How Is Hodgkin Disease Staged?

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. 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 generally starts in the lymph nodes. If it spreads, it is usually to another set of nearby lymph nodes. It can invade (grow into) nearby organs as well. Rarely, Hodgkin disease will start in an organ other than lymph nodes, such as a lung.

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 (computed tomography) scan of the chest/abdomen/pelvis, and PET (positron emission tomography) scan
  • Blood tests
  • Bone marrow aspiration and biopsy (sometimes but not always done)

The medical history/physical exam and biopsies are discussed in 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 make pictures of the inside of the body. Imaging tests may be done for a number of reasons, including:

  • To look for possible causes of certain symptoms, such as enlarged lymph nodes in the chest
  • To help determine the stage of Hodgkin disease
  • To help show if treatment is working
  • To look for possible signs of cancer coming back after treatment

Chest x-ray

Hodgkin disease often enlarges lymph nodes in the chest, which can usually be seen on a plain chest x-ray.

Computed tomography (CT) scan

The CT scan uses x-rays to make 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 neck, chest, abdomen, and pelvis.

Before the test, you might 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. You might 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.

A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and some people 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.

CT-guided needle biopsy: A CT scan can also be used to guide a biopsy needle into a suspicious area. For this procedure, a person lies on the CT scanning table while the doctor moves a biopsy needle through the skin and toward the area. CT scans are repeated until the needle is in the right place. A biopsy sample is then removed and sent to the lab to be looked at under a microscope.

Magnetic resonance imaging (MRI) scan

This test is rarely used in Hodgkin disease, but if the 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 make detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. A contrast material called gadolinium is often injected into a vein before the scan to show details better. This contrast material usually does not 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 is confining and can be distressing to some people. Some children might need sedation. Newer, more open MRI machines might be another option. The MRI machine makes loud buzzing and clicking noises that some people 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. The amount of radioactivity used is very low and will pass out of the body within a day or so. Because cancer cells in the body are growing quickly, they absorb large amounts of the sugar. You then lie a table in the PET scanner for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not detailed like a CT or MRI scan, but it can provide helpful information about your whole body.

PET scans can be used for many reasons in a person with Hodgkin disease:

  • They can help show if an enlarged lymph node contains Hodgkin disease.
  • They can help spot small areas in the body that might be lymphoma, even if the area looks normal on a CT scan.
  • They can help tell if Hodgkin disease is responding to treatment. Some doctors will repeat the PET scan after a few courses of chemotherapy. If it is working, the lymph nodes will no longer take up the radioactive sugar.
  • They can be used after treatment in helping decide whether an enlarged lymph node still contains cancer or is just scar tissue.

Doctors often use a machine that combines the PET scan with a CT scan (known as a PET/CT scan). This lets the doctor 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 of lymphoma better than a CT alone.

Gallium scan

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 tell infections from lymphomas when the diagnosis is not clear.

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.

Bone scan

This test is not usually done unless a person is having bone pain or has lab test results that suggest the Hodgkin disease might have reached the bones.

A different radioactive substance (technetium) is used for a bone scan. 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, so further tests might be needed.

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.

The complete blood count (CBC) is a test that measures the levels of different cells in the blood. Hodgkin disease cells don’t show up in the blood, but a CBC can sometimes reveal signs of Hodgkin disease. For example, 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. It can be elevated in some people with Hodgkin disease.

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

Your doctor might also suggest other blood tests to look for signs of certain infections:

  • HIV test: if you have abnormal symptoms that might be related to HIV infection
  • Hepatitis B virus test: if your doctor plans on using the drug 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 are done sometimes to tell if it has reached 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 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. 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 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 sent to a lab, where they are 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 might be done if certain chemotherapy 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 tube connected to a machine.

Cotswold staging system

A staging system is a way for the cancer care team to sum up the extent of a cancer’s spread. 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, the letter E is added to the stage (for example, stage IE or IIE). If it involves the spleen, the letter S is added.

Stage I: Either of the following means that the disease is stage I:

  • Hodgkin disease is found in only 1 lymph node area or lymphoid organ such as the thymus (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:

  • Hodgkin disease 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:

  • Hodgkin disease is found in lymph node areas on both sides of (above and below) the diaphragm (III).
  • Hodgkin disease 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: Any of the following means that the disease is stage IV:

  • Hodgkin disease has spread widely through 1 or more organs outside of the lymph system. Cancer cells may or may not be found in nearby lymph nodes.
  • Hodgkin disease is found in organs in 2 distant parts of the body (and not in nearby lymph nodes).
  • Hodgkin disease is in the liver, bone marrow, lungs (other than by growing there directly from another site), or cerebrospinal fluid (the liquid that surrounds the brain and spinal cord).

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 labeled by adding the letter X to the stage. Bulky disease may require more intensive treatment.

A vs. B

Each stage may also be assigned a letter (A or B). B is added (stage IIIB, for example) if a person has any of these “B symptoms”:

  • Loss of more than 10% of body weight over the previous 6 months (without dieting)
  • Unexplained fever of at least 100.4°F (38°C)
  • Drenching night sweats

If a person has any B symptoms, it usually means the disease is more advanced, and more intensive treatment is often 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 might 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.

Recurrent or relapsed disease means that Hodgkin disease initially went away with treatment, but it has now come back. If Hodgkin disease returns, it may be in the same place where it started or in another part of the body. This may occur shortly after treatment or years later.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master’s-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Last Medical Review: July 10, 2014 Last Revised: May 23, 2016

American Cancer Society medical information is copyrighted material. For reprint requests, please contact