January 5th, 2011
09:32 AM ET

How many stages are there in non-Hodgkin's lymphoma?

Every weekday, a CNNHealth expert doctor answers a viewer question. On Wednesdays, it's Dr. Otis Brawley, chief medical officer at the
American Cancer Society.

Question asked by Paula Holman-Yorba of San Bernardino, California

How many stages are there in non-Hodgkin's lymphoma?

Expert answer

Two weeks ago, Paula asked about staging of non-Hodgkin's lymphoma. We discussed cancer staging in general. This week, we discuss lymphoma and its staging and prognosis.

Lymphoma is cancer of the lymphatic system, which is an important part of the immune system. The lymphatic system consists of conduits or tubes throughout the body with filters called lymph nodes along the path. The system carries a clear fluid with immune fighting cells such as lymphocytes.

Lymphoma is a disease that is increasing in incidence in the Western world. Common risk factors include exposure to:

• ionizing radiation;

• certain chemicals such as benzene, insecticides, or herbicides; and

• some viruses such as HIV, HTLV 1 and 2.

There is also evidence that people with immune diseases such as rheumatoid arthritis, systemic lupus erythematosus (SLE, or lupus), or celiac sprue are at higher risk of developing lymphoma. Patients with immune hyperstimulation from H. pylori infection of the stomach or hepatitis C are also at increased risk of certain types of lymphoma.

The appropriate treatment and the prognosis for a lymphoma patient are related to a combination of the type of lymphoma and stage of disease. The type of tumor is determined by a pathologist's microscopic examination of a biopsy of the tumor.

There are two major types of lymphoma: the Hodgkin's lymphomas and the non-Hodgkins lymphomas. HL spreads primarily through the ducts of the lymph system. NHL spreads more through blood vessels. There are five subtypes of HD and more than two dozen types of NHL. These NHL are categorized into three groups: the indolent, intermediate and aggressive.

The stage or degree of spread of the disease is determined by the physical examination and radiologic imaging. A TNM stage, discussed last week, is determined and usually translated into what is known as the Ann Arbor staging system with Cotswolds modifications. This is the overall or summary stage, in brief:

• Stage I - Lymphoma involving a single lymph node region (I) or a single node and the organ next to it.

• Stage II - Involvement of two or more lymph node regions in the chest or two or more in the abdomen or the area of the retroperitoneum (low back). There can be direct extension of lymphoma from the lymph node chain into an adjacent organ.

• Stage III - Involvement of lymph node in the abdomen and the chest or the retroperitoneum and the chest. Involvement of the spleen, which is located in the left upper abdomen, is stage III disease.

• Stage IV - Diffuse or disseminated lymphoma involving one or more organs or tissues without associated lymphatic involvement.

Patients with stage I or stage II disease are then further stratified for treatment purposes into favorable and unfavorable prognosis disease, based upon the presence or absence of certain clinical features, such as age and B symptoms (weight loss, fevers, night sweats, and large volume of disease in the chest).

Laboratory studies are done to determine the type of cancerous cells. There are drugs specific to the treatment of what are known as B cell lymphomas. B cell positive versus T cell positive or other laboratory markers can also be used to predict patterns of spread and patterns of invasion of a lymphoma.

The appropriate treatment of a lymphoma varies by the type of tumor and by the stage. Stage I and II lymphomas can often be treated with radiation alone. They are of limited size and spread, such that they can be illuminated by one radiation beam. Stage III and IV lymphomas generally must be treated with a series of chemotherapy drugs active in lymphoma. Type of tumor is very important, as indolent lymphoma usually presents as widely spread or stage IV disease, but can often be appropriately watched, and treatment can sometimes be deferred for a decade or more. On the other hand, the aggressive lymphomas can be a medical emergency requiring immediate treatment.

The international prognostic index (IPI) is used to determine prognosis for patients with lymphoma. The index takes into account the the type of lymphoma, stage of disease, and what markers or genes are expressed in the tumor. As a whole, lymphoma is one of the most treatable of malignancies. While the prognosis for many of the lymphomas can be very good, there are some lymphomas that are very difficult to treat.

