Stage and grade of non-Hodgkin lymphoma

Knowing the extent of the lymphoma helps your doctor plan the right treatment. This is called staging. Lymphomas are also grouped as either low grade or high grade.

Staging of non-Hodgkin lymphoma

The stage of lymphoma describes how many areas of the body are affected by lymphoma and where these are.

Your doctor will also ask you about any symptoms you have. All this information helps doctors plan the right treatment for you.

Staging of lymphoma can sometimes be complicated. Your doctor or specialist nurse will explain what stage you have.

Number staging

The stage of a lymphoma is usually described using numbers from 1 to 4.

Stages 1 and 2 NHL are sometimes called early stage (limited or localised lymphoma).

Stages 3 and 4 NHL are sometimes called advanced lymphoma.

In some situations, stage 2 lymphoma that is large (bulky – see below) is treated as advanced disease.

Stage 1

The lymphoma is either:

in a single lymph node, one group of lymph nodes, or in one organ of the lymphatic system, such as the tonsils
or in another part of the body outside the lymph system (extra-nodal – see below).

Stage 1 – Lymphoma in a single group of lymph nodes

The body’s lymph nodes are shown. 4 nodes in the neck and 4 under the arm are highlighted to show there is lymphoma in these 2 areas. — Image: The diagram shows the outline of a front facing body with a side view of the head. There is a band just below the lungs that goes all the way across the upper chest. This is the diaphragm. The lungs are lightly outlined with one on either side of the chest. In the neck on the left side of the diagram below the ear there is a group of small round lymph nodes. These are highlighted to show there is lymphoma in this area. There is a light outline of lots of other groups of lymph nodes shown throughout the body. They connect to each other through a network of fine tubes. There is no lymphoma in these nodes.

Stage 2

The lymphoma is either:

in two or more groups of lymph nodes
or in another part of the body (extra-nodal) and in one group of lymph nodes.

For both these, the sites of lymphoma are on the same side of the diaphragm – either above or below it. The diaphragm is the sheet of muscle underneath the lungs that separates the chest from the tummy (abdomen).

Stage 2 – Lymphoma in 2 groups of lymph nodes

Lymphoma in two groups of lymph nodes — Image: The diagram shows the outline of a front facing body with a side view of the head. There is a band just below the lungs that goes all the way across the upper chest. This is the diaphragm. The lungs are lightly outlined with one on either side of the chest. In the neck on the left side of the diagram below the ear there is a group of small round lymph nodes. These are highlighted to show there is lymphoma in this area. On the left side of the diagram in the area under the arm at the shoulder there is another group of lymph nodes. These are also highlighted to show there is lymphoma in this area. There is a light outline of lots of other groups of lymph nodes shown throughout the body. They connect to each other through a network of fine tubes. There is no lymphoma in these nodes.

Stage 3

There are areas of lymphoma above and below the diaphragm.

Stage 3 – Lymphoma in 2 groups of lymph nodes, above and below the diaphragm

The body’s lymph nodes are shown. 4 nodes in the neck and 4 in the groin are highlighted to show there is lymphoma in these 2 areas. — Image: The diagram shows the outline of a front facing body with a side view of the head. There is a band just below the lungs that goes all the way across the upper chest. This is the diaphragm. The lungs are lightly outlined with one on either side of the chest. In the neck on the left side of the diagram below the ear there is a group of small round lymph nodes. These are highlighted to show there is lymphoma in this area. On the left side of the diagram at the top of the thigh there is another group of lymph nodes. These are also highlighted to show there is lymphoma in this area.

Stage 4

The lymphoma is more widespread and may also affect organs such as the bone marrow, lungs or liver.

Stage 4 – Lymphoma has also spread to the lung and bone marrow

The body’s lymph nodes are shown. Lymphoma is shown in 4 nodes in the neck, 4 nodes in the groin, a lung and bone marrow in the hipbone. — Image: The diagram shows the outline of a front facing body with a side view of the head. There is a band just below the lungs that goes all the way across the upper chest. This is the diaphragm. The lungs are shown with one on either side of the chest. The outline of the lung on the left side of the diagram is highlighted to show there is lymphoma in this area. In the neck on the left side of the diagram below the ear there is a group of small round lymph nodes. These are highlighted to show there is lymphoma in this area. On the left side of the diagram at the top of the thigh there is another group of lymph nodes. These are also highlighted to show there is lymphoma in this area. On the right side of the diagram at the top of the thigh is the outline of the hipbone (femur). The centre of the upper part of the bone is shaded to show the bone marrow. The shading is used to show that there is lymphoma in the bone marrow.

Extra-nodal lymphoma

Lymphoma is sometimes found in parts of the body outside the lymph nodes (called extra-nodal lymphoma). Extra-nodal sites include the liver, lungs, spinal cord and bone marrow.

Extra-nodal lymphoma is described by adding the letter E (for extra-nodal) after the stage number. For example, the lymphoma may be described as 1E.

The staging of extra-nodal lymphoma depends on whether the lymphoma:

started in an organ outside the lymph nodes – this is called primary extra-nodal NHL

or started in the lymph nodes and then spread somewhere else.

If you have extra-nodal lymphoma, your doctor can explain how this affects the stage.

Bulky disease

If an area of lymphoma is large, it is often called bulky disease. The letter X may be added after the stage number. For example, the lymphoma may be described as 1X.

B symptoms

Sometimes the letter B is added after the stage number. For example, the lymphoma may be described as stage 1B. This is used to show if you have any symptoms doctors call B symptoms. These are:

heavy drenching night sweats

unexplained high temperatures

unexplained weight loss.

If you have any B symptoms, it usually means the lymphoma is more advanced. If you do not have any of these symptoms, the letter A is used instead, for example stage 1A.

Grades of non-Hodgkin lymphoma

Lymphomas are also often grouped as either low grade or high grade. The grade of the lymphoma is also an important factor in your treatment plan.

Low-grade lymphomas

These grow very slowly and are sometimes called indolent lymphomas. They may need little or no treatment for months or possibly years. Some people will never need treatment. Follicular lymphoma (FL) is the most common type of low grade NHL.

High-grade lymphomas

These grow more quickly and are sometimes called aggressive lymphomas. They usually cause symptoms and need immediate treatment. Diffuse large B-cell lymphoma (DLBCL) is the most common type of high-grade lymphoma.

About our information

References

Below is a sample of the sources used in our non-Hodgkin lymphoma (NHL) information. If you would like more information about the sources we use, please contact us at cancerinformationteam@macmillan.org.uk

National Institute of Health and Care Excellence (NICE). Blood and bone marrow cancers. NICE Pathways. Last accessed 3 December 2020.

Non-Hodgkin’s lymphoma: diagnosis and management; NICE Guideline (July 2016).

Newly Diagnosed and Relapsed Follicular Lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up; European Society for Medical Oncology (2020).

Reviewers

This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Senior Medical Editor, Professor Rajnish Gupta, Macmillan Consultant Medical Oncologist.

Our cancer information has been awarded the PIF TICK. Created by the Patient Information Forum, this quality mark shows we meet PIF’s 10 criteria for trustworthy health information.