Lymphoma - Non-Hodgkin: Stages

Approved by the Cancer.Net Editorial Board, 12/2016

ON THIS PAGE: You will learn about how doctors describe lymphoma’s location and spread. This is called the stage. To see other pages, use the menu.

Staging is a way of describing where NHL is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis. There are different stage descriptions for different types of cancer.

When staging NHL, doctors evaluate:

  • The number of cancerous lymph node areas

  • The location of the cancerous lymph nodes: regional (in the same area the cancer started) or distant (in other parts of the body)

  • Whether the cancerous lymph nodes are on 1 or both sides of the diaphragm, the thin muscle under the lungs and heart that separates the chest from the abdomen

  • Whether the disease has spread to the bone marrow, spleen, or extralymphatic organs (organs that are not part of the lymphatic system), such as the liver, lungs, or brain

The stage of lymphoma describes the extent of spread of the tumor using the Roman numerals I through IV (I, II, III, or IV). This staging system is helpful for the most common subtypes of lymphoma. For other subtypes, the disease has often spread throughout the body by the time it is diagnosed. In these situations, the prognostic factors become more important (see “International Prognostic Index” and “Functional status,” below). It is important to remember that even stage IV lymphomas can often be treated successfully.

  • Stage I: Either of these conditions applies:

    • The cancer is found in 1 lymph node region (stage I).

    • The cancer has invaded 1 extralymphatic organ or site (identified using the letter “E”) but not any lymph node regions (stage IE).

  • Stage II: Either of these conditions:

    • The cancer is in 2 or more lymph node regions on the same side of the diaphragm (stage II).

    • The cancer involves 1 organ and its regional lymph nodes, with or without cancer in other lymph node regions on the same side of the diaphragm (stage IIE).

  • Stage III-IV: There is cancer in lymph node areas on both sides of the diaphragm (stage III), or the cancer has spread throughout the body beyond the lymph nodes (stage IV). Lymphoma most often spreads to the liver, bone marrow, or lungs. Stage III-IV lymphomas are common, still very treatable, and often curable, depending on the NHL subtype. Stage III and stage IV are now considered a single category because they have the same treatment and prognosis.

  • Progressive: If the cancer grows larger or spreads while the patient is being treated for the original lymphoma, it is called progressive disease. This is also called refractory NHL.

  • Recurrent: Recurrent lymphoma is lymphoma that has come back after treatment. It may return in the area where it first started or in another part of the body. Recurrence may occur shortly after the first treatment or years later. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above. This is also called relapsed NHL.

The original source for this material is 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, published in the Journal of Clinical Oncology, September 20, 2014; vol. 32, no. 27: 3059–3067.

International Prognostic Index

In addition to stage, a scale called the International Prognostic Index (IPI) is important in planning treatment for aggressive lymphomas. Researchers developed the IPI based on evidence from thousands of patients with lymphoma. The results showed that certain features can help predict how well treatment would work. Patients are classified into low-risk or high-risk groups depending on which risk factors listed below apply.

IPI risk factors include:

  • Age 60 or older

  • Stage III or stage IV disease

  • Blood test results showing higher-than-normal levels of LDH, a group of substances found in the blood called lactate dehydrogenase

  • Lower overall health or performance status

  • Cancer in more than 1 organ or site outside the lymph node region

For patients with follicular lymphoma, doctors consider additional factors. Those factors include the level of a part of a patient’s blood, called hemoglobin, and the number of lymph node groups involved.

Doctors use these factors to estimate the chance of cure. For incurable lymphoma, they help predict how aggressive the lymphoma might be. This index is now widely used to help doctors make decisions about treatment recommendations.

Functional status

To determine a patient’s prognosis, the doctor may also test how well a patient is able to function and carry out daily activities by using a functional assessment scale. The Eastern Cooperative Oncology Group (ECOG) Performance Status or the Karnofsky Performance Scales (KPS) are 2 of those scales.

  • ECOG Performance Status. A lower score indicates a better functional status. Typically, the better someone is able to walk and care for himself or herself, the better the prognosis.

    1. Fully active, able to carry on all pre-disease performance without restriction

    2. Restricted in physically strenuous activity but able to walk and carry out light work while standing or sitting, such as light house work or office work

    3. Able to walk and capable of all self-care but unable to carry out any work activities; up and about for more than 50% of waking hours

    4. Capable of only limited self-care; confined to bed or chair for more than 50% of waking hours

    5. Completely disabled; cannot carry out any self-care; totally confined to bed or chair

    6. Dead

  • KPS. A higher score indicates a better functional status.

    • 100: Normal; no complaints; no evidence of disease

    • 90:  Able to carry on normal activity; minor symptoms of disease

    • 80:  Normal activity with effort; some symptoms of disease

    • 70:  Cares for self; unable to carry out normal activity or active work

    • 60:  Requires occasional assistance but is able to care for needs

    • 50:  Requires considerable assistance and frequent medical care

    • 40:  Disabled; requires special care and assistance

    • 30:  Severely disabled; hospitalization is indicated, but death is not imminent

    • 20:  Very sick; hospitalization necessary; active treatment necessary

    • 10:  Approaching death; fatal processes progressing rapidly

    • 0:   Dead

Information about the cancer’s type, subtype, and stage, as well as prognostic factors, will help the doctor recommend a treatment plan. The next section in this guide is Treatment Options. Or, use the menu to choose another section to continue reading this guide.