New Lymphoma Guidelines

Updates Impact Lymphoma Staging and Response Assessment

PET-CT scan.

Cancer staging and response criteria need to be updated periodically to reflect advances, and that’s exactly what Dr. Cheson and colleagues did recently.

What is the Lugano Classification?

The Lugano Classification is the set of recommendations for initial evaluation, staging and assessment of response in patients with Hodgkin lymphoma and non-Hodgkin lymphoma (NHL). These recommendations are the result of two International Conferences held on 2011 and 2013 on Malignant Lymphoma in Lugano, Switzerland and were published in the Journal of Clinical Oncology by Cheson and colleagues in June 2014.

What are Staging Criteria?

A staging system is a way to summarize how far a cancer has spread. Staging systems can change for a variety of reasons, such as incorporating a new technology, or phasing out some factor that proves, over the years, to be less relevant or useful than previously believed. Roman numerals I through IV refer to the different stages from I the least advanced to IV the most advanced. In general, individual stages are linked to the likelihood of a particular prognosis or outlook and to specific treatment. The American Cancer Society (ACS) has on its website a good overview of staging for many different cancers including Hodgkin Lymphoma. According to the ACS, the Ann Arbor staging system is the most common staging system used for non-Hodgkin lymphoma in adults.

What are Response Criteria?

Response criteria are the rules and tools used to judge and compare treatments. Sometimes these rules are imperfect, but they nonetheless serve to standardize how responses are measured and talked about.

Without clear response criteria, two different study investigators might refer to a patient having a "complete response" and mean two totally different things.

What Changed in the New Criteria?

A few key changes (Adapted from summary by Matthew Stenger) include the following:

  • PET-CT* scans were officially added for the imaging of lymphomas (for those lymphomas that are imaged well with PET-CT).
  • According to the new guidelines, if a PET-CT is done, biopsy is no longer needed in the routine staging of Hodgkin lymphoma and most diffuse large B-cell lymphoma (DLBCL). Bone marrow biopsy is, however, still needed in certain cases.

  • Surveillance scans after remissions are discouraged, particularly for diffuse large B-cell lymphoma and Hodgkin lymphoma. Experts say this represents an unnecessary expense because most of the time patients and physicians detect the recurrence before any scan is done.

*PET CT stands for Positron Emission Tomography CT scan. The CT part you may already be familiar with. It stands for computed tomography, or the use of x-ray imaging to create pictures of  sections through the body, and the use of computers to create and compile the images for analysis. The PET part shows the metabolic activity levels of the cells in areas being imaged, and helps to identify cancer cells. PET scans are very commonly used to evaluate lymphoma.


Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Lister TA. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. 2014;32(27):3059-3068.

American Cancer Society. How is non-Hodgkin lymphoma staged? Accessed January 2015.

Smith, Monica. New Lymphoma Recommendations Reflect Advances. Accessed January 2015.

Matthew Stenger. Updated Recommendations for Evaluation, Staging, and Response Assessment for Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification. Accessed January 2015.

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