinpoint the exact place of the lymphoma better than a CT alone.
During this test, a small dose of radioactive gallium is injected into a vein. It goes to lymph tissue. A few days later a special camera is used to find the gallium.
This test can find tumors that might be Hodgkin disease in lymph nodes and other organs. But it is not used as much now as in the past because most doctors do a PET scan instead.
Hodgkin disease sometimes causes bone damage, which may be picked up on a bone scan. This test is not often done unless a person is having bone pain or has lab test results that suggest the Hodgkin disease may have reached the bones.
A radioactive substance is also used for bone scans. After it is injected, it travels to damaged areas of the bone. A special camera can then spot it.
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 do with certain treatments.
Hodgkin disease cells do not show up in the blood, but a complete blood count (CBC) can sometimes show signs of the disease. This test measures the levels of different cells in the blood. A shortage of red blood cells (called anemia) can be a sign of more advanced Hodgkin disease. A high white blood cell count is another sign, although it can also be caused by infections.
Blood tests might also be done to check how well the liver and kidneys are working, to look for signs that that cancer may have reached the bones, and to look for signs of certain infections.
Bone marrow biopsy and aspiration
If a person has Hodgkin disease, these tests are sometimes done to tell if the cancer is in the bone marrow. Often both are done at the same time from the back of the hip bone or, in some cases, from the breast bone (sternum), or other bones. A long thin needle is used to remove small bits of bone marrow. A piece of bone might also be removed with a thicker needle. The area is numbed first. But even with numbing, most people still feel some brief pain. The whole process takes only a few minutes. The samples are then checked for signs of Hodgkin disease.
Most children having these tests either get drugs to make them drowsy or have general anesthesia so they are asleep.
Tests of heart and lung function
These tests are not used to help stage Hodgkin disease, but they may be done if certain chemo drugs that could affect the heart or the lungs are going to be used.
- Heart function may be checked with an echocardiogram (an ultrasound of the heart) or a MUGA scan.
- Lung function may be checked with pulmonary function tests, in which you breathe into a machine through a tube.
Cotswold staging system
A staging system is a way for members of the cancer care team to describe the extent of a cancer’s spread. The staging system for Hodgkin disease is known as the Cotswold system. It has 4 stages, labeled with the Roman numerals I, II, III, and IV. The higher the number, the more advanced the disease. If Hodgkin disease affects an organ outside of the lymph system, the letter E is added to the stage. If it affects the spleen, the letter S is added.
This term is used to describe tumors in the chest that are at least ⅓ as wide as the chest or tumors in other places that are at least 4 inches (10 centimeters) across. If bulky disease is present the letter X is added to the stage. Bulky disease may need more intense treatment.
A vs. B
Each stage may also be assigned an A or B. The letter A is added if the person doesn’t have certain symptoms that can be caused by Hodgkin disease. The letter B is added if they have any of these symptoms:
- Loss of more than 10% of body weight over the past 6 months (without dieting)
- Fever of 100.4°F or greater for an unknown reason
- Drenching night sweats
If a person has any of these B symptoms, more intense treatment is usually recommended.
Resistant or recurrent Hodgkin disease
These terms are not part of the formal staging system, but doctors or nurses might use them sometimes to describe what is going on with the disease.
The terms resistant or progressive disease are used when the disease does not go away or keeps growing while you are first being treated.
Recurrent or relapsed disease means that Hodgkin disease went away at first with treatment, but now has come back. If Hodgkin disease returns, it may be in the same place where it started or in another part of the body. This could happen shortly after treatment or years later.
Other factors that can affect outlook
Certain factors, if present, no matter what the stage, tend to make the outlook more serious, so the doctor might want to use more intense treatment. These include:
- Having B symptoms or bulky disease
- Being male
- Being older than 45
- Having a high white blood cell count
- Having a low red blood cell count
- Having a low blood lymphocyte count
- Having a low blood albumin level
- Having a high blood ESR level
Last Medical Review: 08/19/2014
Last Revised: 08/27/2014