Hodgkin lymphoma

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Staging Hodgkin lymphoma

Staging is a way of describing or classifying a cancer based on the extent of cancer in the body. Extent includes the size of the tumour and where the cancer is in the body. Your healthcare team uses the stage to plan treatment and estimate your prognosis.

Cotswold system

The most common staging system for Hodgkin lymphoma (HL) is the Cotswold system. Each stage is given a number from 1 to 4. Stages 1 to 4 are usually given as the Roman numerals I, II, III and IV. Generally, the higher the number, the more the cancer has spread.

Stage details

Doctors may add the following letters to give more details about the stage.

E means that the HL affects an organ or area of the body outside of the lymphatic system (called an extralymphatic site).

S means that HL affects the spleen.

A means that the person doesn’t have B symptoms.

B means that the person has one or more B symptoms, which are:

  • unexplained fever of 38°C or higher
  • drenching night sweats
  • unexplained weight loss of more than 10% of body weight over the last 6 months

X means that the HL is bulky. Bulky disease includes tumours in:

  • the chest that are at least one-third as wide as the chest
  • other areas that are 10 cm or more across

Stage I


HL is in only one lymph node area or one lymphatic organ, such as the thymus.


HL is in one organ or area of the body outside of the lymphatic system.

Stage II


HL is in 2 or more lymph node areas on the same side of (either above or below) the diaphragmdiaphragmThe thin muscle below the lungs and heart that separates the chest cavity from the abdomen..


HL is in one organ and the nearby lymph nodes. It may also be in other lymph node areas on the same side of (either above or below) the diaphragm.

Stage III


HL is in lymph node areas both above and below the diaphragm.


HL is in lymph node areas both above and below the diaphragm and in the spleen.

Stage IV


HL has spread to more than one organ or area of the body outside the lymphatic system.


HL is in one organ outside the lymphatic system and in lymph nodes farther from where it started.

Relapsed HL

Relapsed, or recurrent, HL means that the cancer has come back after it has been treated. If it comes back in the same place that the cancer first started, it’s called local relapse. It can also relapse in another part of the body, which is called a distant metastasis, or a distant relapse.

Refractory HL

Refractory HL means that the cancer did not go away with treatment or it continued to grow during treatment. Refractory disease is also called resistant or progressive disease.


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