What are the Stages of Hodgkin's Lymphoma?

Written by Hexahealth Care Team, last updated on 15 December 2023
What are the Stages of Hodgkin's Lymphoma?

Hodgkin's lymphoma, a type of cancer that affects the lymphatic system, is classified into different stages to determine its extent and guide treatment decisions. Understanding the Hodgkin's lymphoma stages is essential for patients, their families, and the doctor to comprehend the progression and prognosis of the disease. 

This article will make you understand each of the Hodgkin’s lymphoma stages, from the initial diagnosis to stage 4 Hodgkin’s lymphoma, its treatment based on lymphoma stages,  survival rate, and prognosis factors related to Hodgkin's lymphoma. 

What is Hodgkin's lymphoma?

The cancer termed Hodgkin lymphoma, also known as Hodgkin disease, develops in the lymphatic system when there is an abnormal growth of white blood cells called lymphocytes. Dr. Thomas Hodgkin, in 1832, recorded multiple instances of persons exhibiting symptoms of lymph node-related malignancy. 

  1. It is characterised by the presence of abnormal cells called Reed-Sternberg cells, which are large, atypical cells found in the lymph nodes. 

  2. Hodgkin's lymphoma is less common than non-Hodgkin's lymphoma, but it has a high cure rate, especially in its early stages.

  3. The exact cause of Hodgkin's lymphoma is unknown, but certain risk factors have been identified. These include a weakened immune system, a family history of the disease, and exposure to certain viruses, such as the Epstein-Barr virus. 

  4. It most commonly affects young adults between the ages of 15 and 40 and older adults over the age of 55.

  5. Hodgkin's lymphoma symptoms can vary but often include swollen lymph nodes in the neck, armpits, or groin, persistent fatigue, unexplained weight loss, fever, night sweats, and itching.

  6. Diagnosis of Hodgkin's lymphoma involves a combination of physical examinations, imaging tests, and biopsies of affected lymph nodes or other involved tissues. 

    1. Once diagnosed, the doctor uses a specific staging system, which takes into account the location and extent of the disease. 

    2. This staging helps determine the appropriate treatment plan, which may include immunotherapy, chemotherapy, radiation therapy, targeted therapy, or stem cell transplantation.

    Hodgkin's Lymphoma Types

    Hodgkin's lymphoma is divided into two main types: classical Hodgkin's lymphoma and nodular lymphocyte-predominant Hodgkin's lymphoma. These types are distinguished based on the characteristics of the cancer cells observed under a microscope.

    1. Classical Hodgkin's Lymphoma:

      1. Nodular Sclerosis Hodgkin's Lymphoma: This is the most common subtype, accounting for about 70 to 80% of all cases. It is characterised by the presence of Reed-Sternberg cells and fibrotic bands dividing the lymph nodes into nodules.

      2. Mixed Cellularity Hodgkin's Lymphoma: This subtype accounts for about 25% of cases. It is characterised by abundant Reed-Sternberg cells mixed with other immune cells.

      3. Lymphocyte-Rich Hodgkin's Lymphoma: This subtype is less common, making up about 5% of cases. It is characterised by many reactive immune cells, particularly lymphocytes, and a few Reed-Sternberg cells.

      4. Lymphocyte-Depleted Hodgkin's Lymphoma is the rarest subtype, accounting for less than 1% of cases. It is characterised by numerous Reed-Sternberg cells and a minimal number of surrounding immune cells.

    2. Nodular Lymphocyte-Predominant Hodgkin's Lymphoma:

      1. Nodular Lymphocyte-Predominant Hodgkin's Lymphoma (NLPHL): This type is distinct from classical Hodgkin's lymphoma and accounts for about 5% of cases. It is characterised by lymphocyte-predominant cells, known as popcorn cells, which resemble lymphocytes.

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Staging System Used in Hodgkin's Lymphoma

Following a Hodgkin’s lymphoma diagnosis, medical professionals will attempt to determine whether the cancer has spread and, if so, how far. This process is known as staging.

The staging process determines the spread of cancer in the body and helps evaluate the cancer's severity and the most effective course of treatment. When discussing survival rates, doctors also refer to the stage of the malignancy.

