Part of node or whole node.
Extracapsular into adjacent soft tissues or organ parenchyma. A TNM classification is not used as the primary site of origin is often uncertain and attribution of N and M stages would therefore be arbitrary.
Stage: Ann Arbor classification
I Single lymph node region or localized extralymphatic site/organ II Two or more lymph node regions on same side of the diaphragm or single localized extralymphatic site/organ and its regional lymph nodes ± other lymph node regions on the same side of the diaphragm
III Lymph node regions on both sides of the diaphragm ± a localized extralymphatic site/organ or spleen
IV Disseminated (multifocal) involvement of one or more extralym-phatic organs ± regional lymph node involvement, or single extra-lymphatic organ and non-regional nodes.
A Without weight loss/fever/sweats B With weight loss/fever/sweats:
Figure 35.3. Malignant lymphoma. |W
Involvement of lymph node regions on both sides of the diaphragm (III) (Fig. 35.3), which may also be accompanied by localized involvement of an associated extralymphatic organ or site (IIIE) (Fig. 35.4), or by involvement of the spleen (IIIS), or both (IIIE+S) (Fig. 35.5) +
Figure 35.3. Malignant lymphoma. |W
fever >38°C night sweats weight loss >10% of body weight within the previous 6 months. Subscripts, e.g. IIIE denotes stage III with extranodal disease
IIIS denotes stage III with splenic involvement III3 denotes stage III with involvement of 3 lymph node regions: >2 is prognostically adverse. Lymph node regions: head, neck, face intrathoracic intra-abdominal axilla/arm groin/leg pelvis.
Other major structures of the lymphatic system are the spleen, thymus, Waldeyer's ring (palatine, lingual and pharyngeal tonsils), vermiform appendix and ileal Peyer's patches. Minor sites include bone marrow, liver, skin, lung, pleura and gonads.
Bilateral involvement of axilla/arm or inguinal/leg regions is considered as involvement of two separate regions.
Direct spread of lymphoma into adjacent tissues or organs does not alter the classification, e.g. gastric lymphoma into pancreas and with involved perigastric lymph nodes is stage IIE.
Involvement of two or more discontinuous segments of gastrointestinal tract is multifocal and classified as stage IV, e.g. stomach and ileum. However, multifocal involvement of a single extralymphatic organ is IE.
Involvement of both organs of a paired site, e.g. lungs, is also IE. Regional nodes for an extranodal lymphoma are those relevant to that particular side, e.g. gastric lymphoma—perigastric, left gastric, common hepatic, splenic and coeliac nodes.
Once the primary tissue diagnosis has been made staging laparotomy has been largely replaced by assessment of clinical and radiological parameters, e.g. abnormal liver function tests and imaging for hepato-/splenomegaly and lymphadenopathy. Bone marrow biopsy remains part of normal staging which is otherwise mostly clinical. Bone marrow or nodal granulomas per se are not sufficient for a positive diagnosis of involvement and diagnostic Hodgkin's cells are needed. Bone marrow involvement by NHL can be diffuse, nodular or focal and paratrabecular infiltration is a characteristic site.
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