Non-Hodgkin lymphoma (NHL) is a type of cancer that affects white blood cells in the lymphatic system. Doctors classify NHL into four stages, depending on how widespread it is. The stage of NHL will influence a person’s outlook, but other factors can also contribute.

NHL is one of two main types of lymphoma, a cancer of the lymphatic system.

According to the American Cancer Society (ACS), NHL is one of the most common forms of cancer in the United States, accounting for 4% of all cancer cases.

Although the outlook for NHL varies depending on the type, it is generally positive. NHL has four stages — the earlier stages tend to be more treatable as the cancer has not spread as far.

This article outlines the stages of NHL. It also discusses the outlook and treatment options.

Learn about the symptoms of NHL.

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The ACS states that the current staging system for NHL is called the Lugano classification.

Doctors use roman numerals from I to IV, which means 1–4. If NHL affects an organ outside of the lymph system, known as extra-nodal, doctors add an ‘E.’

Stage I

This is the earliest stage of NHL.

A doctor will diagnose stage I if the cancer cells are only present in a single lymph node region (LNR). This can include the:

  • spleen
  • thymus
  • waldeyer’s ring
  • one or more lymph nodes in a single LNR

Stage I also refers to lymphoma in an organ outside the lymphatic system. Doctors classify this as stage IE.

Stage II

Stage II means the cancer has reached two LNRs on the same side of the diaphragm. This can be above or below the diaphragm.

For example, stage II means there are two affected LNRs in the upper body or lower body.

If the affected regions are in both the upper and lower body, the lymphoma has progressed past stage II.

Doctors can also diagnose stage IIE. This occurs when one LNR is affected, and the cancer has also spread to a nearby organ.

Stage III

This is when the lymphoma affects LNRs above and below the diaphragm.

Doctors also diagnose stage III if they detect lymphoma in a lymph node above the diaphragm and in the spleen.

Stage IV

This is the latest possible stage of NHL.

Doctors diagnose stage IV NHL when the lymphoma has become widespread in an organ outside the lymphatic system.

The lymphoma may have spread to the:

This is another term a doctor may use to describe the lymphoma. It is not a separate stage but a characteristic that can affect treatment and outlook.

Doctors use the term ‘bulky’ when large tumors develop in any of the lymph node areas. The criteria doctors use to designate this characteristic will vary with the type of NHL.

Bulky lymphoma often requires more intensive treatment.

Staging can have a direct effect on a person’s outlook.

A relative survival rate helps give an idea of how long a person with a particular condition will live after receiving a diagnosis compared with those without the condition.

For example, if the 5-year relative survival rate is 70%, a person with the condition is 70% as likely to live for 5 years as someone without the condition.

It is important to remember that these figures are estimates. A person can consult a healthcare professional about how their condition is going to affect them.

The National Cancer Institute Surveillance, Epidemiology, and End Results Program provides the following 5-year relative survival rates for NHL based on stage:

Stage5-year relative survival rate
stage I86.5%
stage II78.1%
stage III72.3%
stage IV63.9%
unknown stage69.1%

The outlook of some lymphomas is less dependent on stage. In these cases, doctors use the International Prognostic Index.

The index uses five factors to obtain a score:

  • age
  • stage
  • if the lymphoma is outside the lymphatic system
  • how well people perform everyday activities
  • blood levels of lactate dehydrogenase (LDH)

This score then places people in risk groups ranging through low, low intermediate, high intermediate, and high. Doctors then use this designation to plan treatment.

To determine stage, doctors use a variety of tests and sources of information, such as:

  • Physical exam: Doctors examine the person’s body, paying special attention to lymph nodes to locate any swellings.
  • Medical history: This includes symptoms, risk factors, and other medical conditions, such as autoimmune diseases.
  • Biopsy: A doctor removes the lymph node to test in a lab. This can help confirm an NHL diagnosis.
  • Imaging tests: These include X-ray and ultrasound, CT, MRI, and PET scans.
  • Blood tests: Blood cell counts can indicate if lymphoma has reached the bone marrow. They will also measure levels of LDH.

Staging lymphoma is important in establishing a person’s treatment options.

Doctors refer to stages I and II as ‘limited’ and stages III and IV as ‘advanced.’ An advanced or bulky diagnosis indicates that treatment will be more challenging.

Other classifications can also influence treatment, such as the type of lymphoma and the grade of lymphoma.

NHL can originate in either B or T cells. The most common is B-cell lymphoma.

The grade refers to how fast the cancer spreads, and doctors split it into indolent or aggressive lymphoma. Aggressive lymphoma requires immediate treatment, while doctors can monitor indolent lymphomas without treatment.

There are many types of NHL. Treatment will depend on the type of NHL as well as the stage.

Generally, treatment options for NHL can be any one of or a combination of:

Doctors treat the most common form of NHL, diffuse large B-cell lymphoma, with chemotherapy and a drug cycle in stages I–II.

The later stages require more drug cycles and monitoring to determine how well the treatment is working.

NHL is a common form of cancer that affects the lymph system. There are many different types.

Doctors use staging to show how far the cancer has spread from the original area it developed. There are four stages of NHL.

The outlook for NHL is generally positive — diagnosing NHL at an earlier stage has a more positive outlook than later stages. However, many other factors contribute to a person’s outlook.