To determine the stage of lymphoma, several factors are considered:

  1. Medical history of the patient.

  2. The patient has specific symptoms known as B symptoms.

  3. A physical examination is conducted.

  4. Results of biopsy tests.

  5. Imaging tests are carried out, including a chest X-ray, CT scan of the chest/abdomen/pelvis, and PET scan.

  6. Occasionally, a bone marrow aspiration and biopsy are also conducted, although not always.

Lugano Classification

The Lugano classification is a system used by the cancer care team to determine the extent of the spread of Hodgkin's lymphoma. 

  • Hodgkin lymphoma has four stages: 1, 2, 3, and 4, each of which refers to the extent to which the lymphoma cancer stages have spread from a specific lymph node location to the rest of the body. Stage 4 lymphoma suggests a significant spread. 

  • The categories—A, B, E, S, and X—evaluate the presence of particular symptoms and the potential extent of the disease's progress across the body.

Hodgkin's Lymphoma Stages

Cancer staging of Hodgkin's lymphoma is a way to determine the extent and spread of the disease and Hodgkin's lymphoma stages within the body. It helps doctors understand where the cancer is located, whether it has spread, and if it affects other body parts. Below are the details about the Hodgkin’s lymphoma stages.

Stage I Hodgkin’s Lymphoma

Stage I indicates that Hodgkin lymphoma is limited and can be defined as follows:

  1. The lymphoma is found in only one lymph node portion or lymphoid organ, such as the thymus.

  2. This stage is localised to one part of an organ outside the lymphatic system.

Stage II Hodgkin’s Lymphoma

Stage II suggests the following possibilities:

  1. The lymphoma is seen in two or more lymph node portions on the same facet of the diaphragm, which is the tissue between the chest and abdomen.

  2. Or else, the cancer spreads from one lymph node area into a nearby organ outside the lymphatic system or the spleen.

Stage III Hodgkin’s Lymphoma

Stage III indicates the following scenarios:

  1. The lymphoma is present in lymph node areas on both sides of the diaphragm, possibly with localized involvement of an organ outside the lymphatic system or the spleen.

Stage IV Hodgkin’s Lymphoma

Stage 4 lymphoma implies that Hodgkin lymphoma has spread extensively to at least one organ outside the lymphatic system, for example, the liver, bone marrow, or lungs.

Other Modifiers for Hodgkin’s Lymphoma Staging

The doctors may also use other ways to describe Hodgkin’s lymphoma stages.

Bulky Disease 

This term is used when tumors in the chest are at least ⅓ the width of the chest or tumors in other areas are at least 10 centimeters (about 4 inches) across. It is denoted by adding the letter X to the stage. The bulky disease is particularly significant in stage II lymphomas, as it may require more intensive treatment.

A, B, E, S, and X Categories

Different categories are also used to stage cancer and indicate the presence or absence of particular symptoms and the extent of cancer spread beyond the lymph nodes. 

Here's what each category represents:

  1. Category A: No symptoms have developed.

  2. Category B: Symptoms like unexplained weight loss, drenching night sweats, or fever of at least 100.4°F (38°C) have appeared.

  3. Category E: Extranodal cancers have spread from the lymph nodes to other tissues or organs.

  4. Category S: The cancer has spread to the spleen. Around 30 percent of Hodgkin lymphoma patients experience an enlarged spleen called splenomegaly.

  5. Category X: The disease is considered "bulky," with large tumors more than 10 cm in size spanning the chest region.

Resistant or Recurrent Hodgkin Lymphoma

Resistant or recurrent Hodgkin lymphoma is not officially part of the staging system, but doctors or nurses may use these terms to describe the lymphoma's status:

  1. Resistant or Progressive Disease: Used when the lymphoma does not respond to the therapy or progresses during the treatment duration

  1. Recurrent or Relapsed Disease: Indicates that the lymphoma went into remission with treatment but has now returned. The recurrence can happen in the exact location or a different body part shortly after treatment or years later.

Treating Hodgkin's Lymphoma based on the Stage

The stage of the disease influences treatment for Hodgkin's lymphoma, assisting medical professionals in creating a suitable and efficient treatment strategy. 

