Lymphoma (staging)

Dr Derek Smith and A.Prof Frank Gaillard et al.

There are a number of lymphoma staging systems for both Hodgkin lymphoma and non-Hodgkin lymphoma including the Ann Arbor classification, Cotswolds-modified Ann Arbor classification, and the most current, Lugano classification

Evolution of lymphoma staging and treatment response evaluation criteria:

  • 1971: Ann Arbor staging system
  • 1989: Cotswolds modifications of the Ann Arbor staging system with introduction of the use of computed tomography (CT)
  • 1999: International Working Group Response Criteria: five clinical response categories based on lesions sizes
  • 2007: International Harmonization Project Criteria: CT evaluation with additional use of relative qualitative evaluation 18F-FDG PET-CT
  • 2009: Deauville five-point scale: qualitative evaluation with graduation of 18F-FDG uptake on 18F-FDG PET-CT
  • 2014: Lugano classification
Lugano classification

The Lugano classification resulted from meetings in 2011 and 2013. The goal of this classification is to simplify and standardise the response assessment and reporting, enabling better understanding and communication among professionals. 

In addition to using CT, classification contemplates the use of 18F-FDG PET-CT for staging and interim treatment response assessment in cases of 18F-FDG-avid lymphoma (Hodgkin and diffuse large B-cell non-Hodgkin). Combined 18F-FDG PET-CT has been found to be more accurate than CT alone for response assessment. Lymphoma types with low or variable FDG uptake should keep being staged with CT. 

Diagnostic contrast-enhanced CT examination should still be included at initial staging for optimal anatomic assessment, which may be completed as part of the 18F-FDG PET-CT. 

Lesions measurement guidelines

Eligible lesions:

  • lymph nodes: the longest diameter in axial plane should be >1.5 cm
  • extranodal lesions: the longest diameter in the axial plane should be >1.0 cm

Lesions chosen should be measurable in two dimensions.

CT (or 18F-FDG PET-CT): tumor burden is to be calculated at baseline staging:

  • choose up to six of the largest nodes, nodal complexes or other lymphoma deposits
  • measure the longest diameter and shortest diameter of each lesion in the axial plane
  • multiply the longest diameter and shortest diameter for each lesion to give the “product of the diameters”
  • add these to give the “sum of the product of the diameters” (SPD) - the SPD calculated at the time of staging will serve as the baseline for sequential quantification of tumor burden at interim and end-of-therapy FDG PET-CT

Spleen measurement includes the largest transverse diameter and the perpendicular diameter in the axial plane, besides the craniocaudal diameter in the coronal plane. Splenomegaly is defined as vertical splenic length >13.0 cm.

See also
Lugano classification recommendations
  • update of the Ann Arbor classification for an anatomic description of disease extent: previously Ann Arbor stage I or II are now categorised as having “limited” disease and previously Ann Arbor stage III or IV are now categorised as having “advanced” disease
  • tumor bulk: a single nodal mass, in contrast to multiple smaller nodes, of 10 cm or greater than a third of the transthoracic diameter at any level of thoracic vertebrae as determined by CT is retained as the definition of bulky disease for Hodgkin Lymphoma. For follicular non-Hodgkin Lymphoma we should consider 6 cm and for large B-cell non-Hodgkin Lymphoma from 6 to 10 cm
  • update of Cotswolds modifications: as the presence of B symptoms affects only Hodgkin lymphoma treatment, the modifier “B” should be used in patients with this lymphoma type. The associated “X” modifier is no longer applied in Hodgkin or non-Hodgkin lymphoma, instead, the longest diameter of a mass is simply recorded for staging purposes

Below we can see the Cotswolds-modified Ann Arbor classification.

Cotswolds-modified Ann Arbor classification
  • stage I: one nodal group or lymphoid organ (e.g. spleen or thymus)
    • stage IE: one extranodal site
  • stage II: two or more nodal groups, same side of diaphragm
    • stage IIE: localised extranodal site with stage II criteria, both on the same side of the diaphragm
  • stage III: nodal groups on both sides of the diaphragm
    • stage IIIS(1): with splenic involvement
    • stage IIIE(2): with localised extranodal site
    • stage IIISE: both
  • stage IV: disseminated involvement of one or more extralymphatic organ (e.g. lung, bone) +/- any nodal involvement

Additional staging variables:

  • A: asymptomatic
  • B: presence of B symptoms (fever, night sweats and weight loss)
  • X: bulky nodal disease: nodal mass >1/3 of intrathoracic diameter or 10 cm in dimension
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Article information

rID: 1457
Section: Staging
Tag: cases, cases
Synonyms or Alternate Spellings:
  • Hodgkin's lymphoma staging (Ann Arbor)
  • Hodgkin's lymphoma staging
  • Hodgkin's lymphoma staging (Cotswold's + Ann Arbor)
  • Ann Arbor classification
  • Cotswolds-modified Ann Arbor classification
  • Lugano classification

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Cases and figures

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    The longest diame...
    Figure 1: nodal measurement (Lugano)
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    Case 1: Cotswald Ann Arbor stage IIIS(1)
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    Figure 2: splenic measurement (Lugano)
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    Case 2: stage IV
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    Splenic lesions i...
    Figure 3: extranodal measurement (Lugano)
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    Figure 4: Lugano classification: response evaluation criteria (table)
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