Non-Hodgkin's Lymphoma

Stage is important in selecting a treatment for patients with non-Hodgkin’s lymphoma (NHL). Chest and abdominal computed tomographic (CT) scans are usually part of the staging evaluation for all lymphoma patients. The staging system is similar to the staging system used for Hodgkin’s lymphoma. Noncontiguous lymph node involvement, uncommon in Hodgkin’s lymphoma, is more common among patients with NHL. Involvement of Waldeyer’s ring, epitrochlear nodes, and the gastrointestinal tract is also more common. Extranodal presentations are more common in NHL. A single extranodal site is occasionally the only site of involvement in patients with diffuse lymphoma. Bone marrow and hepatic involvement are especially common in patients with low-grade lymphomas. Cytologic examination of cerebrospinal fluid may be positive in patients with aggressive NHL. Involvement of hilar and mediastinal lymph nodes is less common than in Hodgkin’s lymphoma. Mediastinal adenopathy, however, is a prominent feature of lymphoblastic lymphoma and primary mediastinal B-cell lymphoma, entities primarily found in young adults.

The majority of patients with NHL present with advanced (stage III or stage IV) disease that can often be identified with limited staging procedures such as CT scanning and biopsies of the bone marrow and other accessible sites of involvement. Laparoscopic biopsy or laparotomy is not required for staging but may be necessary to establish a diagnosis or histologic type.[1] Positron emission tomography with fluorine-18-fluorodeoxyglucose can be used for initial staging and for follow-up after therapy as a supplement to CT scanning.[2,3,4,5]

Staging Subclassification System

The Ann Arbor staging system is commonly used for patients with NHL.[6,7] In this system, stage I, stage II, stage III, and stage IV adult NHL can be subclassified into A and B categories: B for those with well-defined generalized symptoms and A for those without such symptoms. The B designation is given to patients with any of the following symptoms:

• Unexplained loss of more than 10% of body weight in the 6 months before diagnosis.
• Unexplained fever with temperatures above 38° C.
• Drenching night sweats.

Occasionally, specialized staging systems are used. The physician should be aware of the system used in a specific report.

Stage I

Stage I NHL means involvement of a single lymph node region (I) or localized involvement of a single extralymphatic organ or site (IE).

Stage II

Stage II NHL means involvement of two or more lymph node regions on the same side of the diaphragm (II) or localized involvement of a single associated extralymphatic organ or site and its regional lymph nodes with or without other lymph node regions on the same side of the diaphragm (IIE). The number of lymph node regions involved may be indicated by a subscript (e.g., II₃).