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After adult Hodgkin lymphoma has been diagnosed, tests are done to find out if cancer cells have spread within the lymph system or to other parts of the body. There are three ways that cancer spreads in the body. Stages of adult Hodgkin lymphoma may include A, B, E, and S. The following stages are used for adult Hodgkin lymphoma: Stage I Stage II Stage III Stage IV Adult Hodgkin lymphoma may be grouped for treatment as follows: Early Favorable Early Unfavorable Advanced Favorable Advanced Unfavorable

After adult Hodgkin lymphoma has been diagnosed, tests are done to find out if cancer cells have spread within the lymph system or to other parts of the body.

The process used to find out if cancer has spread within the lymph system or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For adult Hodgkin lymphoma, CT scans of the chest, abdomen, and pelvis are taken.
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
• Bone marrow aspiration and biopsy: The removal of bone marrow, blood, and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views the bone marrow, blood, and bone under a microscope to look for signs of cancer.

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  Bone marrow aspiration and biopsy. After a small area of skin is numbed, a Jamshidi needle (a long, hollow needle) is inserted into the patient’s hip bone. Samples of blood, bone, and bone marrow are removed for examination under a microscope.

• Laparotomy: A surgical procedure in which an incision (cut) is made in the wall of the abdomen to check the inside of the abdomen for signs of disease. The size of the incision depends on the reason the laparotomy is being done. Sometimes organs are removed or tissue samples are taken and checked under a microscope for signs of disease. This procedure is done only if it is needed to make decisions about treatment.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Surgical biopsy: The removal of tissue using a scalpel. A pathologist views the tissue under a microscope to look for cancer cells.
• Thoracentesis: The removal of fluid from the space between the lining of the chest and the lung, using a needle. A pathologist views the fluid under a microscope to look for cancer cells.

For pregnant women with Hodgkin lymphoma, staging tests that protect the fetus from the harms of radiation are used. These include:

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

• Through tissue. Cancer invades the surrounding normal tissue.
• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

Stages of adult Hodgkin lymphoma may include A, B, E, and S.

Adult Hodgkin lymphoma may be described as follows:

• A: The patient has no symptoms.
• B: The patient has symptoms such as fever, weight loss, or night sweats.
• E: "E" stands for extranodal and means the cancer is found in an area or organ other than the lymph nodes or has spread to tissues beyond, but near, the major lymphatic areas.
• S: "S" stands for spleen and means the cancer is found in the spleen.

The following stages are used for adult Hodgkin lymphoma:

Stage I

Stage I is divided into stage I and stage IE.

• Stage I: Cancer is found in one lymph node group.
• Stage IE: Cancer is found in an area or organ other than the lymph nodes.

Stage II

Stage II is divided into stage II and stage IIE.

• Stage II: Cancer is found in two or more lymph node groups on the same side of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
• Stage IIE: Cancer is found in an area or organ other than the lymph nodes and in lymph nodes near that area or organ, and may have spread to other lymph node groups on the same side of the diaphragm.

Stage III

Stage III is divided into stage III, stage IIIE, Stage IIIS, and stage IIIS+E.

• Stage III: Cancer is found in lymph node groups on both sides of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
• Stage IIIE: Cancer is found in lymph node groups on both sides of the diaphragm and in an area or organ other than the lymph nodes.
• Stage IIIS: Cancer is found in lymph node groups on both sides of the diaphragm and in the spleen.
• Stage IIIS+E: Cancer is found in lymph node groups on both sides of the diaphragm, in an area or organ other than the lymph nodes, and in the spleen.

Stage III is also divided into stage III(1) and stage III(2) as follows:

• Stage III(1): Cancer is found only in the upper abdomen above the renal vein.
• Stage III(2): Cancer is found in lymph nodes in the pelvis and/or near the aorta.

Stage IV

In stage IV, the cancer either:

• is found throughout one or more organs other than the lymph nodes and may be in lymph nodes near those organs; or
• is found in one organ other than the lymph nodes and has spread to lymph nodes far away from that organ.

Adult Hodgkin lymphoma may be grouped for treatment as follows:

Early Favorable

Early favorable adult Hodgkin lymphoma is stage I or stage II, without risk factors.

Early Unfavorable

Early unfavorable adult Hodgkin lymphoma is stage I or stage II with one or more of the following risk factors:

• A tumor in the chest that is larger than 1/3 of the width of the chest or at least 10 centimeters.
• Cancer in an organ other than the lymph nodes.
• A high sedimentation rate (in a sample of blood, the red blood cells settle to the bottom of the test tube more quickly than normal).
• Three or more lymph nodes with cancer.
• Symptoms such as fever, weight loss, or night sweats.

Advanced Favorable

Advanced favorable adult Hodgkin lymphoma is stage III or stage IV with three or fewer of the following risk factors:

• Being male.
• Being aged 45 years or older.
• Having stage IV disease.
• Having a low blood albumin (protein) level (below 4).
• Having a low hemoglobin level (below 10.5).
• Having a high white blood cell count (15,000 or higher).
• Having a low lymphocyte count (below 600 or less than 8% of the white blood cell count).

Advanced Unfavorable

Advanced unfavorable Hodgkin lymphoma is stage III or stage IV with four or more of the following risk factors:

• Being male.
• Being aged 45 years or older.
• Having stage IV disease.
• Having a low blood albumin (protein) level (below 4).
• Having a low hemoglobin level (below 10.5).
• Having a high white blood cell count (15,000 or higher).
• Having a low lymphocyte count (below 600 or less than 8% of the white blood cell count).

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