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soundoff (19 Responses)
  1. JC

    Thank you for this. When I was a child, I had a friend die of lymphoma. Treatments have come such a long way and it's not an automatic death sentence anymore, even at stages III and IV. This article was very informative and easy to read.

    January 5, 2011 at 11:22 | Report abuse | Reply
  2. Patricia

    JC, you're absolutely correct. I was diagnosed with Stage IV lymphoma in 1994. I've written about this experience on a blog for anybody to read. The blog is


    For a while I was selling and giving away meditation cds based on what I myself did. But, I'm not doing that anymore and just hope the blog can give others some insight and comfort. P.

    January 5, 2011 at 12:21 | Report abuse | Reply
  3. Khan

    Good Article. I am a Stage IV Burkitt's Lymphoma survivor since last 3 years. Burkitt's lymphoma is a very agressive type of Lymphoma which requires a strong regimen of Chemotherapy (McGrath Protocol) where I had to stay in hospital 24/7 for every cycle.
    I want to start an awareness about this disease since it is very common in children, Adults aged 30-35(quite strangely) and older (60 and above). There is a facebook group I had started for survivors to share their stories.

    January 5, 2011 at 12:39 | Report abuse | Reply
    • Jon

      What is the group on facebook called? I would love to join it.

      January 5, 2011 at 13:37 | Report abuse |
    • notimeforcancer

      I was diagnosed with stage II Hodgkins Lymphoma. The entire upper portion of my body is riddled with inflamed/infected lymphnodes and tumors. I have been doing the AVBC chemo but no radiation since it is ALL over the place. I am a married mom of three in her early 30's and this just threw our entire family off our game. My 10 yr old needs councilling and needs me to always wear a hat (he has PDD-NOS- so there are other issues there, though). I am so grateful to know that I am so far from alone. The support from my community- both online and off- has been KEY to my healing. I am scheduled to continue through March but this year will be THE BEST EVER!!! Thank you for your encouraging post and I will be checking out your blog!

      January 5, 2011 at 14:02 | Report abuse |
    • khan

      Please try this on Facebook
      http://www.facebook.com/#!/group.php?gid=163454643668468 or search for Burkitt's Lymphoma Survivors group. I dont have contents to put on the group page, if you have information that you can share please feel free.

      January 5, 2011 at 19:26 | Report abuse |
  4. Patricia

    Good article. I am a stage 4 follicular lymphoma surivor of five years. Although I have had several months of chemo, only to have continuing reaccurances, I am still going strong, and believe there will be a treatment to knock this for good.

    January 5, 2011 at 13:28 | Report abuse | Reply
  5. Jon

    I am, also, a survivor of Burkitt's Lymphoma. I was diagnosed in October 2009, Went through 6 months of intensive chemotherapy. 8 cycles and hospitalized for the administration of the chemo. I would like to help others who are newly diagnosed with some sort of support group. I didn't have it, and I know it would have helped. We were very much in the dark about the process.

    January 5, 2011 at 13:32 | Report abuse | Reply
  6. Jeannie

    My mom is a lymphoma survivor of more than 15 years. Hers was detected by suffering from a bout of double pneumonia. She had chemo and was in remission for a number of years, however, it has reared its ugly head again. She is now 80 yrs old and still lives independently and walks 2 miles daily!

    January 5, 2011 at 13:53 | Report abuse | Reply
  7. Patricia

    dear no time for cancer. My son was fifteen when I was diagnosed. It had an incredable affect on him...No child should have to worry about losing there mom. Counseling for him helped, and the support of the church and friends. That is the worse thing for us when we are diagnosed is what our loved ones go thru. Hang in there..

    January 5, 2011 at 14:07 | Report abuse | Reply
  8. Monkey

    I was diagnosed with Hodgkin's lymphoma in 1995 at the age of 16. My first node swelled in my neck about 6 months before my diagnosis and I was told that it was just an infected node due to my ear piercings. (Ear, Nose, Throat doc took one look at me and judged me by my appearance). They drained it and sent me on my way. 6 months later OOPS! you have cancer and it's now moved into your chest and you're in stage II. Needless to say it was a long summer of not learning to drive, chemotherapy (throwing up!) and a fall and winter of radiation. I've heard that chemo is alot easier than it was back then when they gave you the anti-nausea meds AFTER the treatement in pill form and then you just throw that right back up. Thanks for the article, I always wondered what the difference in the two was.

