What are the staging guidelines for NHL/B-cell lymphoma?

Updated: Feb 23, 2021
  • Author: Mohammad Muhsin Chisti, MD, FACP; Chief Editor: Emmanuel C Besa, MD  more...
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In 2014, the International Conference on Malignant Lymphomas (a multidisciplinary team of researchers representing major lymphoma clinical trial groups and cancer centers from North America, Europe, Japan, and Australasia) published guidelines for the evaluation, staging, and response assessment of patients with malignant lymphomas. This staging system is known as the Lugano Modification of the Ann Arbor staging system. [15]  In 2015, the National Comprehensive Cancer Network (NCCN) adopted this system. [16]

The revised recommendations for staging include the following [15] :

  • Positron emission tomography–computed tomography (PET-CT) is preferred for fluorodeoxyglucose (FDG)-avid lymphomas; CT is indicated for non-avid lymphomas

  • PET-CT is preferred for pretreatment assessment and routine staging

  • Contrast-enhanced CT is more accurate for measurement of nodal size and is also preferred for radiation planning

  • PET-CT is preferred for determining splenic involvement, with cutoff for splenomegaly of more than 13 cm

  • Bone marrow biopsy is usually not required if the PET-CT scan indicates bone or marrow involvement but if the scan is negative, a bone marrow biopsy is indicated to identify involvement by discordant histology, if clinically relevant

  • Liver size is not a reliable measure; liver involvement is suggested by diffusely increased or focal uptake, with or without focal or disseminated nodules

  • Prior Ann Arbor staging divided patients according to absence (A) or presence (B) of disease-related symptoms (B symptoms include weight loss >10%, fever, drenching night sweats); these are not required in NHL staging since they are not prognostic

In addition, these guidelines offered consensus on further modifications to the Ann Arbor staging classification, as shown in Table 1, below [16, 15] :

  Table 4. Non-Hodgkin lymphoma staging. (Open Table in a new window)


Area of Involvement

Extranodal (E) Status


Single node or adjacent group of nodes

Single extranodal lesions without nodal involvement


Multiple lymph node groups on same side of diaphragm

Stage I or II by nodal extent with limited contiguous extranodal involvement

II bulky*

Multiple lymph node groups on same side of diaphragm with “bulky disease”



Multiple lymph node groups on both sides of diaphragm; nodes above the diaphragm with spleen involvement



Multiple noncontiguous extranodal sites


*Stage II bulky disease is considered limited or advanced; this distinction is made on the basis of histology and a number of prognostic factors.

Suffixes A and B are not required. X for bulky disease replaced with documenting of largest tumor diameter. Definition of “bulky” disease varies, depending on lymphoma histology.

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