Staging

Staging helps to define where the Hodgkin lymphoma is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer’s stage, so staging may not be complete until all 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 (chance of recovery). There are different stage descriptions for different types of cancer.

When staging Hodgkin lymphoma, doctors evaluate the following:

• The number of cancerous lymph node areas
  
  
• The location of the cancerous lymph nodes: regional (in the area where the cancer began) or distant (in other parts of the body)
  
  
• Whether the cancerous lymph nodes are on one 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 outside the lymph system) such as the liver, lungs, or bone

The stage of lymphoma describes the extent of the spread of the tumor, first using the terms stage I through IV (one through four), and then using a letter (A or B).

Stage I: Either one of these conditions:

• The cancer is found in one lymph node region (stage I).
  
  
• The cancer involves one extralymphatic organ (identified using the letter “E”) or site but not any lymph node regions (stage IE).

Stage II: Either one of these conditions:

• The cancer is in two or more lymph node regions on the same side of the diaphragm (stage II).
  
  
• The cancer involves a single organ and its regional lymph nodes (located near the site of the lymphoma), with or without cancer in other lymph node regions on the same side of the diaphragm (stage IIE).

Stage III:

• There is cancer in lymph node areas on both sides of the diaphragm (stage III).
  
  
• In addition, there may be involvement of an extralymphatic organ (stage IIIE), involvement of the spleen (using the letter “S,” stage IIIS), or both (stage IIIES).

Stage IV: Lymphoma is called stage IV if there is disseminated (multifocal) involvement, meaning that the lymphoma has spread throughout multiple areas. Common sites for disseminated disease are the liver, bone marrow, or lungs.

Recurrent: Recurrent lymphoma is lymphoma that comes back after treatment. Lymphoma 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.

In Hodgkin lymphoma, each stage may be subdivided into "A" and "B" categories:

A means that an individual did not experience B symptoms, listed below.

B means that an individual experienced any one of the following symptoms:

• Unexplained weight loss of more than 10% of original body weight during the six months before diagnosis
  
  
• Unexplained fever with temperatures above 100.4º F (38º C)
  
  
• Drenching night sweats. Most patients report that either their nightclothes or the sheets on the bed are actually wet. Sometimes, heavy sweating occurs during the day.

Prognostic factors. In addition to stage, doctors use other prognostic factors to help plan the best treatment and predict how successful treatment will be. In patients with Hodgkin lymphoma, several factors can predict whether the disease will return and which treatments will be successful. Individuals are treated as high risk or low risk based on how many risk factors are present.

Below are poor prognostic factors for patients with advanced Hodgkin lymphoma. In general, the fewer poor prognostic factors a patient has, the longer remission he/she should experience and the more successful treatments should be.

• Low blood albumin (a type of protein) levels (less than 4 g/L)
  
  
• Low hemoglobin (red blood cell count) (less than 10.5 g/dL)
  
  
• Being a male
  
  
• Age 45 and over
  
  
• Stage IV disease
  
  
• White blood cell count of greater than 16,000 per cubic millimeter
  
  
• Lymphocyte count of less than 600 per cubic millimeter, or less than 8% of the total white blood cell count, or both

Below are prognostic factors for patients with early-stage Hodgkin lymphoma. Prognosis depends on several factors, including:

• Age. The effect of age on outcome is also connected with gender and with results of some blood tests, particularly the ESR. Older age, being male, and a higher ESR are associated with a less favorable outcome.
  
  
• Subtype of Hodgkin lymphoma. Lymphocyte predominant Hodgkin lymphoma, nodular sclerosis Hodgkin lymphoma, and lymphocyte rich classical Hodgkin lymphoma have a more favorable outcome.
  
  
• The presence of a large mediastinal mass [a large lymphoma node mass in the center of the chest that is larger than 10 centimeters (cm)] is regarded as a less favorable feature. (Small mediastinal masses are not unfavorable.)
  
  
• The number of lymph node sites involved; the higher the number of sites involved, the less favorable the prognosis.

Used with permission of the AJCC, Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.