Non-Hodgkin Lymphoma Stages

After someone is diagnosed with non-Hodgkin lymphoma (NHL), doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage describes how much cancer is in the body. It helps determine how serious the lymphoma is and how best to treat it.

How is the stage determined?

Tests used to gather information for staging can include:

• Physical exams
• Biopsies of enlarged lymph nodes or other abnormal areas
• Blood tests
• Imaging tests, such as PET and CT scans
• Bone marrow aspiration and biopsy (often but not always done)
• Lumbar puncture (spinal tap – not always done)

In general, the results of imaging tests such as PET or CT scans are the most important when determining the stage of the lymphoma.

Lugano classification

A staging system is a way for members of a cancer care team to sum up the extent of a cancer’s spread. The current staging system for NHL in adults is known as the Lugano classification, which is a modified version of the older Ann Arbor system.

The stages are described by Roman numerals I through IV (1-4). Limited stage (I or II) lymphomas that affect an organ outside the lymph system (an extranodal organ) have an E added (for example, stage IIE).

Stage I

Either of the following means the disease is stage I:

• The lymphoma is in only 1 lymph node area or lymphoid organ such as the tonsils (I).
• The cancer is found only in 1 area of a single organ outside of the lymph system (IE).

Stage II

Either of the following means the disease is stage II:

• The lymphoma is in 2 or more groups of lymph nodes on the same side of (above or below) the diaphragm (the thin band of muscle that separates the chest and abdomen). For example, this might include nodes in the underarm and neck area but not the combination of underarm and groin nodes (which would be stage III).
• The lymphoma is in a group of lymph node(s) and in one area of a nearby organ (IIE). It may also affect other groups of lymph nodes on the same side of the diaphragm.

Stage III

Either of the following means the disease is stage III:

• The lymphoma is in lymph node areas on both sides of (above and below) the diaphragm.
• The lymphoma is in lymph nodes above the diaphragm, as well as in the spleen.

Stage IV

The lymphoma has spread widely into at least one organ outside the lymph system, such as the bone marrow, liver, or lung.

Bulky disease

This term is often used to describe large tumors in the chest. It is especially important for stage II lymphomas, as bulky disease might need more intensive treatment.

Staging small lymphocytic lymphoma (SLL)/chronic lymphocytic leukemia (CLL)

The system above is most often used to stage SLL if it is only in lymph nodes. But if the disease is in the blood or bone marrow, it is often staged using the systems for CLL. See Chronic Lymphocytic Leukemia Stages.

How staging might affect treatment

The stage of a lymphoma is important when determining a person’s treatment options, but it is more important for some types of lymphoma than for others. For many of the more common types of NHL, treatment is based in part on whether the lymphoma is “limited” (stage I or stage II non-bulky) or “advanced” (stage III or IV). For stage II bulky lymphomas, certain other factors (known as prognostic factors) are used to help determine if the lymphoma should be treated as limited or advanced.

For some other types of NHL, such as fast-growing lymphomas like Burkitt lymphoma, the stage is less important when deciding on treatment.

See Treating B-cell Non-Hodgkin Lymphomas and Treating T-cell Non-Hodgkin Lymphomas for more on this.