Staging of Non-Hodgkin's Lymphoma

Li Liu, MD
Last Modified: November 1, 2001

Dear OncoLink "Ask the Experts,"
My girlfriend was recently diagnosed with Adult non-Hodgkin's Lymphoma. She had a bone marrow biopsy done and her doctor says she has lymphoma in her bones. Now the nurse said that she is in stage IV. Does the bone marrow having lymphoma mean stage 4? Exactly how much worse is stage IV than the other stages? What are the averages on remission and time it lasts?

I THANK YOU Very Much!  

Li Liu, MD, Editorial Assistant for OncoLink, responds:

Dear S,
Thank you for your interest and question.

Patients with non-Hodgkin's Lymphoma (NHL) are staged with the Ann Arbor system. Stage IV is defined as either of the following:

  1. Cancer has spread to more than one organ or organs outside the lymph system. Cancer cells may or may not be found in the lymph nodes near these organs.
  2. Cancer has spread to only one organ outside the lymph system, but lymph nodes far away from that organ are involved.
When the bone marrow is involved by lymphoma cells, it means Stage IV disease, since bone marrow is considered as an extra-lymphatic organ.

In addition to the Ann Arbor system, there are a variety of pretreatment clinical factors which have been found to be associated with the prognosis of patients with NHLs:

  • age at diagnosis (³60 vs. <60);
  • systemic symptoms (fever, weight loss> 10% of body weight, and sweats);
  • performance status;
  • serum lactate dehydrogenase (LDH);
  • number of nodal and extranodal sites of disease;
  • tumor bulk.
The adult non-Hodgkin's lymphomas are divided into two groups: indolent lymphomas, which are slower growing and have fewer symptoms, and aggressive lymphomas, which grow more quickly.

The optimal treatments for patients with Stage IV indolent NHL remain controversial. The reasons for controversy relate to the fact that the vast majority of patients with advanced stages of low-grade lymphoma are not cured with current therapeutic options. The treatments are quite divergent, which include:

  1. Watchful waiting until symptoms appear.
  2. Chemotherapy with either a single drug or combination chemotherapy
  3. Chemotherapy plus radiation therapy plus bone marrow transplantation or peripheral stem cell transplantation is being tested in clinical trials.
For patients with aggressive Stage IV NHL, the standard treatment has been doxorubicin-based combination chemotherapy, including CHOP (Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone). Long term disease-free survival is in the range of 35% to 45%. Bone marrow transplantation or peripheral stem cell transplantation is under clinical evaluation.

Your girlfriend should discuss these treatment options with her medical oncologist.

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