The available treatments may change depending on the precise Hodgkin's lymphoma stage. According to its various stages, Hodgkin's lymphoma is treated as follows:

Stage IA and IIA: Favorable

These stages include Hodgkin's lymphoma (HL), which is restricted to only one side of the diaphragm (either above or below), and possesses no unfavorable factors. Here are the characteristics of this stage:

  1. It is not bulky.

  2. HL is present in less than three different lymph node areas.

  3. It does not cause any of the B symptoms.

  4. The erythrocyte sedimentation rate (ESR is a blood test detecting inflammation in the body) is not elevated.

Treatment approach for favourable stages:

  1. Treatment for many patients in this stage involves chemotherapy, typically 2 to 4 cycles of the ABVD (Doxorubicin Hydrochloride (Adriamycin), Bleomycin Sulfate, Vinblastine sulfate, and Dacarbazine) regimen. 

  2. This is followed by radiation therapy targeting the initial site of the disease, known as involved site radiation therapy (ISRT). 

  3. Alternatively, selected patients may receive chemotherapy alone for 3 to 6 cycles.

  4. After a few rounds of chemotherapy, doctors often order a PET/CT scan to assess the effectiveness of the treatment and determine if further treatment is necessary.

  5. Radiation therapy alone may be considered if a person cannot undergo chemotherapy due to other health conditions.

Stages I and II: Unfavourable

These stages refer to Hodgkin's lymphoma (HL) that is localized on one side of the diaphragm (above or below) but exhibits one or more of the following risk factors:

  1. The tumor is bulky (large).

  2. HL is present in three or more distinct areas of lymph nodes.

  3. Cancer is detected outside the lymph nodes (extranodal involvement).

  4. B symptoms are observed.

  5. The erythrocyte sedimentation rate (ESR) is high.

Treatment approach for unfavourable stages:

  1. The treatment approach is generally more intensive than for favorable diseases. Typically, it involves initiating chemotherapy, often with the ABVD regimen, for four to six cycles or using alternative regimens like three cycles of Stanford V.

  2. PET/CT scans are frequently conducted after several rounds of chemotherapy to assess the necessity and extent of further treatment. 

  3. Subsequently, additional chemotherapy may be administered, which may differ from the previous regimen. 

  4. At this stage, radiation therapy (specifically involved field radiation therapy or IFRT) is commonly employed to target the tumor sites, mainly if the disease is initially bulky.

Stages III and IV

In stages three and stage 4 Hodgkin's lymphoma, cancer has spread extensively throughout the body, involving both lymph nodes above and below the diaphragm and other organs. 

  1. To treat these advanced stages, doctors usually use more intensive chemotherapy regimens compared to earlier stages. 

  2. The ABVD regimen, consisting of at least six cycles, is commonly employed. However, some doctors prefer a more aggressive approach, using the Stanford V regimen for three cycles or the BEACOPP regimen for up to 8 cycles, especially if there are multiple negative prognostic factors. 

  3. Another treatment option for specific individuals is combining chemotherapy with the drug brentuximab vedotin (Adcetris).

  4. During or after chemotherapy, PET/CT scans may be performed to assess the comprehensive effectiveness of the treatment. Based on the scan results, additional chemotherapy may be administered if necessary. 

  5. In some instances, radiation therapy may be given following chemotherapy, mainly if there are large tumor areas.

  6. For individuals whose Hodgkin's lymphoma does not respond to initial treatment, alternative chemotherapy drugs or high-dose chemotherapy, possibly accompanied by radiation therapy, followed by a stem cell transplant, may be recommended. 

  7. Another possibility is treatment with immunotherapy drugs like Brentuximab Vedotin, Nivolumab, or Pembrolizumab.

It is widely recommended by experts that HL patients who show resistance to treatment or experience a relapse should consider participating in a clinical trial. Clinical trials offer alternative medicines and therapies for patients in such cases.

Survival Rates for Different Hodgkin’s Lymphoma Stages

Hodgkin's lymphoma survival rates can vary based on a number of variables, including the disease stage at the time of diagnosis. It's crucial to keep in mind that survival statistics are broad projections and might not correctly forecast a person's prognosis. Here is a summary of Hodgkin's lymphoma survival rates at various stages:

  1. Stage I and II: The overall survival rate for early-stage Hodgkin's lymphoma is generally high, with a five-year survival rate ranging from 90% to 95%.

