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Hodgkin Lymphoma





Staging of Hodgkin lymphoma is based on the Cotswald Modification of the Ann Arbor Staging System originally developed in 1971.  This is the same staging system used for adults.


Hodgkin Lymphoma Staging System:

Stage I

Involvement of single lymph node region (I) or

Localized involvement of a single extralymphatic organ site (IE)


Stage II

Involvement of two or more lymph node regions on same side of the diaphragm (II) or localized involvement of a single associated extralymphatic organ or site and its region on the same side of the diaphragm (IIE)


Stage III

Involvement of lymph node regions on both sides of the diaphragm (III), which may also be accompanied by localized involvement of an associated extralymphatic organ or site (IIIE), or by involvement of the spleen (IIIS) or both (IIIE+S)


Stage IV

Disseminated involvement of one or more extralymphatic organs, with or without associated lymph node involvement; or isolated extralymphatic organ involvement with distant (non-regional) nodal involvement


Note: S = spleen involvement; E = extranodal extension

Further subclassified depending on whether or not systemic symptoms are present:

A = No B symptoms.
B = B symptoms present with at least one of the following:

  • Unexplained weight loss >10% (from baseline over the past 6 months)
  • Unexplained recurrent fever >38°
  • Drenching night sweats.


Disease size/ Bulk:

Large mediastinal mass:

  • Tumor diameter > 1/3 the thoracic diameter (measured transversely at
    the level of the dome of the diaphragm on a 6 foot upright PA Chest X-ray)
  • If hilar nodal disease is present, the maximal mediastinal tumor measurement may be taken at the level of the hilus.

Large extra-mediastinal nodal aggregate:

  • Continuous aggregate of nodal tissue that measures > 6 cm in the longest transverse diameter in any nodal area.


In supraclavicular, infraclavicular, epitrochlear, brachial, preauricular, and popliteal nodes:

  • Any node with longest transverse diameter >1.5 cm at the time of diagnosis should be considered compatible with involvement by Hodgkin lymphoma.
  • No significant infection or other reason should be present

In cervical, axillary, inguinal and mesenteric lymph nodes

  • Any node may reach a diameter of 2 cm before being considered involved with lymphoma if reactive hyperplasia is considered possible.


To assess response to chemotherapy:

  • Measurable lesions (up to a max of 6 lesions in total), have baseline measurements and then are followed for response.
  • Target lesions for measurement should be large and easily assessed
  • Lesion size is expressed as the product of the perpendicular diameters (PPD), and serves as a surrogate measurement of area with dimensions of cm².
  • The PPD is obtained by multiplying the longest diameter of the lesion by the maximal diameter perpendicular to the longest diameter.


External Link:

Staging and Diagnostic Evaluation at the National Cancer Institute







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