Staging

Staging helps to define where NHL 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 NHL, doctors evaluate the following:

• The number of cancerous lymph node areas
  
  
• The location of the cancerous lymph nodes: regional (in the same area 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 lymphatic system) such as the liver, lungs, or brain

The stage of lymphoma describes the extent of spread of the tumor, using Roman numerals one through four (I, II, III, or IV).

Stage I: Either one of these conditions:

• The cancer is found in one lymph node region (stage I).
  
  
• The cancer has invaded one extralymphatic organ or site (identified using the letter “E”) 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, 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).
  
  
• There may also be involvement of an extralymphatic organ (stage IIIE), the spleen using the letter “S” (stage IIIS), or both (stage IIIES).

Stage IV: Lymphoma is called stage IV if there is disseminated involvement of organs beyond the lymph nodes. Common sites for spread are the liver, bone marrow, or lungs.

Progressive or recurrent: Progressive disease is present if the cancer becomes larger or spreads while the patient is being treated for the original lymphoma. Recurrent lymphoma is lymphoma that comes 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.

International Prognostic Index

In addition to stage, a scale called the International Prognostic Index (IPI) is important in planning treatment. The IPI was developed based on evidence from thousands of patients with lymphoma. The results indicated that certain features could help predict how successful treatment will be, with individuals classified into low-risk or high-risk groups. As explained in Symptoms, each stage may also be subdivided into “A” and “B” categories, based on the presence or absence of specific symptoms.

Features that the IPI identifies as risk factors:

• Age 60 or older
  
  
• Stage III or stage IV disease
  
  
• Blood test results showing higher than normal levels of LDH (a group of enzymes called lactate dehydrogenase)
  
  
• Lower overall health or performance status
  
  
• Presence of cancer in multiple extranodal sites (organs or sites outside the lymph node region)
  
  
• For patients with follicular lymphoma, additional features, such as the level of a patient’s hemoglobin and the number of lymph node groups involved, are also used.

These factors are used to estimate the chances of cure. For noncurable lymphoma, they help to predict how aggressive the lymphoma will be for an individual patient. This index is now used widely to help doctors make decisions about treatment.

Functional status

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

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

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

1  Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2  Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours

3  Capable of only limited self-care, confined to bed or chair more than 50% of waking hours

4  Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

5  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 on 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 not imminent

20  Very sick, hospitalization necessary; active treatment necessary

10  Moribund, fatal processes progressing rapidly

0   Dead

Used with permission of the American Joint Committee on Cancer (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.