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 patient 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 a nearby set 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 only one organ other than lymph nodes, such as the lung. 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 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. One or more of these tests may be used to help determine the stage of Hodgkin disease.

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 that better outlines 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 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 moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in when the pictures are being taken. Doctors may advise medicine for some children to help keep them calm or even asleep during the test.

Spiral CT (also known as helical CT) is now available in many medical centers. This type of CT scan uses a faster machine. The scanner part of the machine rotates around the body continuously, allowing doctors to collect the images much more quickly than standard CT. This lowers the chance of blurred images occurring as a result of body movement. It also lowers the dose of radiation received during the test. The slices it images are thinner, which 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 to be 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 better see details. The 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, glucose (a form of sugar) containing a radioactive atom is injected into the blood. Because cancer cells in the body grow rapidly, they absorb large amounts of the radioactive sugar. A special camera can then create a picture of areas of radioactivity in the body.

PET scans can help tell if an enlarged lymph node contains Hodgkin disease or is benign. The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body.

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 glucose. PET scans can also be used after treatment in helping decide whether an enlarged lymph node still contains cancer or is merely scar tissue.

Recently, newer equipment has been developed that combines the PET scan with a CT scan. 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 can help pinpoint the exact location of the disease.

Gallium scan

During this test, the radiologist injects a small dose of radioactive gallium 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.

This test is not used as much now as in the past, because most doctors do a PET scan instead. It 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, 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 used to stage Hodgkin disease, but they 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 a more advanced Hodgkin disease. A high white blood cell count is another possible sign, although it can also be caused by infections.

Blood tests may also be done to check liver and kidney function and to look for signs that that cancer may have reached the bones.

Bone marrow aspiration and biopsy

If Hodgkin disease has been diagnosed, these tests may be done in some cases 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 usually 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 brief general anesthesia so they are asleep.

The samples are then viewed under a microscope to look for signs of Hodgkin disease.

Cotswold staging system

The staging system for Hodgkin disease 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 the lymph node(s) 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 nearby organs (IIIE), to the spleen (IIIS), or to both (IIIES).

Stage IV: The following means that the disease is 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 B symptoms are present:

• loss of more than 10% of body weight over the previous 6 months
• unexplained fever of at least 101.5°F
• drenching night sweats

These symptoms usually mean the disease is more advanced. If any of these is present, 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

The terms resistant or progressive disease are used when the disease does not go away or progresses 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.

Survival rates by stage

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Doctors often use 5-year survival rates as a standard way of discussing prognosis. Of course, many people live much longer than 5 years. Five-year relative survival rates, such as the numbers below, are adjusted in ways that exclude the impact of diseases other than cancer on survival. That is, people with Hodgkin disease who die of other causes are not counted

These numbers come from the National Cancer Institute's SEER database, looking at more than 11,000 people diagnosed with Hodgkin disease between 1988 and 2001. They are based on people who were initially treated several years ago. Advances in treatment since then mean that people diagnosed today may have a more favorable outlook than the numbers above.

It's important to keep in mind that these numbers are general statistics, and they may not apply to any one person's situation. Factors other than stage, including the prognostic factors listed below, also affect a person's outlook.

Other prognostic factors

Along with the stage, certain other factors tend to make the prognosis (outlook) more serious and may prompt the doctor to give more intensive treatment. These are:

• having B symptoms or bulky disease
• being male
• being older than 45
• having a high white blood cell 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

Last Medical Review: 07/21/2009
Last Revised: 07/21/2009