Stages of Hodgkin lymphoma

Staging describes how much lymphoma there is in the body and where it is when first diagnosed. This is often called the extent of lymphoma. Information from tests is used to find out the size of the tumour, whether the lymphoma has spread from where it first started and where the lymphoma has spread. Your healthcare team uses the stage to plan treatment and estimate the outcome (your prognosis).

The most common staging systems for Hodgkin lymphoma (HL) are the Ann Arbor and Lugano staging systems. The systems are similar, and Lugano is based on the Ann Arbor system. In both of these systems there are 4 stages. Often the stages 1 to 4 are written as the Roman numerals I, II, III and IV.

Generally, the higher the stage number, the more the lymphoma has spread. Stages 1 and 2 are often referred to as early HL. Stages 3 and 4 may be called advanced HL. Talk to your doctor if you have questions about staging.

Doctors stage HL by looking at:

  • the number of groups of lymph nodes that have lymphoma
  • whether the lymphoma is localized or generalized – localized means the cancerous lymph nodes are only in 1 area of the body; generalized means the cancerous lymph nodes are in many areas of the body
  • which lymph nodes have lymphoma and whether they are on one or both sides of the diaphragm
  • whether the lymphoma is found in an organ or tissues other than lymph nodes

A, B, E and X categories

The following letters may be added to the stage number based on aspects of the disease:

A – You don’t have a fever, excessive sweating or weight loss.

B – You have an unexplained fever that doesn’t go away, drenching night sweats and unexplained weight loss.

E – The lymphoma is in nearby tissue outside of the lymph nodes (called an extranodal site).

X – There are large areas of lymphoma (called bulky disease).

Stage 1

Lymphoma is in 1 group of lymph nodes.

Stage 1E

Lymphoma is in only 1 area outside of the lymph nodes.

Stage 2

Lymphoma is in 2 or more groups of lymph nodes. The lymph nodes with lymphoma are either all above or all below the diaphragm.

Stage 2E

Lymphoma is in lymph nodes either all above or all below the diaphragm and has also spread into tissue near the lymph nodes.

Stage 3

Lymphoma is in lymph nodes both above and below the diaphragm.

Stage 3E

Lymphoma is in lymph nodes both above and below the diaphragm and has also spread into tissue near the lymph nodes.

Stage 4

Lymphoma is widespread and found in areas of the body outside of the lymph nodes, such as the lungs, liver, bone and bone marrow. Lymphoma is also usually in the lymph nodes.

Relapsed HL

Relapsed (recurrent) HL means that the lymphoma has come back after it has been treated. If it comes back in the same place that the lymphoma first started, it’s called local relapse. But it may come back in another part of the body.

When HL relapses, it usually comes back in the same form that it started in. This means that a low-grade (indolent) HL usually relapses as a low-grade lymphoma. But sometimes a low-grade type of HL relapses as a high-grade (aggressive) type of HL.

Refractory HL

Refractory HL means that the lymphoma has not responded to treatment. Refractory HL is also called progressive disease.

Expert review and references

  • American Cancer Society. What is Hodgkin Lymphoma . 2018: Monday, January 14, 2019.
  • American Society of Clinical Oncology. Lymphoma - Hodgkin . 2017.
  • Brierley JD, Gospodarowicz MK, Wittekind C (eds.). TNM Classification of Malignant Tumours. 8th ed. Wiley Blackwell; 2017.
  • 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. Journal of Clinical Oncology. 2014:
  • Lash, Bradley W. Medscape Reference: Hodgkin Lymphoma Treatment and Management . 2018.
  • National Cancer Institute. Adult Hodgkin Lymphoma Treatment (PDQ®) Patient Version . 2018.