How is classical Hodgkin lymphoma staged?

Before making any treatment decisions about classical Hodgkin lymphoma (cHL), a healthcare team will “stage” the cancer. This process will determine if the cancer has spread and where it has spread. The stage of cHL, along with numerous other factors such as a patient’s age, overall health, and medical history, will help the healthcare team determine the best approach to treatment.

Classical Hodgkin lymphoma begins in lymph nodes, which are part of the body’s immune system and contain white blood cells. When this type of cancer starts to spread, it usually spreads to nearby lymph nodes. As it progresses, cHL can also spread to nearby organs.

When diagnosing cHL, oncologists will take a full medical history and conduct a comprehensive physical exam, with a focus on the lymph nodes in the neck, underarms, groin, and other parts of your body where the cancer may travel, including the spleen and liver.

An oncologist will also biopsy a swollen lymph node to make the diagnosis and identify the subtype. There are four subtypes of classic Hodgkin lymphoma:

• Nodular sclerosis
• Mixed cellularity classic Hodgkin lymphoma
• Lymphocyte-depleted classic Hodgkin lymphoma
• Lymphocyte-rich classic Hodgkin lymphoma

Blood tests and imaging tests such as X-rays, CT scans, and PET scans are important tools in the staging process. These imaging tests can spot enlarged lymph nodes, determine whether organs other than lymph nodes are involved, and can identify any large tumors. A bone marrow aspiration and biopsy may be needed to check for lymphoma cells in the bone marrow.

A healthcare team will consider all of the information gathered in this process to confirm the diagnosis and determine the stage.

Understanding the stages of cHL

Staging for classic Hodgkin lymphoma uses a four-part staging system:

• Stage I. Lymphoma is found only in a single part of one organ that's not considered to be part of the lymph system OR HL cells are found in one lymph node area or one lymphoid organ, like the thymus gland.
• Stage II: Lymphoma is in two or more lymph node regions on the same side of the diaphragm, OR in a lymph node and a nearby organ on the same side of the diaphragm. (The diaphragm is a muscle that sits at the base of the chest).
• Stage III: The lymphoma has spread to two or more regions on both sides of the diaphragm. (There may also be evidence of disease in an organ outside of the lymphatic system.)
• Stage IV: Lymphoma cells have spread to sites and organs outside the lymphatic system, such as the liver, lungs, or bones.

Categories

In addition to a stage, cHL is also assigned a category. Categories are designated with the letters A, B, E, S, and X. These categories help further classify the cancer and match it with the best treatment option.

• A is used when no B symptoms are present
• B is used when B symptoms are present. B symptoms suggest that the cancer is more aggressive (and are explained in the next section).
• E is used when there are cancer cells in organs or tissues outside the lymphatic system.
• S is used when there are lymphoma cells in the spleen.
• X is used when there is something called “bulky disease” which refers to large masses over 10cm in size.

B symptoms

As mentioned above, B symptoms are symptoms that indicate a cancer that is more aggressive. Classic Hodgkin B symptoms include:

• Unexplained weight loss, typically more than 10 percent of body weight over the previous six months.
• Unexplained fever of at least 100.4°F
• Intense night sweats. These sweats require changing pajamas and sheets.

Treatment

Once the cancer has been staged and categorized, a healthcare team can decide on the best approach to treatment. The two most commonly used treatments for cHL are chemotherapy and radiation therapy. Stem cell transplants may be used to treat cases where the lymphoma recurs after treatment or is resistant to treatment. Additional treatment options, including immunotherapy and targeted therapy, may be used if the disease relapses.

Remember, while understanding a diagnosis and staging are important, cancer is a different experience for everyone, and your best source of information is your healthcare team.