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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Oncology

Mapping the Disease: Staging and Your Prognosis

At a Glance

Non-Hodgkin lymphoma is staged from I to IV using the Ann Arbor system based on where it has spread. Unlike solid tumors, stage IV lymphoma is common and highly treatable. Doctors use PET scans and IPI scores to determine your prognosis and tailor your specific treatment plan.

Staging is the process of determining how much lymphoma is in your body and where it is located. This information, combined with other health factors, helps your medical team create a prognosis—a prediction of how the disease is likely to behave and respond to treatment [1][2].

The Ann Arbor Staging System

The most common way to stage Non-Hodgkin Lymphoma is the Ann Arbor system, which categorizes the disease into four stages based on the location of the cancer cells [3]:

  • Stage I: The lymphoma is in only one lymph node region (like one side of the neck) or one organ outside the lymph system [4].
  • Stage II: The lymphoma is in two or more lymph node regions, but they are all on the same side of the diaphragm (the breathing muscle that separates your chest from your abdomen) [4].
  • Stage III: The lymphoma is in lymph node regions on both sides of the diaphragm [4].
  • Stage IV: The lymphoma has spread widely into organs outside the lymph system, such as the liver, lungs, or bone marrow [4].

A Crucial Note About Stage IV: It is essential to understand that unlike solid tumors (like breast or colon cancer) where Stage IV often means a terminal diagnosis, Stage IV lymphoma is very common and remains highly treatable. Because lymphoma is a blood cancer, it naturally travels through the body. Even at Stage IV, aggressive lymphomas are frequently curable [4].

The “A” and “B” Designations

Your stage may also include a letter. “A” means you do not have systemic symptoms. “B” means you have at least one of the “B symptoms”: drenching night sweats, unexplained fevers, or significant unintentional weight loss [3][4]. Having “B symptoms” often suggests the disease is more active and may require a different treatment approach [3][5].

The Role of PET/CT Scans

In modern oncology, the PET/CT scan has revolutionized how we stage lymphoma. A PET scan uses a small amount of radioactive sugar to identify “hot spots” where cancer cells are active, while the CT scan provides a detailed map of your internal anatomy [6][7].

  • Replacing Bone Marrow Biopsies: In the past, almost everyone with NHL needed a bone marrow biopsy (using a needle to take a sample from the hip bone). Today, if a PET/CT scan clearly shows lymphoma in the bone marrow, a biopsy may not be necessary for aggressive B-cell lymphomas [8][9]. However, biopsies are still often used for indolent (slow-growing) lymphomas, where PET scans are sometimes less accurate [10][11].

Calculating Your Risk: The IPI Score

Doctors use the International Prognostic Index (IPI) to go beyond staging and look at your overall risk level. The original IPI uses five factors to assign a score [12]:

  1. Age: Is the patient over 60?
  2. Stage: Is it Stage III or IV?
  3. Extranodal Involvement: Is the lymphoma in more than one organ outside the lymph nodes?
  4. Performance Status: How well can the patient perform daily activities?
  5. LDH Level: Is the level of this enzyme in the blood higher than normal?

Modern Variations: NCCN-IPI

A newer version called the NCCN-IPI is now frequently used, especially for Diffuse Large B-Cell Lymphoma (DLBCL). It is considered more accurate because it uses more specific age groups and LDH levels to better identify which patients might need more intensive monitoring or newer therapies [13][12]. Your total score helps your doctor classify your risk as low, intermediate, or high, which directly guides the aggressiveness of your treatment [14][15].

Common questions in this guide

What does stage IV Non-Hodgkin lymphoma mean?
Stage IV means the lymphoma has spread into organs outside the lymph system, such as the liver, lungs, or bone marrow. Unlike many solid tumors, stage IV lymphoma is very common and remains highly treatable and frequently curable.
What are B symptoms in lymphoma staging?
B symptoms refer to specific systemic signs that indicate the lymphoma may be more active. These include drenching night sweats, unexplained fevers, and significant unintentional weight loss.
Do I need a bone marrow biopsy for lymphoma staging?
You may not need a bone marrow biopsy if a PET/CT scan clearly shows lymphoma in your bone marrow. However, biopsies are still often necessary for slow-growing lymphomas where PET scans may be less accurate.
What is an IPI score for lymphoma?
The International Prognostic Index (IPI) score helps doctors determine your overall risk level. It calculates your prognosis based on your age, cancer stage, spread outside the lymph nodes, ability to perform daily tasks, and blood LDH levels.
How does my LDH level affect my lymphoma prognosis?
Lactate dehydrogenase (LDH) is an enzyme in the blood that can indicate tissue damage or cancer cell activity. Higher than normal LDH levels can increase your IPI score, suggesting a higher risk level that may require more intensive treatment.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What is my official Ann Arbor stage, and does it include a 'B' designation for systemic symptoms?
  2. 2.Based on my PET/CT scan, do I still need a bone marrow biopsy to complete my staging?
  3. 3.What is my IPI or NCCN-IPI score, and which risk category (low, intermediate, or high) does it place me in?
  4. 4.How does my age and my LDH (lactate dehydrogenase) level specifically impact my prognostic score?
  5. 5.Does the presence of lymphoma in organs outside my lymph nodes (extranodal sites) change my treatment intensity?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (15)
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    Trends Analysis of Non-Hodgkin Lymphoma at the National, Regional, and Global Level, 1990-2019: Results From the Global Burden of Disease Study 2019.

    Cai W, Zeng Q, Zhang X, Ruan W

    Frontiers in medicine 2021; (8()):738693 doi:10.3389/fmed.2021.738693.

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    A comparison of clinical staging using the Lugano versus Ann Arbor classifications in Japanese patients with Hodgkin lymphoma.

    Makita S, Maruyama D, Maeshima AM, et al.

    Asia-Pacific journal of clinical oncology 2020; (16(3)):108-114 doi:10.1111/ajco.13248.

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    [Clinicopathological characteristics and prognosis of non-Hodgkin lymphoma in oral and maxillofacial regions: An analysis of 369 cases].

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    Simplified MIPI-B prognostic stratification method can predict the outcome well-retrospective analysis of clinical characteristics and management of newly-diagnosed mantle cell lymphoma patients from China.

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    Medicine 2019; (98(1)):e13741 doi:10.1097/MD.0000000000013741.

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    Imaging for diagnosis, staging and response assessment of Hodgkin lymphoma and non-Hodgkin lymphoma.

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    Pediatric radiology 2019; (49(11)):1545-1564 doi:10.1007/s00247-019-04529-8.

    PMID: 31620854
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    Magnetic Resonance Imaging and [18F]-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography-Guided Therapy Improves Survival in Upper Aerodigestive Tract NK/T-Cell Lymphoma, Nasal Type: A Prospective Cohort Study.

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    FDG PET/CT to detect bone marrow involvement in the initial staging of patients with aggressive non-Hodgkin lymphoma: results from the prospective, multicenter PETAL and OPTIMAL>60 trials.

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    Performance of Positron Emission Tomography-Computed Tomography and Bone Marrow Biopsy in Detecting Bone Marrow Infiltration in Lymphoma Cases

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    Prospective Assessment of Bone Marrow Involvement with Positron Emission Tomography vs Bone Marrow Biopsy in Patients with Lymphoma.

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This page explains Non-Hodgkin lymphoma staging and prognostic scoring for educational purposes. Always consult your oncologist to discuss your specific stage and what it means for your treatment plan.

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