    January 5, 2011 at 14:45 | Report abuse | Reply
    • Laura H

      We just found out today that my step-daughter has NHL and she is 17. She also had a bump in her neck that they kept saying was nothing and now NHL. We are scared to death and meet on Monday to find out more and to start the next steps. Any information you give me us would be great. We have not told our daughter the entire truth, not sure if that is good or bad but that was her mom's decision. Please send a response if you like to my email address. Thanks in advance.

      May 7, 2011 at 17:39 | Report abuse |
  9. JoeKnowMe

    I was diagnosed 10 years ago with NHL Large Diffuse B-Cell. Had 6 cycles of CHOP +R (rituxan). Glad these options were available. Haven't looked back since. Thank you American modern medicine.

    January 5, 2011 at 15:31 | Report abuse | Reply
  10. Matt

    I was originally diagnosed with Crohns disease in 2002. Landed in the hospital 3 times in a year, and they decided to remove some inflamed tissue to buy me some years. After the surgery, the surgeon told my wife, "textbook Crohn's". Well, 2 days later he was singing a different tune: "Pathology indicates Lymphoma, no sign of Crohn's" So, I spent almost 2 weeks in hospital recovering. Originally the oncologist told me I had a slow growing system NHL, and that we'd do "watch and wait" therapy. 3 weeks after I left the hospital, I got a call on a Sunday from the oncologist. He told me, "it isn't what they told me it was. You have a very aggressive NHL and need to start chemo right away!". It turned out I had stage IV large diffuse T cell. Well, that was no fun, I must say. Anyway, 6 rounds of CHOP (5 with +R), and all gone. So, been almost 7 years now. My oncologist told me if it comes back, it is most likely a new occurrence. During the surgery, I had my ascending colon removed, my sigmoid colon removed, and 1/2 my transverse colon removed, plus 20 cm of bowel. I had fistulas everywhere and was a mess. Dr told my wife: "looked like someone dropped a hand grenade in there." There were times I felt self pity while lying in recovery, but, for me, I try to remain logical – ok, cancer, you say? – well let's get rid of it and move on. I was lucky. My wife had a hard time with it. We have 4 kids, the oldest only 9 in 2003, and some as young as 1. I don't think they remember much. Last week I had a squamous cell carcinoma removed from my arm, so the score is now me: 2, cancer: 0. Let's hope the shutout continues.... Good luck to all who face this disease (any variation thereof). It can be difficult, but it can be beat.

    January 5, 2011 at 21:17 | Report abuse | Reply
  11. Leong Wei Jyee

    Hello, The rituxmab treats B-cells but it knocks out all the B-Cell instead of the bad ones. Any actual targeted therapy where it only targets the bad B-cell?

    January 5, 2011 at 21:19 | Report abuse | Reply
    • shelley farrell

      Rituxan works on big B cells only.

      January 5, 2011 at 23:12 | Report abuse |
  12. Alan

    I lost my father to NHL in 1986, after a 5 year fight with the disease. After only being given a year to live, at age 39, he managed to fight on bravely for another four years.....acting as a guinea pig for my experimental treatments now being used to some positive effect. I was only 14 when he passed, and there's not a day I haven't thought of him over the past 24+ years. I can only hope that one day the medical community to rid us of this insideous disease.....

    January 5, 2011 at 22:42 | Report abuse | Reply
  13. dan ross

    I was diagnosed with mantle cell lymphoma in April of 2010. Went through 7 months of chemo and one round so far of radiation. I agree that no one should have to tell their family and friends they will not be with them in the near future. The treatment I received from the James Hospital in Columbus Ohio have placed the lymphoma in remission for now. I promised myself as long as I can I will fight for a cure and more research. We need to help the medical community in every way possible to find a cure for this disease.

    January 9, 2011 at 12:34 | Report abuse | Reply
  14. irisb


    October 8, 2013 at 10:39 | Report abuse | Reply

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