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Non-Hodgkin's Lymphoma Staging: Ann Arbor Staging System

Ann Arbor staging is the most commonly used a system for Non-Hodgkin’s Lymphoma Staging. It helps to determine the disease prognosis and to select an appropriate treatment strategy.

It assigns four stages (I, II, III, and IV) to NHL. Letter ‘E’ can be added, which indicate that HL affects an organ outside of the lymphatic system (extranodal site).

Each stage can also be subdivided into A and B categories. “A” indicates absence of B symptoms and “B” indicates presence of classic B-symptoms (unexplained weight loss, fever, and night sweats).

Sometimes, letter X is added to Stage I or II, which indicate bulky disease. A bulky disease can be assessed with the help of mediastinal mass ratio (MMR, a ratio of the maximum width of the tumor mass and the maximum intrathoracic diameter) as a tumor mass of >0.33 MMR. Alternatively, a bulky disease is defined as a single node or nodal mass that is 10 cm or greater in diameter.

Following table describe the characteristics of NHL according to different Lugano stages:

LUGANO STAGE DESCRIPTION
I NHL is limited to only one site in the lymphatic system (single lymph node or lymphoid organ) OR only one site outside the lymphatic system is involved (IE).
II NHL has extended to 2 or more lymph nodes regions on the same side of the diaphragm OR involvement of an extralymphatic site adjacent to the involved nodal site (IIE).
III NHL has spread to lymph nodes regions on both sides of the diaphragm OR NHL has affected lymph nodes above the diaphragm and the spleen (IIIS).
IV Involvement of liver and/or bone OR involvement of a nodal site with non-regional extranodal site involvement.

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Prognostic factors: Besides the stages of NHL, many factors have been identified in clinical research studies for different NHL types, which can predict the prognosis of disease. These factors are generally taken into account before starting the treatment of NHL. Following are certain examples:

  • International Prognostic Index (IPI): IPI is a tool that is used for risk stratification and overall disease prognosis in NHL patients based on patient’s age, performance status (a score that assesses overall health and well-being of an individual), serum LDH level, assigned stage, and the number of extranodal sites involved. In patients younger than 60 years, tumor stage, performance status, and serum LDH level are considered as the prognostic factors. The NHL patients can be divided into 4 different risk groups (low, low-intermediate, high-intermediate, and high). The assigned risk-group is used to assess the prognosis of patient. This system works best for DLBCL and other aggressive NHL types.
  • Follicular Lymphoma International Prognostic Index (FLIPI): FLIPI is a tool that is used exclusively for risk stratification in FL patients based on patient’s age, serum LDH levels, hemoglobin levels, assigned stage, and the number of nodal sites involved. The FL patients are divided into 3 risk groups: Low, Intermediate, and High. Recently, another similar risk stratification system, FLIPI-2 was designed that can predict treatment outlook in patients treated with modern chemoimmunotherapy regimens.
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