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Ann Arbor staging in Hodgkin lymphoma | CION Cancer Clinics
Ann Arbor staging gives Hodgkin lymphoma a stage from I to IV. Stages I and II mean lymph node areas on one side of the diaphragm, the breathing muscle under the lungs. Stage III means both sides. Stage IV means spread into an organ such as the liver or bone marrow. Letters such as A, B, E and bulky add detail that shapes treatment. At CION Cancer Clinics, our haematology team plans myeloma and lymphoma care with you, discussed at a tumour board and explained in plain words.
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Medically reviewed by Dr. Basudev PokhrelConsultant Haematologist · last reviewed September 2026, next review due September 2027
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On this page
- How does Ann Arbor staging work in Hodgkin lymphoma?
- What does each stage mean?
- What do the letters and words beside the stage mean?
- Which tests decide the stage?
- What counts as a B symptom, and why does it matter?
- What do families often get wrong about the stage?
- What can the stage not tell you?
- Common questions about Hodgkin lymphoma staging
The short answer
How does Ann Arbor staging work in Hodgkin lymphoma?
Ann Arbor staging sorts Hodgkin lymphoma into four stages, I to IV, based on how many lymph node areas are involved and whether they sit on one or both sides of the diaphragm, the breathing muscle under the lungs. Stage IV means the disease has spread into an organ such as the liver, lungs or bone marrow.
The letters that follow the number
The stage number is followed by letters. "A" means no B symptoms, "B" means B symptoms are present, and "E" means the lymphoma has grown from a node into nearby tissue. So "stage IIB" means nodes on one side of the diaphragm, with B symptoms. Many reports also add "bulky" or "X" when one mass is especially large.
What most centres use today
Most haematologists now use the Lugano classification. It is built on Ann Arbor, keeps the same four stages, and uses a PET-CT scan to stage the disease. You may see either name on your report. For you the meaning is almost the same.
Stage is one part of the picture. Treatment is also shaped by symptoms, blood tests, age, the size of the largest mass and how the disease responds.The four stages
What does each stage mean?
A "node area" is a group of glands, such as those on one side of the neck, in one armpit, or in the centre of the chest.
Stage I
Lymphoma in one lymph node area, or in one organ outside the lymph nodes without node involvement.
Grouped as
- Early stage
Stage II
Two or more node areas, all on the same side of the diaphragm. For example, the neck and the chest, but not the abdomen.
Grouped as
- Early stage, favourable or unfavourable
- Sometimes treated as advanced if bulky
Stage III
Node areas on both sides of the diaphragm, such as the neck and the abdomen. The spleen may also be involved.
Grouped as
- Advanced stage
Stage IV
Lymphoma has spread into one or more organs outside the lymph system, such as the liver, lungs, bone or bone marrow.
Grouped as
- Advanced stage, still treatable with a plan aimed at remission
Not sure whether this applies to you?
Ask an oncologistOn your report
What do the letters and words beside the stage mean?
- A
- None of the B symptoms described below.
- B
- At least one B symptom: unexplained fevers, drenching night sweats, or unexplained weight loss.
- E (extranodal)
- The lymphoma has grown from a node into a nearby organ or tissue, such as the lung next to a chest node.
- Bulky or X
- One mass is especially large, often a mass in the centre of the chest. Bulky disease usually means more treatment.
- S
- The spleen is involved.
- Remission
- Scans and tests no longer show active lymphoma. It is a result of treatment, not a stage.
Working out the stage
Which tests decide the stage?
Examination and history
Your haematologist feels for swollen glands and an enlarged liver or spleen, and asks about fevers, night sweats, itching and weight loss.
Blood tests
A full blood count, liver and kidney tests, and the ESR, a marker of inflammation. The ESR helps sort early-stage disease into favourable or unfavourable groups.
PET-CT scan
The main staging scan. It shows active lymphoma throughout the body, including in bone marrow, and is used again later to check the response.
Sometimes more
A bone marrow biopsy is now rarely needed when a PET-CT is done. Heart and lung tests are often arranged before chemotherapy starts.
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B symptoms
What counts as a B symptom, and why does it matter?
B symptoms are three specific signs that the lymphoma is affecting the whole body. Having any one of them adds a "B" to the stage, and usually points towards more treatment.
