Staging

The traditional staging for Hodgkin lymphoma and non-Hodgkin lymphoma was initially presented at the Ann Arbor Symposium on Staging of Hodgkin lymphoma, April, 1971. For the Ann Arbor System, clinical staging includes all of the non-invasive procedures; pathologic staging is based on findings made as a result of invasive procedures such as laparotomy or mediastinotomy.

Definitions for TNM clinical staging and pathologic staging using the Ann Arbor system are the same. T, N, and M elements are not applicable to this staging system.

Criteria for TNM Clinical Staging: Physical examination and history; urinalysis; chest x-ray; blood chemistries; bilateral bone marrow biopsies, plus lymphangiogram, abdominal CT scan. Also (optional, depending on previous findings) bone imaging, technetium scans, CT scans, chest tomography, upper GI series, lumbar puncture, ultrasound, gallium scans, liver/spleen scan.

Criteria for TNM Pathologic Staging: All of the clinical studies above, plus biopsy of accessible extranodal primary site(s). Staging laparotomy (including splenectomy, wedge liver biopsy, and multiple lymph node biopsies) is not required but may be used for additional staging information if indicated. Otherwise, liver biopsy, or other biopsies to determine distant metastases.

The Cotswolds Modifications of the Ann Arbor Staging Classification

  • Add a suffix X to designate bulky disease (defined as a mass of nodes with one diameter of > 10 cm or a mediastinal mass of > 1/3 of the transthoracic {mediastinal} width)
  • The number of anatomic regions involved should be indicated by a subscript (e.g., II3)
  • Stage III may be subdivided into:
    • III1 with or without splenic, hilar, celiac, or portal nodes
    • III2 with para-aortic, iliac, or mesenteric nodes
  • Staging should be identified as clinical stage (CS) or pathologic stage (PS)
  • A new category of response to therapy, unconfirmed/uncertain complete remission, should be introduced because of the persistent radiologic abnormalities of uncertain significance

Ann Arbor Staging (AJCC Stage Groups)

Illustration of Stage I: Single lymph node region Illustration of Stage II: 2 or more node regions, same side of diaphragm
Stage I also: single extranodal organ (Ie) Stage II also: single extranodal organ plus its regional lymph nodes with or without other nodes on same side of diaphragm (IIe)
Illustration of Stage III: Node regions both sides of diaphragm Illustration of Stage IV: Diffuse extralymphatic involvement
Stage III also: localized involvement of extralymphatic organ or site plus nodes on both sides of diaphragm (IIIe) OR involved lymph nodes on both sides of diaphragm plus spleen (IIIs)

Hodgkin Lymphoma and Non-Hodgkin Lymphomas
Relationship of Staging Systems

Description of Extent
(based on Ann Arbor definitions)		 Summary Stage Ann Arbor Staging * AJCC Staging Stage†
Involvement of a single lymph node region Localized I I
A single extralymphatic organ or site Localized Ie Ie
Involvement of more than one lymphatic region on only one side of the diaphragm Regional, NOS II II
Localized involvement of one extralymphatic organ or site and its regional lymph nodes with or without other nodes on the same side of the diaphragm Regional, NOS IIe IIe
Involvement of more than one lymphatic region on only one side of the diaphragm plus involvement of the spleen Distant IIs IIs
Involvement of lymph node regions on both sides of the diaphragm Distant III III
Involvement of lymph node regions on both sides of the diaphragm plus localized involvement of an extralymphatic organ or site Distant IIIe III
Involvement of lymph node regions on both sides of the diaphragm plus involvement of the spleen Distant IIIs IIIs
Diffuse or disseminated involvement of one or more extralymphatic organs or tissues with or without associated lymph node enlargement. Organs considered distant include liver, bone, bone marrow, lung and/or pleura, and kidney. Distant IV IV
Isolated extralymphatic organ involvement with distant (non-regional) nodal involvement Distant IV IV

Collaborative Stage Elements

For more details on Collaborative Stage, see the Intro to Collaborative Staging module.