Staging Non-Hodgkin Lymphoma

Your oncologist needs to know the extent (stage) of non-Hodgkin lymphoma to plan the best treatment. Staging is a careful attempt to determine whether the cancer cells have moved to other areas of the body. And if they have, how extensively have they spread? 

Lymphoma usually starts in a lymph node. Because of this, the cancer cells can spread to nearly any other part of the body rather easily. Some of the most common areas it can spread include the liver, lungs, bone, and bone marrow.

Tests to Determine the Stage of Non-Hodgkin Lymphoma

After a diagnosis of non-Hodgkin lymphoma, the hematologist will need to find out if it’s spread beyond the area where it started. There may be one or more of the following necessary:

• Bone marrow aspiration and biopsy: Since lymphocytes start developing in the bone marrow, a small sample of bone marrow might be taken to see if it has been affected. The doctor uses a thick needle to remove a small sample of bone marrow from your hip bone or another large bone. A pathologist then looks for lymphoma cells in the sample. If found in the bone marrow, different treatments may be recommended. Local anesthesia may be used to help control pain.
• Spinal tap: The doctor uses a long, thin needle to remove fluid from the spinal column. Local anesthesia can help control pain. You must lie flat for a few hours afterward so that you don’t get a headache. The lab checks the fluid for lymphoma cells in the cerebrospinal fluid (CSF) found in the brain and spine.
• Pleural or peritoneal fluid sampling: If fluid builds up in the chest or the abdomen, it will likely be tested for cancer cells.
• PET scan: If not already performed, a PET scan (usually combined with CT) will show the cancer care team if there are lymphoma cells in other areas of the body that can’t be detected yet using any other method. You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Lymphoma cells use sugar faster than normal cells, and areas with lymphoma look brighter in the images. 
• Bone scan. If pain is reported in the bones or there are other signs of bone metastasis, a scan will be done. A radioactive substance called technetium is injected into a vein. It travels to damaged areas of bone, and a special camera can then detect the radioactivity. 

Stages of Non-Hodgkin Lymphoma 

Staging is a method to determine how far cancer has spread in the body based on the location of the lymphoma cells in organs or tissues and the number of areas affected. The stage and other factors help doctors determine the most effective cancer treatment.

The Lugano classification system, which replaced the older Ann Arbor system, is currently used for staging lymphoma. The stages of non-Hodgkin lymphoma are classified as Roman numerals I, II, III, or IV (1 through 4), depending on the extent of tumor spread. In contrast to other cancers, a stage IV lymphoma diagnosis doesn’t indicate how well or poorly the patient will respond to treatment but rather the specific location of the disease. Even though stage IV lymphomas are the most advanced, they can still be treated successfully.  

Stage I Non-Hodgkin’s Lymphoma 

Either of these conditions applies:

• The cancer is found in one lymph node region (such as in the neck or underarm) (stage I).
• The cancer has invaded one extra lymphatic organ or site (identified using the letter “E”) but not any lymph node regions (stage IE).

Stage II Non-Hodgkin’s Lymphoma 

Either of these conditions applies: 

• The cancer is found in two or more lymph node regions on the same side of (either above or below) the diaphragm (stage II).
• The cancer involves one 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 Non-Hodgkin’s Lymphoma 

There is lymphoma in lymph nodes on both sides of the diaphragm (stage III), or the cancer has spread to various areas of one or more organs or tissues and the lymph nodes. Lymphoma may be found in the liver, blood, or bone marrow. (stage IV). Stage III-IV lymphomas are common, treatable, and often curable, depending on the NHL subtype. Stage III and IV are now considered a single category; therefore, they have the same treatment and prognosis. 

Progressive or Refractory Non-Hodgkin’s Lymphoma

Progressive disease or refractory NHL refers to cancer that grows larger or spreads while the patient is undergoing treatment for the original lymphoma. 

Recurrent Non-Hodgkin’s Lymphoma

Cancer that comes back after treatment is referred to as recurrent cancer. Recurrent cancer could either return to the area where it first started or somewhere else in the body. There may be times when recurrent lymphoma needs to be re-staged using the system above. 

The Lymphoma Staging Process Also Evaluates the Patient’s Prognosis

Part of the staging process for non-Hodgkin lymphoma includes an assessment of the patient’s prognosis or most likely outcome. The Eastern Cooperative Oncology Group (ECOG) Performance Status is a common scale based on how well the patient can carry out daily activities. After an assessment, the results are graded based on a functional assessment scale. 

The (ECOG) Performance Status grades are as follows:

• 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 housework, 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 for more than 50% of waking hours.
• 4: Completely disabled. Cannot carry on any self-care. Confined to bed or chair.
• 5: Dead

A lower score means the patient has a better prognosis. Typically, the better someone can walk and care for themselves, the better the prognosis.

Lymphoma Treatments Based on the Subtype of NHL, Staging, and the Patient’s Overall Health

Your lymphoma doctor, who is a hematologist/oncologist, will recommend a treatment plan most likely to be effective based on your NHL stage and overall prognosis. 

Learn about the treatment options available for non-Hodgkin lymphoma.