Diagnosing and staging

Lymphoma does not have telltale symptoms that immediately point to a lymphoma diagnosis. You may visit your doctor because of swollen lymph nodes or bumps near your lymph nodes, or you may have “cold and flu-like” symptoms that do not go away.

After doing a physical exam, your doctor may recommend additional tests. A pathologist and/or a hematopathologist (a pathologist who is experienced in diagnosing blood cancers) will analyze any blood, bone marrow or tissue samples.

Following are descriptions of tests that may be used to diagnose lymphoma.

Blood Tests

  • Complete blood count (CBC) measures the levels of white blood cells, red blood cells and platelets in the blood.
  • Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells fall in a test tube over a period of time. A higher rate can mean lymphoma is present.
  • Flow cytometry helps determine whether an increase in the number of lymphocytes in the blood is caused by lymphoma, some other blood disorder, or a reaction to another condition, such as an infection.
  • Immunofixation test identifies and measures small amounts of abnormal protein in the blood or urine.
  • Immunophenotyping identifies specific types of cancer cells in the blood, bone marrow or lymph nodes.
  • Serum lactate dehydrogenase (LDH) test measures an enzyme that is expressed at higher levels when lymphocytes divide or when cells are damaged.


Doctors remove and examine lymph nodes or other tissues to check for lymphoma cells. They may use additional tests to distinguish different cell types.

Bone Marrow Biopsy and Aspiration

A bone marrow biopsy involves removal of a sample of marrow from within the bone, usually the pelvic bone. For bone marrow aspiration, liquid bone marrow is removed, usually from the back of the pelvic bone or breastbone. Often, both a biopsy and aspiration are done to collect multiple samples.

Imaging Tests

Imaging tests are used to help determine the extent and spread of disease:

  • Computed tomography (CT), also called tomography or CAT, involves the use of a scanner to create three-dimensional X-ray images of organs, tissues and bones.
  • Magnetic resonance imaging (MRI) involves the use of magnetic fields to visualize internal structures of the body.
  • Positron emission tomography (PET) and integrated PET/CT are diagnostic tests used to create images of bones, organs and tissues for the evaluation of metabolic activity and function in different areas of the body. A small amount of radioactive glucose is injected into the body and a special camera is used to show were glucose has collected in the body. This scan can help identify areas of the body affected by lymphoma.
  • Ultrasound uses high-energy sound waves that bounce off internal tissues and organs to create an image called a sonogram.
  • X-ray uses low-dose radiation to create pictures of the inside of the body. X-rays, usually of the chest bone, may be done to look for spread of disease.

Staging Lymphoma

The Ann Arbor staging system is the most commonly used system for staging non-Hodgkin lymphoma. A modification of this system, called the Cotswold system, is used for staging Hodgkin lymphoma.

A patient will receive a diagnosis of Stage I, II, III or IV. In both of these classification systems, a higher stage number indicates more advanced disease. In addition to the staging systems, oncologists also use the International Prognostic Index (IPI) to predict the risk of disease recurrence and overall survival for patients with non-Hodgkin lymphoma. The IPI accounts for the age and general health of the patient, the stage of the disease, whether organs outside the lymphatic system are involved, and the presence or absence of elevated levels of lactate dehydrogenase in the blood.

The IPI assigns one point for each of the following risk factors:

  • Age: greater than 60 years
  • Performance status: poor general health
  • Lactate dehydrogenase in the blood: higher than normal levels
  • Extranodal sites: involvement of more than one organ outside the lymph nodes
  • Stage: III or IV

Each point contributes to the overall IPI score of zero to five. A person’s risk is considered low if the score is a zero or one, and high if the score is greater than three.

The Follicular Lymphoma International Prognostic Index (FLIPI) is similar to the IPI but the factors are levels of hemoglobin and the amount of lymph nodes affected by the disease. The FLIPI is sometimes used to predict outcomes for people with follicular lymphomas, which tend to grow more slowly.

Lymphoma Stages

Stage Description
Stage I The disease is in only one lymph node area or lymphoid organ.
Stage IE The disease is in only one area of a single organ outside the lymphatic system.
Stage II The disease is in two or more lymph node areas on the same side (above or below) of the diaphragm.
Stage IIE The disease extends from one lymph node area to a nearby organ, with possible spread to one or more lymph node areas on the same side of the diaphragm.
Stage III The disease is in lymph node areas on both sides (above and below) of the diaphragm.
Stage IIIE The disease is in lymph node areas above and below the diaphragm and has spread to an organ outside the lymphatic system.
Stage IV The disease has spread outside the lymphatic system to an organ that is not directly next to the involved lymph node area(s); or it has spread to the bone marrow, lungs, cerebrospinal fluid or liver.
Letters accompany a stage to indicate whether additional factors are present:
A: Fever, night sweats and weight loss are not present.
B: Fever, night sweats and weight loss are present.
E: The cancer affects an organ or tissue outside the lymphatic system.
S: The cancer affects the spleen.
X: Bulky disease is present (disease in the chest that is one-third as wide as the chest or tumors in other places that are at least 4 inches across).


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