Stages of Hodgkin lymphoma

The stages of Hodgkin lymphoma tell you about the number and places in the body affected by lymphoma.

Knowing the stage of Hodgkin lymphoma helps your doctor decide what treatment you need.

Doctors use the Lugano classification system to stage Hodgkin lymphoma. There are 4 stages, from stage 1 to 4. Doctors can also simplify the staging into early, intermediate or advanced stage.

How doctors work out your stage

Doctors look at whether your lymphoma is on:

• the same side of the diaphragm or
• on both sides of the diaphragm 

They also look at whether it is inside or outside the lymphatic system .

They will measure the size of the lymphoma. They do this by doing various tests, such as a CT or PET scan. Your doctor will also take your symptoms into consideration.

The diaphragm

The diaphragm (pronounced dia-fram) is the big breathing muscle that separates the chest from the tummy (abdominal) area. 

Doctors use the diaphragm as a guide because it is about halfway down the body.

Inside or outside of the lymphatic system

Doctors look at whether your lymphoma is affecting your lymph nodes  and organs inside the lymphatic system. These are called lymphatic sites. If it is affecting areas outside the lymphatic system they are called extranodal sites.

Lymphatic sites

Lymphatic sites include a group of lymph nodes or an organ in the lymphatic system, such as the:

• thymus
• spleen
• tonsils

Extranodal sites

Extranodal sites are sometimes called extralymphatic sites. They are outside the lymphatic system and include the:

• lungs
• liver
• blood
• bone marrow
• kidneys
• brain

Your doctor may use the letter E (for extranodal) after the stage number if you have lymphoma outside the lymphatic system. For example stage 1E. Your doctor or nurse can explain what this means for you.

B symptoms

Your doctor will add the letter B to your stage (for example, stage 1B) if you have any of the following symptoms:

• heavy sweating at night
• high temperatures that come and go, often at night
• unexplained weight loss, more than a tenth (10%) of your body weight in the last 6 months

If you don't have any of these symptoms your doctor will add the letter A to your stage (for example, stage 2A).

People with B symptoms may need more treatment than those without them.

Bulky disease

This means you have either:

• lymphoma that is 10cm or more

• lymphoma in the centre of your chest (mediastinum) which is a third of the width of your chest or bigger

Stage 1

This means that you have one of the following:

• lymphoma in a single lymph node or one group of lymph nodes, or an organ of the lymphatic system (such as the thymus)

• lymphoma in an extranodal site (this is called stage 1E)

Below is an example of stage 1 lymphoma. 

Stage 2

This means one of the following:

• your lymphoma is in two or more groups of lymph nodes

• your lymphoma is in an extranodal site and one or more groups of lymph nodes (this is called stage 2E)

In both cases, the 2 sites of lymphoma are on the same side of the diaphragm.

Below is an example of stage 2.

Stage 3

This means that you have lymphoma on both sides of the diaphragm.

Below is an example of stage 3. The lymphoma is in lymph nodes above the diaphragm and the spleen.

Stage 4

Stage 4 means one of the following:

• lymphoma is in the lymph nodes and an extranodal site

• lymphoma is in more than one extranodal site, for example the liver, bones or lungs

Below is an example of stage 4 lymphoma.

Hodgkin lymphoma stages made simple

Your doctor may describe your lymphoma as being early, intermediate or advanced stage.

They will consider risk factors when deciding what stage your Hodgkin lymphoma is. The risk factors are:

• having bulky disease in the centre of your chest (mediastinum)
• being 50 years or older
• if your red blood cells (erythrocytes) are sticking together (erythrocyte sedimentation rate or ESR
• having lots of nodal areas with lymphoma

Early stage

Early (limited) stage generally means you have stage 1 or stage 2 Hodgkin lymphoma with no risk factors. It is also called early stage favourable.

Intermediate stage

Intermediate stage usually means you have stage 1 or 2 with one or more risk factor. Your doctor might call this stage early stage unfavourable Hodgkin lymphoma.

Advanced stage

Advanced stage generally means you have stage 3 or stage 4 Hodgkin lymphoma. However stage 2 with B symptoms and bulky disease or extranodal sites is usually treated as advanced stage (stage 2BX or 2BE).

Hodgkin lymphoma treatment

Treatment for stage 1 and 2 Hodgkin lymphoma is usually 2 to 4 cycles of chemotherapy. You might also have radiotherapy.

Treatment for stage 3 and 4 Hodgkin lymphoma is usually between 4 to 6 cycles of chemotherapy. You might also have:

• steroids
• radiotherapy

Treatment for nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is mostly the same as classical Hodgkin lymphoma. However if you have stage 1A NLPHL with no risk factors you might have radiotherapy on it’s own. You will usually have a PET-CT scan after some treatment so your doctor can see if your lymphoma has changed.

Hodgkin lymphoma that comes back

Hodgkin lymphoma that has come back after it has been treated and gone away is called recurrent[AS1]  or relapsed disease.

Your doctors will not stage it in the same way as when you were first diagnosed. You can still have treatment for relapsed Hodgkin lymphoma and this will often work well. Your treatment may include:

• chemotherapy, usually a high dose
• a stem cell transplant
• targeted therapy
• immunotherapy
• radiotherapy

For some people NLPHL can change (transform) into non Hodgkin lymphoma. If your doctor thinks your NLPHL has come back, you will have another biopsy and they will check if it has transformed. You will have different treatment if your lymphoma has transformed into non Hodgkin lymphoma.