The three B symptoms
The first is unexplained fever above 38 degrees Celsius. The second is drenching night sweats, the kind that soak your clothes or bedsheets. The third is losing more than a tenth of your body weight over six months without trying. A fever from a known infection, or weight lost by dieting, does not count.
Symptoms that are common but do not count
Itching all over the body and tiredness are common in Hodgkin lymphoma. Some people notice pain in their glands after drinking alcohol. These are worth telling your doctor about, but they are not B symptoms and do not change the stage letter.
Be precise when you are asked
Before the appointment, write down when each symptom began, how often it happens and your weight a few months ago. A clear history helps the team give you the right stage.
Commonly believed
What do families often get wrong about the stage?
"Stage IV is the last stage, so nothing can be done."
Hodgkin lymphoma staging is not the same as staging for many solid cancers. Advanced-stage Hodgkin lymphoma is treated with a plan aimed at remission. Ask your haematologist what the aim of treatment is in your case.
"The stage can go up during treatment, so we should repeat scans often."
The stage is set at diagnosis and does not change. Later scans measure response to treatment. They are timed by your team, and extra scans add radiation without helping decisions.
"Night sweats in hot weather mean nothing."
Ordinary sweating in the heat is not a B symptom. Sweats that soak the bedding, night after night, are. Tell the team honestly which kind you have.
"Stage I means only a small operation is needed."
Hodgkin lymphoma is not treated by removing glands. Even stage I is usually treated with chemotherapy, radiotherapy, or both.
Being straight with you
What can the stage not tell you?
The stage cannot tell you on its own how you will do. Two people with the same stage can have different plans, because age, blood tests, bulky disease, B symptoms and the PET-CT scan during treatment all count. This page cannot give you your own outlook. Your haematologist can, once the full picture is in.
Questions worth asking
What is my stage, including the letters? Is my disease grouped as early favourable, early unfavourable or advanced? Is any mass bulky? What treatment does that point to, and when will the next scan be? At CION the haematology team presents each case at a tumour board, a meeting of specialists, before confirming a plan.
Questions we are asked
Common questions about Hodgkin lymphoma staging
What is the difference between Ann Arbor and Lugano staging?
Lugano is an updated version of Ann Arbor. It keeps stages I to IV and uses PET-CT scans for staging and response. It mostly drops the A and B letters in the stage itself, though B symptoms are still recorded because they affect treatment. For most families, the two mean the same thing.
Is stage II early or advanced?
Stage II is usually grouped as early stage. It is then split into favourable or unfavourable depending on risk factors such as a bulky chest mass, a high ESR or B symptoms. Some treatment groups handle stage II with a bulky mass and B symptoms as advanced. Ask how your team groups yours.
Does the stage change if the lymphoma comes back?
The original stage stays on record. If the disease returns, new scans and often a new biopsy are done, and the team describes where it has come back. That new picture guides the next treatment, rather than the stage given at the start.
Do I need a bone marrow biopsy for staging?
Usually not, if you have had a PET-CT scan. The scan picks up lymphoma in the marrow in most people. A marrow biopsy may still be advised if blood counts are unexplained or the scan result is unclear. Your haematologist decides this case by case.
Why does the spleen matter for staging?
The spleen is part of the lymph system. If it is involved, it counts like a lymph node area below the diaphragm. That can move the stage from II to III when there are also nodes above the diaphragm, which usually changes the length of treatment.
What does "bulky disease" mean for treatment?
Bulky disease means one mass is especially large, often in the centre of the chest. It is a risk factor, so it usually means early-stage disease is treated as unfavourable, sometimes with added radiotherapy. Your team measures it on the scan and explains what it means for you.
How long does staging take?
It often takes a week or two, depending on how soon a PET-CT scan and the other tests can be booked. Staging is worth doing carefully, because it sets the length of treatment. If you feel much worse while waiting, tell the team straight away.
Is a PET-CT scan covered by Aarogyasri or insurance?
A PET-CT that is part of an approved lymphoma treatment plan is often covered under Aarogyasri, PM-JAY, CGHS, ECHS, EHS or cashless insurance, depending on eligibility. Scheme rules change, so check the current rules for your card or policy before the scan.
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Sources
- Cancer Research UK — Stages of Hodgkin lymphoma
- American Cancer Society — Hodgkin Lymphoma Stages
- National Cancer Institute — Hodgkin Lymphoma Treatment (PDQ) - Patient Version
- Leukemia & Lymphoma Society — Hodgkin Lymphoma
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
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