    1. With appropriate treatment, the majority of patients achieve long-term remission and have a good prognosis.

  1. Stage III and IV: Advanced-stage Hodgkin's lymphoma has a slightly lower overall survival rate compared to early-stage disease.

    1. The five-year survival rate for stage III Hodgkin's lymphoma ranges from 80% to 85%, while for stage IV, it ranges from 65% to 70%.

    2. However, it's important to note that with advancements in treatment options, including more effective chemotherapy regimens and targeted therapies, survival rates continue to improve.

Prognostic Factors

Besides the stage of the disease, other factors can influence the prognosis of Hodgkin's lymphoma.

  1. Prognostic factors may include the presence of certain symptoms, such as weight loss, fever, and night sweats, as well as the level of certain proteins or markers in the blood.

  2. Additionally, factors like age, gender, overall health, and response to initial treatment can impact a person's prognosis


We learned in this article that Hodgkin's lymphoma is a lymphatic system-related cancer. You have read about Hodgkin's lymphoma condition, its risk factors, symptoms, types, many Hodgkin's lymphoma stages, and treatment options according to lymphoma cancer stages, which is essential for people and families who want awareness. Increasing awareness and encouraging early detection can improve the prognosis and survival rates and strengthen care for Hodgkin's lymphoma patients.

Hexahealth is one of the leading and most reliable names for health and wellness platforms. Our team of experts is available round the clock to provide you with specific and accurate information. From helping you find the best team of doctors to hospitals and other health-related guidance, Hexahealth allows you to smoothen and simplify your medical journey in more ways than one can imagine. Get in touch with us to know more about Hodgkin’s and non-Hodgkin’s lymphoma stages. 

Suggested Reads

Types of Lymphoma Difference between Hodgkin and Non-Hodgkin Lymphoma
Hodgkin Non Hodgkin Lymphoma Treatment Leukemia vs Lymphoma

Frequently Asked Questions

What are the different Hodgkin's lymphoma stages?

Hodgkin lymphoma is classified into stages and categories. The Lugano classification is used for Hodgkin lymphoma staging based on the older Ann Arbor method. Hodgkin’s lymphoma stages can be classified as 1, 2, 3, and 4, defined by how far the disease has reached from a single lymph node area to the rest of the body. The categories—A, B, E, S, and X—measure the presence of certain symptoms and where the disease may have spread in the body.

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What does stage 4 Hodgkins lymphoma indicate?

This is the last and most advanced stage of Hodgkin's lymphoma cancer of this kind. The following is true in stage 4 Hodgkins lymphoma:

  1. Outside the lymphatic system, the cancer has spread to at least one organ, such as the liver, lungs, or bone marrow. This is in addition to lymph node cancer.

  2. Six to eight cycles of chemotherapy, as well as steroids and radiation treatment, are commonly used to treat stage 4 Hodgkin lymphoma.

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Can you explain the staging system for Hodgkin's lymphoma?

When someone is diagnosed with Hodgkin lymphoma (HL), doctors will try to determine whether the HL cancer has reached and, if so, how far it has spread. This is called cancer staging. The cancer stage explains how much cancer is present in the body. It helps determine the cancer's severity and how best to treat it. Doctors also rely on the cancer's stage when discussing survival rates.

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What are the criteria used to determine the stage of Hodgkin's lymphoma?

The Hodgkin's lymphoma stage is built around:

  1. Your medical background

  2. If you experience particular symptoms (referred to as B symptoms),

  3. The physical examination

  4. Biopsies

  5. Imaging studies, such as a chest x-ray, a CT scanning of the chest/abdomen/pelvis, and a PET scan

  6. Aspiration of bone marrow and biopsy (sometimes, but not always)

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How is Hodgkin's lymphoma staged, and what does each stage mean?

Accurately assessing the stage and category of Hodgkin lymphoma is critical when weighing treatment choices.

  1. Stage I: Cancer affects one lymph node region or lymphoid organ in stage 1 Hodgkin lymphoma. 

  2. Stage II: The cancer in stage 2 Hodgkin lymphoma affects two or more lymph node regions in the same body. 

  3. Stage III: Cancer has spread to both sides of the diaphragm in stage 3 Hodgkin lymphoma. It's also possible that the cancer has spread to the lymph nodes above the diaphragm and the spleen. 

