Once Hodgkin disease is diagnosed, tests will be done to figure out the stage of the disease. The treatment and prognosis (outlook) for a patient with Hodgkin disease depend on both the type and the stage of the disease. Staging is the process of finding out how far the cancer has spread.

Hodgkin disease most often starts in one set of lymph nodes and then spreads to a nearby set without skipping areas, at least until late in the disease. Growth into nearby organs can sometimes happen too. The current staging system is based on these facts.

Staging is based on the results from:

• the history and physical exam
• biopsies
• imaging tests, which typically include a chest x-ray, CT scans, and a PET scan
• blood tests
• bone marrow aspiration and biopsy (this is not always done)

If a biopsy has confirmed that Hodgkin disease is present, the next step is staging. This includes taking a medical history, doing a physical exam, and then doing imaging studies.

Imaging tests used to stage Hodgkin disease

One or more of the following tests may be used to help learn the extent of the Hodgkin disease.

Chest x-ray: 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: This test gives your doctor a better look at lymph nodes in the chest, belly (abdomen), and pelvis, as well as other organs. The CT scan is like an x-ray but 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 an image of a "slice" of the body.

Often after the first set of pictures is taken, you or your child may be asked to drink a liquid or get an intravenous (IV) injection of a kind of dye that helps better outline places in the body. A second set of CT scan pictures is then taken. 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 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. You might feel a bit confined by the ring you have to lie in when the pictures are being taken. Doctors may use medicine for some children to help keep them calm or even asleep during the test.

Magnetic resonance imaging (MRI): 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. MRI scans use radio waves and strong magnets instead of x-rays to take pictures. 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 upset people with a fear of enclosed spaces.

Positron emission tomography (PET): PET scans involve injecting a form of sugar that contains a small amount of radioactivity 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 an swollen lymph node contains Hodgkin disease. They are also used to tell how well treatment is working. Lately, newer machines combine the PET scan with a CT scan. PET/CT scans can help pinpoint the exact location of the lymphoma.

Gallium scan: During this test, a small dose of radioactive gallium is injected into a vein. It goes to lymph tissue in the body. 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 is not used as much now as in the past, because most doctors do a PET scan instead.

Bone scan: 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. 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.

Other tests

Blood tests: Blood tests aren't used to stage Hodgkin disease, but they may be useful in getting a sense of how advanced the disease is and how well a person 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. 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 of liver and kidney function might also point to Hodgkin disease in that organ.

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. Both are most often done at the same time from the back of the hip bone. 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 the numbing, many people feel some pain. The whole process takes only a few minutes.

Cotswold staging system

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 is. If Hodgkin disease affects an organ outside of the lymph system but is next to an affected lymph node, the letter "E" is added to the stage. If it involves the spleen, the letter "S" is added.

"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 4 inches 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 any of these B symptoms are present:

• loss of more than 10% of body weight over the past 6 months
• fever of 101.5°F or greater without any known cause (except the Hodgkin disease)
• drenching night sweats

If any of these is present, more intense treatment is usually recommended.

Resistant and recurrent Hodgkin disease

The terms resistant or progressive disease are used when the disease does not go away or keeps on growing while you are first being treated. Recurrent or relapsed disease means that Hodgkin disease responded well to treatment at first and went away, but it has now come back. If Hodgkin disease returns, it may do so in the place where it first started or in another part of the body. This may happen shortly after treatment or years later.

Other factors

Certain factors, if present, no matter what the stage, tend to make the outlook (prognosis) more serious and often cause the doctor to use more intense treatment. These are:

• having B symptoms or bulky disease
• being male
• age over 45
• having a high white blood cell (WBC) count (above 15,000)
• having a low red blood cell count (hemoglobin level below 10.5)
• having a low blood lymphocyte count (below 600)
• having a low blood albumin level

Survival rates of Hodgkin disease

The 5-year relative survival rate refers to the percentage of patients who live at least 5 years after their cancer is found. Many of these patients live longer than 5 years. Five-year relative survival rates don't count people who die of something other than the cancer. These rates are based on people who were first treated several years ago. Advances in treatment since then mean that people diagnosed today may have a better outlook than the numbers listed here.

While statistics provide an overall picture, keep in mind that every person is unique and the numbers can't predict exactly what will happen in your case.

Last Medical Review: 08/06/2009
Last Revised: 08/06/2009