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The Ann Arbor staging system for Hodgkin lymphoma was originally published in 1971 and updated with the Cotswolds modifications in 1989.r It is also used for staging patients with non-Hodgkin lymphoma. Patients are assigned to one of four stages according to the sites involved by lymphoma. Numbers and letters indicate the number of regions involved and the presence of systemic symptoms or extranodal disease. This system was further updated with the Lugano modifications in 2014 which clarified the use of PET/CT in initial staging and response to treatment.r

Lugano Classification adapted from the Ann Arbor staging system with Cotswolds modifications


Revised staging system for primary nodal lymphomas

© JCO 2014


A or B:

All cases are subclassified to indicate the absence (A) or presence (B) of one or more of the following three systemic symptoms:

  • unexplained persistent or recurrent fever with temperatures above 38°C during the previous month
  • recurrent drenching night sweats during the previous month
  • unexplained weight loss exceeding 10 percent of body weight during the six months prior to diagnosis.


The presence of limited local spread of the disease from one nodal area or structure to surrounding or extranodal tissues in the same area of the body is indicated by the letter 'E', as in stage IIE. More extensive extranodal disease is designated stage IV (see above).

Bulky disease:

A single nodal mass, in contrast to multiple smaller nodes, of 10 cm or ≥⅓ of the transthoracic diameter at any level of thoracic vertebrae as determined by CT; record the longest measurement by CT scan. The term "X" (used in the Ann Arbor staging system) is no longer necessary.

Lugano criteria for involvement of site:

© JCO 2014

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22 Jan 2020