  4. Stage IV: Cancer has gone to at least one organ outside the lymphatic system in stage 4 Hodgkin lymphoma, such as the liver, lungs, or bone marrow. This is in addition to lymph node cancer.  

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Are there specific tests to determine the stage of Hodgkin's lymphoma?

Imaging tests generate images of the inside of the body using X-rays, sound waves, magnetic fields, or radioactive particles. Imaging examinations can assist in determining the stage (amount) of Hodgkin lymphoma.

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Can the stage of Hodgkin's lymphoma affect the treatment approach?

Many factors influence treatment options, including:

  1. Hodgkin's Lymphoma subtype

  2. The Hodgkin's lymphoma stage (extent)

  3. Whether or not the disease is substantial (bulky).

  4. Whether or not the disease causes B symptoms

  5. The results of blood tests and other laboratory testing

  6. The age and health of a person

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What are the survival rates associated with each stage of Hodgkin's lymphoma?

Survival Rates for Hodgkin lymphoma by stage:

  • Stage I and II: You have a good chance of five-year survival, with rates around 90% to 95%.

  • Stage III: The five-year survival rate typically averages around 80% to 85%.

  • Stage IV: The survival rate at this stage is approximately 65% to 70% over five years.

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Does the stage of Hodgkin's lymphoma impact the prognosis?

The stage of Hodgkin's lymphoma is critical in determining prognosis and therapy plans. However, how far the HL has gone and which organs or sections of tissue it affects can fluctuate across stages. As a result, clinicians use a variety of criteria to establish prognoses for both early and advanced HL. These are unfavorable (adverse) hazards because they increase the likelihood that the HL will return (relapse) following treatment.

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Are there different symptoms associated with each stage of Hodgkin's lymphoma?

Another category of staging considers symptoms and divides each stage into two halves, A and B, such as stage IA or stage IB. The categories—A, B, E, S, and X—measure certain symptoms and the capacity to which the disease has spread in the body.

If a patient has symptoms like fevers, shaking chills, drenching night sweats, or accidental weight loss, their stage will begin with a B, such as stage IB or IIB. The symptoms must be obvious. If patients do not exhibit these symptoms, their stage will begin with an A, such as Stage IA or IIA.  

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Are there different symptoms associated with each stage of Non-Hodgkin's lymphoma?

Another level of staging considers symptoms and divides each stage into two halves, A and B, such as stage IA or stage IB. The categories—A, B, E, S, and X—measure certain symptoms and the area to which the disease has spread in the body.

NHL can also be classified into several categories, with the following letters appended to the stage number based on symptoms:

  1. A: You do not have a fever, excessive sweating, or weight loss.

  2. B: You have an unusual fever, drenching night sweats, and unexplained weight loss.

  3. E: The lymphoma is outside the lymph nodes in adjacent tissue (called an extranodal location).

  4. S: The lymphoma has metastasized to the spleen.

  5. X: There are extensive sections of NHL regarding bulkiness.

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All the articles on HexaHealth are supported by verified medically-recognized sources such as; peer-reviewed academic research papers, research institutions, and medical journals. Our medical reviewers also check references of the articles to prioritize accuracy and relevance. Refer to our detailed editorial policy for more information.

  1. Lymphoma - Hodgkin - Stages [Internet]. Cancer.net. 2012.link
  2. Hodgkin Lymphoma Stages | Hodgkin Disease Stages [Internet]. www.cancer.org.link
  3. Hodgkin Lymphoma Treatment Protocol by Stage [Internet]. www.cancer.org.link
  4. gknation. Hodgkin Lymphoma | Leukemia and Lymphoma Society [Internet]. Lls.org. 2015.link
  5. Hodgkin Lymphoma Survival Rates | Hodgkin Disease Survival Rates [Internet]. www.cancer.org.link

Updated on : 15 December 2023


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HexaHealth Care Team

HexaHealth Care Team brings you medical content covering many important conditions, procedures falling under different medical specialities. The content published is thoroughly reviewed by our panel of qualified doctors for its accuracy and relevance.

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