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Hodgkin Lymphoma Stages

After someone is diagnosed with Hodgkin lymphoma (HL), doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes how much cancer is in the body. It helps determine how serious the cancer is and how best to treat it. Doctors also use a cancer's stage when talking about survival statistics.

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

The stage is based on:

  • Your medical history
  • If you have certain symptoms (called B symptoms)
  • The physical exam
  • Biopsies
  • Imaging tests, which typically include a chest x-ray, CT scan of the chest/abdomen/pelvis, and PET scan
  • Bone marrow aspiration and biopsy (sometimes, but not always done)

These exams, tests, and biopsies are discussed in Tests for Hodgkin Lymphoma.

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

Lugano classification

A staging system is a way for the cancer care team to sum up the extent of a cancer’s spread. The staging system used for Hodgkin lymphoma is the Lugano classification, which is based on the older Ann Arbor system. It has 4 stages, labeled I, II, III, and IV.

For limited stage (I or II) HL that affects an organ outside of the lymph system, the letter E is added to the stage (for example, stage IE or IIE).

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

  • HL is found in only 1 lymph node area or lymphoid organ such as the thymus (I).
  • The cancer is found only in 1 part of 1 organ outside the lymph system (IE).

Stage II: Either of the following means that the HL is stage II:

  • HL is found in 2 or more lymph node areas on the same side of (above or below) the diaphragm, which is the thin 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 HL is stage III:

  • HL is found in lymph node areas on both sides of (above and below) the diaphragm (III).
  • HL is in lymph nodes above the diaphragm and in the spleen.

Stage IV: HL has spread widely into at least one organ outside of the lymph system, such as the liver, bone marrow, or lungs.

Other modifiers may also be used to describe the Hodgkin lymphoma 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's usually labeled by adding the letter X to the stage. It's especially important for stage II lymphomas, because 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 lymphoma 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 lymphoma

Resistant or recurrent HL is not part of the formal staging system, but doctors or nurses might use these terms to describe what's going on with the lymphoma in some cases.

  • The terms resistant or progressive disease are used when the lymphoma does not go away or progresses (grows) while you're being treated.
  • Recurrent or relapsed disease means that HL went away with treatment, but it has now come back. If the lymphoma returns, it might be in the same place where it started or in another part of the body. This can happen shortly after treatment or years later.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as editors and translators with extensive experience in medical writing.

American Joint Committee on Cancer. Hodgkin and Non-Hodgkin Lymphoma. In: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017: 937.

Bartlett NL, Foyil KV. Chapter 105: Hodgkin lymphoma. In: Niederhuber JE, Armitage JO, Dorshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 5th ed. Philadelphia, Pa. Elsevier: 2014.

Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: The Lugano classification. J Clin Oncol. 2014;32:3059-3068.

National Comprehensive Cancer Network, Clinical Practice Guidelines in Oncology (NCCN Guidelines®), Hodgkin Lymphoma, Version I.2018 -- December 20, 2017. Accessed at on March 19, 2018.

Younes A, Carbone A, Johnson P, Dabaja B, Ansell S, Kuruvilla J. Chapter 102: Hodgkin’s lymphoma. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015.

Last Revised: May 1, 2018

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